American College of Cardiology/American Heart Association Chronic Heart Failure Evaluation and Management Guidelines: Relevance to the geriatric practice

BACKGROUND: Heart failure (HF) is the only cardiovascular disease with increasing incidence and prevalence. Most HF patients are older adults. With the aging of the population and effective treatment of hypertension and coronary artery disease, the two major underlying causes of HF, the number of older Americans with HF is expected to rise significantly in the coming decades. HF is the number one hospital discharge diagnosis for older adults. It is one of the causes of frequent hospital readmissions, reflecting acute decompensation and compromised quality of life for patients and increased cost and resource use for the healthcare system. It is also associated with approximately 300,000 deaths annually, most in older adults. Advances in the management of HF in the past several decades have significantly decreased the mortality and morbidity associated with this condition. Randomized controlled trials have demonstrated the beneficial effects of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, beta-blockers, and spironolactone on survival and quality of life of HF patients, but there is evidence of underuse of evidence-based care for HF. Several national guidelines have been published since 1994 that recommended evidence-based evaluation and management of HF. In 1995, the American College of Cardiologists (ACC) and the American Heart Association (AHA) published their first HF guidelines that recommended left ventricular (LV) function evaluation for all patients presenting with HF and use of ACE inhibitors for all patients with LV systolic dysfunction (LVSD) unless contraindicated. The guidelines recommended the use of hydralazine and isosorbide dinitrate in patients who could not use ACE inhibitors. In addition, digoxin was recommended in patients with HF due to LVSD but not adequately responsive to ACE inhibitors and diuretics and in those with atrial fibrillation and rapid ventricular rates. Diuretic use was recommended for symptomatic patients with evidence of fluid overload. Use of anticoagulation was restricted to patients with atrial fibrillation or to those with a history of systemic or pulmonary embolism. Beta-blockers were reserved for HF patients after acute myocardial infarctions. Recent advances in the management of HF called for a revision of the guidelines. PURPOSE: The purpose of revising the 1995 ACC/AHA guidelines was to incorporate recent advances in pharmacological and nonpharmacological approaches to HF treatment and to assist physicians in clinical decision-making in the management of HF. METHODS: The ACC/AHA invited representatives from the American College of Chest Physicians, the Heart Failure Society of America, the International Society for Heart and Lung Transplantation, the American Academy of Family Physicians, and the American College of Physicians-American Society of Internal Medicine to participate in the preparation of the guidelines. The writing committee searched pertinent medical literature in English using computerized databases such as MEDLINE and EMBASE and manually searching the bibliographies of the selected articles. The writing committee classified HF into four stages, including patients who are at high risk for developing HF. According to this new classification, Stage A and B represent asymptomatic patients, the former at high risk for developing HF but no structural disorder, the latter with structural disorders of the heart. Stage C encompasses patients with underlying structural heart disorders who are symptomatic, either currently or in the past. Stage D includes end-stage HF patients. This new classification is intended to complement the New York Heart Association (NYHA) functional classification of HF into Class I (asymptomatic), Class II (symptomatic on less than ordinary exertion), Class III (symptomatic on ordinary exertion), and Class IV (symptomatic at rest). RESULTS: The recommendations are categorized into those for evaluation and management.