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Major heart-failure guidelines show few meaningful differences

June 03, 2019

By Will Boggs

NEW YORK (Reuters Health) - There are few significant differences between the American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) clinical guidelines for the diagnosis and treatment of acute and chronic heart failure (HF), according to a new report.

"The U.S. and European guidelines are concordant far more than discordant," said Dr. G. William Dec of Massachusetts General Hospital, in Boston.

"This is not surprising, since the majority of the class I and IIa recommendations are based on the results of randomized clinical trials performed throughout the world," he told Reuters Health by email. "Interpretation of the studies is not difficult since there is usually a clear message. Recommendations based on clinical expertise without clear randomized trial data carry less weight and varied between guidelines."

In their report, online June 4 in the Journal of the American College of Cardiology, Dr. Dec and colleagues summarized major recommendations regarding the diagnosis and treatment of cardiomyopathies and symptomatic HF from the ACC/AHA and ESC.

Both guidelines recommend transthoracic echocardiography for initial diagnostic testing and, in terms of prevention, both advise cardiac MRI to assess for myocardial scarring.

For patients with heart failure with reduced ejection fraction (HFrEF), both guidelines recommend triple neurohormonal blockade and beta blockers with addition of mineralocorticoid receptor antagonists for NYHA functional class II-IV and left ventricular ejection fraction (LVEF) of 35% or less; both also recommend ivabradine for persistently symptomatic HF with sinus rhythm, LVEF of 35% or less, and a resting heart rate of at least 70 beats/minute despite evidence-based dosing of beta blockers.

For patients with heart failure with preserved ejection fraction (HFpEF), both guidelines recommend diuretics for volume control, high blood pressure management, and relief of ischemia.

Both guidelines also suggest implantable cardioverter-defibrillator (ICD) therapy for primary or secondary prevention in appropriate patients and recommend cardiac resynchronization therapy (CRT) for patients with NYHA functional class II-IV, LVEF of 35% or less, and left bundle branch block (LBBB) with QRS of 150 ms or longer.

Among the differences between the guidelines, ACC/AHA advises specific angiotensin-receptor blockers (ARBs) and beta blockers, whereas ESC recommends these medications as a class.

For patients with HFpEF and diabetes or high blood pressure, ACC/AHA offers no recommendation for diabetes management and recommends guideline-directed medical therapy (GDMT) with a blood pressure goal of

"Despite a high level of class I recommendations, the implementation of appropriate pharmacologic therapy, particularly up-titration to recommended doses of neurohormonal antagonists, has still not been applied to most patients with (HFrEF)," Dr. Dec said. "Similarly, the use of CRT therapy and ICD are underutilized."

"Although there has been great progress in the treatment of heart failure with reduced ejection fraction, we still do not have effective treatments for heart failure with preserved ejection fraction, and that needs to be the major focus for the future," he said.

Dr. Gregg C. Fonarow of the University of California, Los Angeles, who served on the writing group for the 2013 and 2017 ACC/AHA heart failure guidelines, told Reuters Health by email, "That the two guidelines have such high concordance in key recommendations should reinforce the importance of and need to intensify efforts for implementing these guideline recommendations into routine clinical practice."

"Despite extensive evidence and strong recommendations to use guideline-directed medical therapies in patients with heart failure with reduced ejection fraction in both the ACC/AHA and ESC heart failure guidelines, study after study demonstrate large numbers of eligible patients are not receiving one or more of the medications or not receiving optimal doses in the U.S. and in ESC countries," he said. "Substantially greater efforts are needed to apply these evidence-based heart failures guidelines in the right patients, at the right doses, each and every time."


J Am Coll Cardiol 2019.

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