Lippincott Nursing Pocket Card - August 2021

Heart Failure: Guideline-Directed Management and Therapy


Heart Failure: Guideline-Directed Management and Therapy

Guideline-Directed Management and Therapy (GDMT) was developed by the American College of Cardiology and American Heart Association to define the optimal course of treatment for patients in each stage of heart failure (HF) (Yancy et al., 2013). The recommendations are outlined below.


Treatment Recommendations by Stage

Heart Failure Stage Treatment Recommendations
Stage A: At high risk for HF but without structural heart disease or symptoms of HF

  • Heart healthy lifestyle
  • Prevent vascular and coronary disease
  • Prevent left ventricular (LV) structural abnormalities
  • Treat elevated blood pressure (BP) in accordance with current guidelines
    • Diuretic-based antihypertensive therapy
    • Angiotensin converting enzyme inhibitor (ACE inhibitor)
    • Angiotensin receptor blockers (ARB)
    • Beta-blocker
  • Treat dyslipidemia and vascular risk
    • Aggressive statin therapy as appropriate
  • Recognition and control of risk factors that may lead to HF:
    • Diabetes mellitus (DM)
    • Obesity
    • Obtain 3-generation family history of HF to evaluate genetic risk
    • Atrial fibrillation (AF)
    • Evaluate patients receiving or those who have received cardiotoxic chemotherapy
    • Advise patients to avoid tobacco, heavy alcohol use, cocaine, and amphetamines
Stage B: Structural heart disease without signs or symptoms of HF

  • Prevent HF symptoms
  • Prevent further cardiac remodeling/changes
  • All recommendations for Stage A HF apply to Stage B HF.
  • In patients with a history of myocardial infarction (MI) or acute coronary syndrome (ACS) and reduced ejection fraction (EF):
    • ACE inhibitors and beta blockers
    • ARB use in patients intolerant to ACE inhibitors due to cough or angioedema; may use as first-line therapy alternative to ACE inhibitors or for persistently symptomatic patients.
  • In patients with MI, use statin therapy.
In select patients:
  • Implantable cardioverter-defibrillator (ICD) use in asymptomatic ischemic cardiomyopathy at least 40 days post-MI, left ventricular ejection fraction (LVEF) less than or equal to 30%, on GDMT, and in patients with reasonable functional status and expected survival great than 1 year. Goal of therapy is primary prevention of sudden cardiac death.
  • Revascularization or valvular surgery as appropriate
  • Non-dihydropyridine calcium channel blockers with negative inotropic effects; may be harmful in asymptomatic patients with low LVEF and no symptoms of HF after MI.
Stage C: Structural heart disease with prior or current symptoms of HF

(HFpEF): EF greater than or equal to 50%

  • Control blood pressure (BP) – most important!
  • Patient education
  • Manage volume overload
  • Improve health-related quality of life (HRQOL)
  • Prevent hospitalization
  • Prevent mortality
  • All recommendations for Stage A and B HF apply to Stage C HF, as appropriate.
  • Provide education to facilitate HF self-care, including: monitoring symptoms and weight changes, restrict sodium intake, adhere to medication regimen and maintain physical activity
  • Diuretics to relieve congestion/volume overload
  • Identification and management of comorbidities:
    • Coronary revascularization for coronary artery disease (CAD) if angina or MI is present despite GDMT
    • Atrial fibrillation (AF) managed per clinical practice guidelines
    • Sleep disorders: continuous positive airway pressure (CPAP) may increase LVEF and improve functional status
  • Routine use of nutritional supplements is not recommended
  • New: Consider aldosterone receptor antagonists to decrease hospitalizations in select populations with HFpEF (EF greater than or equal to 45%, elevated BNP levels or HF admission within 1 year, creatinine less than 2.5mg/dL, potassium (K) less than 5mEq/L) (Yancy et al., 2017).
  • New: Routine use of nitrates or phosphodiesterase-5 inhibitors are ineffective in increasing activity or quality of life (Yancy et al., 2017).
Stage C: Structural heart disease with prior or current symptoms of HF

(HFrEF): EF less than or equal to 40%

  • Control symptoms
  • Patient education
  • Prevent hospitalization
  • Prevent mortality
New: The 2021 Update to 2017 ECDP for Optimization of Heart Failure Treatment mainly focuses on management of patients with chronic ambulatory HFrEF with LVEF less than or equal to 40% (Maddox et al., 2021).
Evidence based guideline-directed therapy for HFrEF now includes: ARNIs/ACE/ARB, beta-blockers, loop diuretics, aldosterone antagonists, hydralazine/isosorbide dinitrate, and ivabradine.
  • With the exception of loop diuretics, all have shown to improve symptoms, reduce hospitalizations, and/or prolong survival.
  • ARNIs demonstrate a reverse-remodeling effect in chronic HFrEF.
  • Both the EMPEROR-Reduced trial and the DAPA-HF study showed SGLT2 inhibitors to reduce CV death and HF hospitalization in patients with and without type 2 diabetes.
Treatment algorithm for guideline directed medical therapy including novel therapies (Maddox et al., 2021):
  • ARNI/ACEI/ARB (ANRI preferred) AND beta-blocker with diuretic agent as needed.
  • For patients with eGFR greater than or equal to 30 mL/min/1.73m2, or creatinine less than or equal to 2.5 mg/dL in males or less than or equal to 2.0 mg/dL in females or K 5.0 mEq/L or less, NYHA class II-IV:
    • ADD Aldosterone antagonist
    • ADD SGLT2 inhibitor
  • For patients with persistent volume overload, NYHA class II-IV:
    • TITRATE diuretic agent
  • For persistently symptomatic Black patients despite ARNI/beta-blocker/aldosterone antagonist/SGT2 inhibitor, NYHA class III-IV:
    • ADD Hydralazine plus isosorbide dinitrate
  • For patients with resting HR greater than or equal to 70, on maximally tolerated beta-blocker dose in sinus rhythm, NYHA class II-III:
    • ADD Ivabradine
  • If previously on ACEI, ensure 36 hours off before initiation of ARNI.
  • Consider ACE/ARB in patients where ARNI administration is not possible.
  • Use of digoxin for HFrEF lacks new data and is no longer considered to be an effective addition for symptoms while on GDMT.
  • Reassess ventricular function 3-6 months after target doses of GDMT to determine need for device therapies such as CRT or ICD.
  • Surgical treatment is recommended for severe primary chronic MR resulting in HFrEF.
Stage D: Refractory or Advanced HF – symptoms at rest & recurrent hospitalizations [see detailed definition below]

  • Control symptoms
  • Improve HRQOL
  • Reduce hospital readmissions
  • Establish patient’s end-of-life goals
  • Fluid restriction (1.5 to 2 L/day) to reduce congestive symptoms
  • Intravenous (IV) inotropic support:
    • Temporary use in cardiogenic shock until definite therapy (i.e. coronary revascularization, mechanical circulatory support (MSC), cardiac transplant)
    • Continuous use as “bridge therapy” for patients awaiting cardiac transplant
    • Short-term, continuous use for hospitalized patients with severe systolic dysfunction
    • Long-term use as palliative therapy for symptom control (without specific indication, inotropes may be harmful)
  • Temporary or permanent MCS may be beneficial if cardiac recovery anticipated; ventricular assist device (VAD) may be used as “bridge to recovery” or “bridge to decision” for selected patients.
  • Cardiac transplantation for carefully selected patients.
  • Palliative care and hospice.
  • Depending on goals of care, consider ICD deactivation.
Acute management of patients hospitalized with HF
  • IV loop diuretics: initial dose greater than or equal to chronic total daily oral dose
    • Increase diuretic or add another diuretic if diuresis is inadequate.
    • Monitor serum electrolytes, urea nitrogen and creatinine, fluid intake/output, daily weights, vital signs, and clinical signs and symptoms of fluid overload.
  • Continue GDMT except when unstable.
  • Low dose dopamine IV may be added with loop diuretics to improve diuresis*
    • *Inotropic therapy with dopamine, dobutamine, or milrinone should only be used in acute decompensated HF patients who are hypotensive with HFrEF.
  • Initiate beta blocker therapy at low dose after optimization of volume status and discontinuation of IV agents.
  • Thrombosis/thromboembolism prophylaxis
  • Ultrafiltration for volume overload or refractory congestion
  • Adjuvant therapies to relieve dyspnea: IV nitroglycerin, nitroprusside or nesiritide
  • Vasopressin antagonists in patients with volume overload and severe hyponatremia

Strategies for Achieving Optimal GDMT

  • Titrate medications slowly.
  • Frequent follow-up visits and lab monitoring during dose titration (elderly & impaired renal function).
  • Monitor vital signs, including orthostatic BPs before, during, and after titrations.
  • Alternate adjustments of different medication classes.
  • Monitor renal function and electrolytes for increasing creatinine and potassium levels.
  • Reassure patients that symptoms of fatigue and weakness without instability are transient and usually resolve in a few days.
  • Discourage sudden discontinuation of GDMT medications without discussion with prescribing clinicians.
  • Carefully review doses of other medications for HF symptom control during up-titration.

Advanced Heart Failure

Some patients with chronic HF will develop severe symptoms despite optimal GDMT. These patients are classified with ACCF/AHA stage D HF (described above) and include “end-stage HF” and “refractory HF”.

European Society of Cardiology Definition
  • Severe symptoms of HF with dyspnea and/or fatigue at rest with minimal exertion (NYHA class III or IV)
  • Fluid retention (pulmonary and/or systemic congestion, peripheral edema) and/or decreased cardiac output at rest (peripheral hypoperfusion)
  • Objective evidence of severe cardiac dysfunction - at least one of the following:
    • LVEF less than 30%
    • Pseudonormal or restrictive mitral inflow pattern
    • Mean pulmonary artery wedge pressure (PAWP) greater than 16 mm Hg and/or right atrial pressure (RAP) greater than12 mm Hg by pulmonary artery (PA) catheterization
    • High BNP or NT-proBNP plasma levels in the absence of noncardiac causes
  • Severe impairment of functional capacity - one of the following:
    • Inability to exercise
    • 6-Minute walk distance less than or equal to 300 m
    • Peak VO2 less than 12 to 14 mL/kg/min
  • History of 1 or more HF hospitalizations in prior 6 months
  • Presence of all of the previous features despite “attempts to optimize” therapy, including diuretics and GDMT, unless these are poorly tolerated or contraindicated, and CRT when indicated
Clinical Findings of Advanced Heart Failure
  • Repeated (2 or more) hospitalizations or emergency room visits for HF in the past year
  • Progressive deterioration in renal function (i.e. rise in BUN and creatinine)
  • Weight loss without other causes (i.e. cardiac cachexia)
  • Intolerance of ACE inhibitors due to hypotension and/or worsening renal function
  • Intolerance to beta blockers due to worsening HF or hypotension
  • Frequent systolic BP less than 90 mm Hg
  • Persistent dyspnea with dressing or bathing requiring rest
  • Inability to walk 1 block on level ground due to dyspnea or fatigue
  • Recent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose over 160 mg/day and/or use of supplemental metolazone therapy
  • Progressive decline in serum sodium, usually less than 133 mEq/L
  • Frequent ICD shocks

Recommendations for Hospital Discharge

  • Implement performance improvement systems in the hospital and early post-discharge outpatient setting to identify HF for GDMT.
  • Before hospital discharge, at the first post-discharge visit, and in subsequent follow-up visits, the following should be addressed:
    • Initiation of GDMT if not done and not contraindicated
    • Causes of HF, barriers to care, and limitations in support
    • Assessment of volume status and BP with adjustment of HF therapy
    • Titration and optimization of chronic oral HF therapy
    • Assessment of renal function and electrolytes
    • Management of comorbid conditions
    • HF education, self-care, emergency plans, and adherence
    • Palliative or hospice care
  • Arrange multidisciplinary HF disease management for patients at risk for hospital readmission.
  • Schedule follow-up visit within 7 to 14 days and a telephone follow-up within 3 days of hospital discharge.
  • Use clinical risk-prediction tools and/or biomarkers to identify higher-risk patients.
Maddox, T.M., Januzzi, J.L., Allen, L., Breathett, K., Butler, J., David, L., Fanarow, G., Ibrahim, N., Lindenfeld, J., Masoudi, F., Motiwala, S., Oliveros, E., Patterson, J.H., Walsh, M., Wasserman, A., Yancy, C., Youmans, Q.R. (2021). Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction. Journal of the American College of Cardiology, 77, 772-810. 

Yancy, C.W., Jessup, M., Bozkurt, B., Butler, J., Casey, D.E., Dranzer, M.H.,…Wilkoff, B.L. (2013). 2013 ACCF/AHA Guideline for the Management of Heart Failure. Circulation, 128, e240-e327.

Yancy, C.W., Jessup, M., Bozkurt, B., Butler, J., Casey, D.E., Monica M. Colvin, M.M,…Westlake, C. (2016). 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation, 134, e282-e293.

Yancy, C.W., Jessup, M., Bozkurt, B., Butler, J., Casey, D.E., Monica M. Colvin, M.M,…Westlake, C. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation, 136, e137- e161.