"State-of-the-art" is a moving target. The two largest North American cardiology societies have released an update [1] to their 2005 guidelines on "the diagnosis and management of chronic heart failure" [2], which for the first time outlines their recommendations for patients hospitalized with acute heart failure (HF).
The document, also for the first time, includes concrete recommendations on the use of "a fixed-dose combination of hydralazine and isosorbide dinitrate" in self-identified African Americans who are symptomatic on angiotensin-converting enzyme (ACE) inhibitors, beta blockers, and diuretics.
That's a reference to the proprietary medication (BiDil, NitroMed), approved in 2005 for use in blacks on the strength of the African-American Heart Failure Trial (A-HeFT), which, as previously covered by heartwire , saw the drug significantly improve survival and cut HF hospitalizations over 10 months.
A-HeFT had been presented to audiences but was not published when the 2005 guidelines document was being completed, Dr Mariell Jessup (University of Pennsylvania School of Medicine, Philadelphia), told heartwire . It was, in large part, the impetus for this year's update, she said.
Jessup chaired the writing group for the 2009 document, which was developed by the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA), with input from the International Society for Heart and Lung Transplantation. It's available online and will appear in the April 14, 2009 issues of the societies' flagship publications—the Journal of the American College of Cardiology and Circulation—according to a statement from the ACC.
Most of the new acute HF recommendations are the strongest kind (class 1), but are based on a weaker level of evidence (C), Jessup observed. They incorporate the latest findings on using natriuretic peptides for making the diagnosis, management of symptoms, use of medications, and discharge instructions.
The document also contains improved language on the use of implantable cardioverter defibrillators (ICDs) for primary prevention. The previous class 1 recommendation, level of evidence A, was for patients with a left ventricular ejection fraction (LVEF) ≤30%, but "the way we had worded it in 2005 was pretty awkward, because there was this group of patients with an ejection fraction of 30% to 35% that was kind of in no-mans land," Jessup said. ICDs were separately recommended for the LVEF 30% to 35% range, but it was a class 2a recommendation based on a weaker level of evidence (B).
The new document brings the threshold to ≤35% (class 1, evidence level A) to make it consistent with guidelines released in 2008 jointly by the ACC, AHA, and Heart Rhythm Society (as reported by heartwire ).
There is also a new recommendation that "it is reasonable" to use a rhythm- or rate-control strategy in patients with both HF and atrial fibrillation, new recommendations on when to use cardiac resynchronization therapy, and a stronger warning against routine intermittent infusions of inotropic agents in end-stage HF.
The Heart Failure Society of America also has a set of guidelines [3], which it released in 2006 (also reported byheartwire ). It's similar to the ACC/AHA document, according to Jessup. "I think they are generally consistent. The cardiology community is aware that there has been a proliferation of guidelines; I think it's an issue everyone is concerned about," she said, pointing out that the European Society of Cardiology also has a series of guidelines.
The potential for confusion is real. "There's been a great deal of soul searching about the whole guidelines process," she said.
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