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Guideline Summary
Guideline Title
Prevention of ventricular remodeling, cardiac dysfunction, and heart failure: HFSA 2010 comprehensive heart failure practice guideline.
Bibliographic Source(s)
Heart Failure Society of America, Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN. Prevention of ventricular remodeling, cardiac dysfunction, and heart failure: HFSA 2010 comprehensive heart failure practice guideline. J Card Fail. 2010 Jun;16(6):e38-43. [95 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Heart Failure Society of America. Prevention of ventricular remodeling, cardiac dysfunction, and heart failure. J Card Fail 2006 Feb;12(1):e12-5. [57 references]

Scope

Disease/Condition(s)
  • Heart failure (HF)
  • Ventricular remodeling
  • Cardiac dysfunction

Note: Heart failure is a syndrome caused by cardiac dysfunction, generally resulting from myocardial muscle dysfunction or loss and characterized by either left ventricular (LV) dilation or hypertrophy or both.

Guideline Category
Evaluation
Prevention
Risk Assessment
Clinical Specialty
Cardiology
Endocrinology
Family Practice
Internal Medicine
Preventive Medicine
Intended Users
Advanced Practice Nurses
Pharmacists
Physician Assistants
Physicians
Guideline Objective(s)
  • To provide recommendations for the prevention of ventricular remodeling, cardiac dysfunction, and heart failure (HF)
  • To update and expand the previous 2006 clinical practice guidelines
Target Population

Patients with conditions that predispose them to ventricular remodeling, cardiac dysfunction, and heart failure

Interventions and Practices Considered
  1. Clinical assessment with appropriate investigation for risk factors
  2. Risk factor management
  3. Angiotensin-converting enzyme (ACE) inhibitors
  4. Beta-blockers
Major Outcomes Considered

Heart failure rates

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

A literature search with relevant key words and phrases for each guideline section were provided to members of the subcommittees and the full Guideline Committee. Members of each subcommittee were asked to review the search and identify any additional relevant medical evidence for each assigned section.

The following databases were searched:

  • Ovid Medline (1950 to the updated date when the search was conducted)
  • Ovid Medline In-Process and other Non-Indexed Citations
  • PubMed

The searches focused primarily on the period between the last guideline publication and current, although the authors went back to 2005 to account for publication lag between the completion of the guideline and its publication in 2006 (i.e., 2005–2010) in the event there was some information that should/could be added to the 2010 updated document. Generally only non-human studies and publications that were non-English were excluded.

The following search terms were used: Heart failure; ventricular remodeling; risk factors; coronary artery disease; myocardial infarction; hypertension; primary prevention; secondary prevention; practice guideline; diabetes mellitus; dyslipidemias; angiotensin-converting enzyme inhibitors; angiotensin II type 1 receptor blockers; adrenergic beta-antagonists.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Hierarchy of Types of Evidence
Level A Randomized, Controlled, Clinical Trials
May be assigned based on results of a single methodologically rigorous trial
Level B Cohort and Case-Control Studies
Post hoc, subgroup analysis, and meta-analysis
Prospective observational studies or registries
Level C Expert Opinion
Observational studies – epidemiologic findings
Safety reporting from large-scale use in practice
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Heart Failure Society of America (HFSA) Guideline Approach to Medical Evidence

Two considerations are critical in the development of practice guidelines: assessing strength of evidence and determining strength of recommendation. Strength of evidence is determined both by the type of evidence available and the assessment of validity, applicability, and certainty of a specific type of evidence. Following the lead of previous guidelines, strength of evidence in this guideline is heavily dependent on the source or type of evidence used. The HFSA guideline process has used three grades (A, B, or C) to characterize the type of evidence available to support specific recommendations (see Table 1.2 in the original guideline document).

HFSA Guideline Approach to Strength of Recommendation

Determining Strength. Although level of evidence is important, the strength given to specific recommendations is critical. The process used to determine the strength of individual recommendations is complex. The goal of guideline development is to achieve the best recommendations for evaluation and management, considering not only efficacy, but the cost, convenience, side effect profile, and safety of various therapeutic approaches. The HFSA guideline committee often determined the strength of a recommendation by the "totality of evidence," which is a synthesis of all types of available data, pro and con, about a particular therapeutic option. The HFSA guideline employs the categorization for strength of recommendation outlined in Table 1.3 in the original guideline document.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Process of Guideline Development

Key steps in the development of this guideline are listed in Table 1.4 in the original guideline document. Having determined the broad scope of the current guideline, subcommittees of the guideline committee were formed for each section of the guideline. A literature search with relevant key words and phrases for each guideline section were provided to members of the subcommittees and the full Guideline Committee. Members of each subcommittee were asked to review the search and identify any additional relevant medical evidence for each assigned section. Changes in recommendation and background were carried out by each subcommittee with conference calls directed by the Guideline Committee chair. Each section was presented for comments and consensus approval to the Guideline Committee. Once subsections were complete, the Executive Council reviewed and commented on each section and these comments were returned to the Guideline Committee for changes and once complete, for final approval by the Executive Council.

Consensus

The Heart Failure Society of America (HFSA) Guideline Committee sought resolution of difficult cases through consensus building. An open, dynamic discussion meant that no single voice was allowed to dominate. Written documents were essential to this process, because they provided the opportunity for feedback from all members of the group. On occasion, consensus of opinion was sufficient to override positive or negative results of almost any form of evidence. The HFSA process had a strong commitment to recommendations based on objective evidence rigorously reviewed by a panel of experts. Issues that caused difficulty for the HFSA guideline process were some of the more important ones faced by the committee, because they mirrored those that are often most challenging to clinicians in day-to-day practice. The foundation of the HFSA guideline process was the belief that the careful judgment of recognized opinion leaders in these controversial areas is more likely to be correct than ad hoc decisions made "on the spot" by physicians in practice.

Rating Scheme for the Strength of the Recommendations

Classifying the Strength of the Recommendations

"Is recommended" Part of routine care
Exceptions to therapy should be minimized.
"Should be considered" Majority of patients should receive the intervention.
Some discretion in application to individual patients should be allowed.
"May be considered" Individualization of therapy is indicated.
"Is not recommended" Therapeutic intervention should not be used
Cost Analysis

The developer reviewed published cost analyses.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Each section was presented for comments and consensus approval to the Guideline Committee. Once subsections were complete, the Executive Council reviewed and commented on each section and these comments were returned to the Guideline Committee for changes and once complete, for final approval by the Executive Council.

Recommendations

Major Recommendations

The strength of evidence (A, B, C) and strength of recommendations are defined at the end of the "Major Recommendations" field.

Patients with Risk Factors for Ventricular Remodeling, Cardiac Dysfunction, and Heart Failure (HF)

  1. A careful and thorough clinical assessment, with appropriate investigation for known or potential risk factors, is recommended in an effort to prevent development of left ventricular (LV) remodeling, cardiac dysfunction, and HF. These risk factors include, but are not limited to, hypertension, hyperlipidemia, atherosclerosis, diabetes mellitus, valvular disease, obesity, physical inactivity, excessive alcohol intake, dietary choices, and smoking. (Strength of Evidence = A)
  2. The recommended goals for the management of specific risk factors for the development of cardiac dysfunction and HF are shown in the Table below.

These recommendations are based on well-documented data (Pearson et al., 2002; Arnold et al., 2003; Canadian Cardiovascular Society et al., 2008; Chobanian et al., 2003; "Third report," 2002; "Randomised trial," 2001; Bakris et al., 2003; De Backer et al., 2003; Krauss et al., 2000; Krum & McMurray, 2002; Wood, 1998; Zanchetti et al., 2001).

Table: Goals for the Management of Risk Factors for the Development of Heart Failure

Risk Factor Population Treatment Goal Strength of Evidence
Hypertension No diabetes or renal disease <140/90 mmHg A
Diabetes <130/80 mmHg A
Renal insufficiency and
> 1g/day of proteinuria
125/75 A
Renal insufficiency and
≤1 g/day of proteinuria
130/85 A
Everyone with hypertension Limit sodium to ≤1500 mg/day A
Diabetes See American Diabetes Association (ADA) Guideline    
Hyperlipidemia See National Cholesterol Education Program (NCEP) Guideline    
Physical inactivity Everyone Sustained aerobic activity 20 to 30 minutes, 3 to 5 times weekly B
Obesity Body mass index (BMI) >30 Weight reduction to achieve BMI <30 C
Excessive alcohol intake Men Limit alcohol intake to 1 to 2 drink equivalents per day C
Women 1 drink equivalent per day  
Those with propensity to abuse alcohol or with alcoholic cardiomyopathy Abstention  
Smoking Everyone Cessation A
Vitamin/mineral deficiency Everyone Diet high in K+/calcium B
Poor diet Everyone 4 or more servings of fruit and vegetables per day; one or more servings of breakfast cereal per week B
  1. Angiotensin-converting enzyme (ACE) inhibitors are recommended for prevention of HF in patients at high risk of this syndrome, including those with coronary artery disease (CAD), peripheral vascular disease, or stroke. Patients with diabetes and another major risk factor or patients with diabetes who smoke or have microalbuminuria are also at high risk and should receive ACE inhibitors. (Strength of Evidence = A)
  2. Beta-blockers are recommended for patients with prior myocardial infarction (MI) to reduce mortality, recurrent MI, and the development of HF. (Strength of Evidence = A)

Definitions:

Strength of Evidence

Hierarchy of Types of Evidence
Level A Randomized, Controlled, Clinical Trials
May be assigned based on results of a single methodologically rigorous trial
Level B Cohort and Case-Control Studies
Post hoc, subgroup analysis, and meta-analysis
Prospective observational studies or registries
Level C Expert Opinion
Observational studies – epidemiologic findings
Safety reporting from large-scale use in practice

Strength of Recommendations

"Is recommended" Part of routine care
Exceptions to therapy should be minimized.
"Should be considered" Majority of patients should receive the intervention.
Some discretion in application to individual patients should be allowed.
"May be considered" Individualization of therapy is indicated
"Is not recommended" Therapeutic intervention should not be used
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate prevention of ventricular remodeling, cardiac dysfunction, and heart failure

Potential Harms

Some interventions require appropriate patient selection and monitoring to minimize potential harms, and these are specified within the recommendations and accompanying text of the original guideline document.

Contraindications

Contraindications

Some interventions carry relative or absolute contraindications. These contraindications vary according to the specific intervention and are described in the recommendations and accompanying text of the original guideline document.

Qualifying Statements

Qualifying Statements

It must be recognized that the evidence supporting recommendations is based largely on population responses that may not always apply to individuals within the population. Therefore, data may support overall benefit of one treatment over another but cannot exclude that some individuals within the population may respond better to the other treatment. Thus, guidelines can best serve as evidence-based recommendations for management, not as mandates for management in every patient. Furthermore, it must be recognized that trial data on which recommendations are based have often been carried out with background therapy not comparable to therapy in current use. Therefore, physician decisions regarding the management of individual patients may not always precisely match the recommendations. A knowledgeable physician who integrates the guidelines with pharmacologic and physiologic insight and knowledge of the individual being treated should provide the best patient management.

Implementation of the Guideline

Description of Implementation Strategy

The value of a practice guideline is significantly influenced by the scope of its dissemination. The first and second Heart Failure Society of America (HFSA) guidelines were available on the Internet, and thousands of copies were downloaded. The current document will be implemented on the Internet both for file transfer and as a hypertext source of detailed knowledge concerning heart failure (HF).

Implementation Tools
Quick Reference Guides/Physician Guides
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Heart Failure Society of America, Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN. Prevention of ventricular remodeling, cardiac dysfunction, and heart failure: HFSA 2010 comprehensive heart failure practice guideline. J Card Fail. 2010 Jun;16(6):e38-43. [95 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1999 (revised 2010 Jun)
Guideline Developer(s)
Heart Failure Society of America, Inc - Disease Specific Society
Source(s) of Funding

Heart Failure Society of America, Inc

Guideline Committee

Heart Failure Society of America Guideline Committee

Composition of Group That Authored the Guideline

Guideline Committee Members: JoAnn Lindenfeld, MD (Chair); Nancy M. Albert, RN, PhD; John P. Boehmer, MD; Sean P. Collins, MD, MSc; Justin A. Ezekowitz, MBBCh; Michael M. Givertz, MD; Stuart D. Katz, MD; Marc Klapholz, MD; Debra K. Moser, RN, DNSc; Joseph G. Rogers, MD; Randall C. Starling, MD, MPH; William G. Stevenson, MD; W.H. Wilson Tang, MD; John R. Teerlink, MD; Mary N. Walsh, MD

Executive Council: Douglas L. Mann, MD, President; Inder S. Anand, MD; J. Malcolm O. Arnold, MD; John C. Burnett, Jr., MD; John Chin, MD; Jay N. Cohn, MD; Thomas Force, MD; Barry H. Greenberg, MD; Steven R. Houser, PhD; Mariell L. Jessup, MD; Barry M. Massie, MD; Mandeep R. Mehra, MD; Mariann R. Piano, RN, PhD; Clyde W. Yancy, MD; Michael R. Zile, MD

Financial Disclosures/Conflicts of Interest

Committee members and reviewers from the Executive Council received no direct financial support from the Heart Failure Society of America (HFSA) or any other source for the development of the guideline. Support was provided by the HFSA administrative staff, but the writing of the document was performed on a volunteer basis primarily by the Committee. Financial relationships that might represent conflicts of interest were collected annually from all members of the Guideline Committee and the Executive Council. Current relationships are shown in Appendix C of the "2010 HFSA Guideline Executive Summary" companion document (see the "Availability of Companion Documents" field).

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Heart Failure Society of America. Prevention of ventricular remodeling, cardiac dysfunction, and heart failure. J Card Fail 2006 Feb;12(1):e12-5. [57 references]

Guideline Availability

Electronic copies: Available from the Heart Failure Society of America, Inc. Web site External Web Site Policy.

Print copies: Available from the Heart Failure Society of America, Inc., Court International - Suite 240 S, 2550 University Avenue West, Saint Paul, Minnesota 55114; Phone: (651) 642-1633

Availability of Companion Documents

The following are available:

  • Heart Failure Society of America. Executive summary: The 2010 HFSA comprehensive heart failure practice guideline. J Card Fail 2010 Jun. Electronic copies: Available from the Journal of Cardiac Failure Web site External Web Site Policy.
  • Heart Failure Society of America. Development and implementation of a comprehensive heart failure practice guideline. J Card Fail 2010 Jun;16(6):e3-6. Electronic copies: Available from the Journal of Cardiac Failure Web site External Web Site Policy.
  • Heart Failure Society of America. Conceptualization and working definition of heart failure. J Card Fail 2010 Jun;16(6):e34-7. Electronic copies: Available from the Journal of Cardiac Failure Web site External Web Site Policy.
  • PowerPoint slides. HFSA 2010 comprehensive heart failure guideline. Electronic copies: Available from the Heart Failure Society of America, Inc. Web site External Web Site Policy.

Print copies: Available from the Heart Failure Society of America, Inc., Court International - Suite 240 South, 2550 University Avenue West, Saint Paul, Minnesota 55114; Phone: (651) 642-1633

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on July 31, 2006. The information was verified by the guideline developer on August 10, 2006. This NGC summary was updated by ECRI Institute on October 11, 2010. The updated information was verified by the guideline developer on November 23, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please direct inquiries to info@hfsa.org.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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