In late April, the American College of Cardiology, American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Failure Society of America released their latest U.S. guidelines for heart failure management, and placed a far greater emphasis on prevention than at any time before. The guidelines also focus more on patients at risk for developing heart failure – people with hypertension, diabetes, or coronary artery disease – than those who already have it.
A Changing Mindset in the Medical Community
What this means is that, for the first time, these guidelines focus on what are called “stage A” heart failure patients, those without symptoms but at risk for heart failure, a group that was ignored in the past. These new guidelines use the stage A definition from the 2009 guidelines: patients with “risk factors that clearly predispose them toward the development of heart failure; for example, patients with coronary artery disease, hypertension, or diabetes mellitus who do not yet demonstrate impaired left ventricular function.”
When you think about the number of people with high blood pressure (hypertension) or diabetes, you realize just how many patients are affected by these new guidelines.
The First Step Is Blood Pressure
The biggest change to the heart failure guidelines is an entirely new section dedicated to blood pressure, and the first entry is a target blood pressure of less than 130/80 mm Hg for all stage A heart failure patients. The panel chair, Mariell Jessup, MD, called hypertension the most powerful risk factor for heart failure. In fact, she urges patients to think of hypertension as pre-heart failure, a frightening – but empowering – idea. A lot of patients who get symptomatic heart failure are older women who have experienced years of poorly controlled hypertension.
More Guideline Revisions
The updated guidelines contain even more changes. For one thing, they mention that doctors should be checking for anemia is important and that iron is an intervention that might make a difference. Also, we as physicians should look for obstructive sleep apnea in heart failure patients for whom intervention with weight loss might help. This conversation, so often seen as delicate or uncomfortable, is increasingly essential to have with our overweight or obese patients, as losing weight can lead to improvements in a cluster of conditions (diabetes, high blood pressure, high cholesterol, and sleep apnea among them) that can lead to heart failure.
The specifics of how to orchestrate all the guidelines into a specific plan you see enacted on your doctor visits may become clearer later this year, when the ACC/AHA group will release a follow-up “Heart Failure Pathways” document, aimed at bridging the gap between guidelines and actual clinical practice. For now, however, the biggest challenge that remains for us as physicians is how to find time in our patient visits to reiterate this emphasis on heart failure prevention, and put strategies into place to enact it.