ACC Heart Failure Guidelines

Slide Deck
Based on the ACC/AHA 2005 Guideline Update
for the Diagnosis and Management of
Chronic Heart Failure in the Adult
January 2006

Supported by Medtronic, Inc.

Medtronic, Inc. was not involved in the development of this
slide deck and in no way influenced its contents.

ACC/AHA 2005 Guideline Update for the

Management of Patients With Chronic Heart
Failure in the Adult
Writing Committee Members
Sharon Ann Hunt, MD, FACC, FAHA, Chair
William T. Abraham, MD, FACC, FAHA

Donna M. Mancini, MD

Marshall H. Chin, MD, MPH, FACP

Keith Michl, MD, FACP

Arthur M. Feldman, MD, PhD, FACC,

FAHA

John A. Oates, MD, FAHA

Gary S. Francis, MD, FACC, FAHA

Theodore G. Ganiats, MD

Peter S. Rahko, MD, FACC, FAHA

Marc A. Silver, MD, FACC, FAHA

Mariell Jessup, MD, FACC, FAHA

Lynne Warner Stevenson, MD, FACC,

FAHA

Marvin A. Konstam, MD, FACC

Clyde W. Yancy, MD, FACC, FAHA

Applying Classification of
Recommendations and Level of Evidence
Class I

Class IIa

Class IIb

Class III

Benefit >>> Risk

Benefit >> Risk

Additional studies with
focused objectives
needed

Benefit Risk
Additional studies with
broad objectives
needed; Additional
registry data would be
helpful

Risk Benefit
No additional studies
needed

Procedure/ Treatment
SHOULD be
performed/
administered

IT IS REASONABLE to
perform
procedure/administer
treatment

should
is recommended
is indicated
is useful/effective/
beneficial

is reasonable
can be useful/effective/
beneficial
is probably recommended
or indicated

Procedure/Treatment
MAY BE CONSIDERED

may/might be considered
may/might be reasonable
usefulness/effectiveness is
unknown
/unclear/uncertain or not
well established

Procedure/Treatment
should NOT be
performed/administered
SINCE IT IS NOT
HELPFUL AND MAY BE
HARMFUL

is not recommended
is not indicated
should not
is not
useful/effective/beneficial
may be harmful

Applying Classification of
Recommendations and Level of Evidence
Level A
Multiple (3-5)
population risk
strata
evaluated
General
consistency of
direction and
magnitude of
effect

Class I

Class IIa

Recommen Recommendation that

dation in
procedure or
favor of
treatment is
treatment or
useful/
procedure
effective
being useful/
Sufficient
effective
evidence
Some
from multiple
conflicting
randomized
evidence
trials or meta- from multiple
analyses
randomized
trials or metaanalyses

Class IIb

Class III

Recommen Recommendations
dation that
usefulness/
procedure or
efficacy less
treatment not
well
useful/effectiv
established
e and may be
Greater
harmful
conflicting
Sufficient
evidence from
evidence from
multiple
multiple
randomized
randomized
trials or metatrials or metaanalyses
analyses

Applying Classification of
Recommendations and Level of Evidence
Level B
Limited (2-3)
population risk
strata
evaluated

Class I

Class IIa

Class IIb

Recommen Recommen Recommendations

dation that
dation in favor
usefulness/
procedure or
of treatment or
efficacy less
treatment is
procedure
well
useful/effectiv being useful/
established
e
effective
Greater
Limited
Some
conflicting
evidence
conflicting
evidence from
from single
evidence from
single
randomized
single
randomized
trial or nonrandomized
trial or nonrandomized
trial or nonrandomized
studies
randomized
studies
studies

Class III
Recommendation that
procedure or
treatment not
useful/effectiv
e and may be
harmful
Limited
evidence from
single
randomized
trial or nonrandomized
studies

Applying Classification of
Recommendations and Level of Evidence
Level C
Very limited (12) population
risk strata
evaluated

Class I
Recommendation that
procedure or
treatment is
useful/
effective
Only expert
opinion, case
studies, or
standard-ofcare

Class IIa

Class IIb

Class III

Recommen Recommen Recommenddation in favor

dations
ation that
of treatment or
usefulness/
procedure or
procedure
efficacy less
treatment not
being
well
useful/effectiv
useful/effectiv
established
e and may be
e
Only diverging
harmful
Only diverging
expert opinion, Only expert
expert opinion,
case studies,
opinion, case
case studies,
or standard-ofstudies, or
or standard-ofcare
standard-ofcare
care

Heart Failure is a Major and Growing Public

Health Problem in the U.S.

Approximately 5 million patients in this country have

HF

Over 550,000 patients are diagnosed with HF for the

first time each year

Primary reason for 12 to 15 million office visits and

6.5 million hospital days each year

In 2001, nearly 53,000 patients died of HF as a

primary cause

Heart Failure is Primarily a

Condition of the Elderly

The incidence of HF approaches 10 per 1000

population after age 65

HF is the most common Medicare diagnosisrelated group

More dollars are spent for the diagnosis and

treatment of HF than any other diagnosis by
Medicare

Guideline Scope
Document focuses on :

Prevention of HF

Diagnosis and management of

chronic HF in the adult

Definition of Heart Failure

HF is a complex clinical syndrome that can

result from any structural or functional
cardiac disorder that impairs the ability of
the ventricle to fill with or eject blood.

Heart Failure vs. Congestive Heart Failure

Because not all patients have volume overload at

the time of initial or subsequent evaluation, the
term heart failure is preferred over the older
term congestive heart failure.

Causes of HF in Western World

For a substantial proportion of patients,

causes are:
1.

Coronary artery disease

2.

Hypertension

3.

Dilated cardiomyopathy

Stages of Heart Failure

At Risk for Heart Failure:

STAGE A High risk for developing HF
STAGE B Asymptomatic LV dysfunction
Heart Failure:
STAGE C Past or current symptoms of HF
STAGE D End-stage HF

Stages of Heart Failure

Designed to emphasize preventability of HF

Designed to recognize the progressive
nature of LV dysfunction

Stages of Heart Failure

COMPLEMENT, DO NOT REPLACE NYHA
CLASSES

NYHA Classes - shift back/forth in individual

patient (in response to Rx and/or progression of
disease)

Stages - progress in one direction due to cardiac

remodeling

Stage A
Patients at High Risk for
Developing Heart Failure

Stage A Therapy
Recommended Therapies to Reduce Risk Include:
Treating known risk factors (hypertension, diabetes, etc.)
with therapy consistent with contemporary guidelines
Avoiding behaviors increasing risk (i.e., smoking
excessive consumption of alcohol, illicit drug use)
Periodic evaluation for signs and symptoms of HF
Ventricular rate control or sinus rhythm restoration
Noninvasive evaluation of LV function
Drug therapy
Angiotensin Converting Enzyme Inhibitors (ACEI)
Angiotensin Receptor Blockers (ARBs)

Stage A Therapy
Using Therapy Consistent with
Contemporary Guidelines
I IIa IIb III

In patients at high risk for developing HF,

systolic and diastolic hypertension should be
controlled in accordance with contemporary
guidelines.

I IIa IIb III

In patients at high risk for developing HF, lipid

disorders should be treated in accordance
with contemporary guidelines.

Stage A Therapy
Using Therapy Consistent with
Contemporary Guidelines
I IIa IIb III

In patients at high risk for developing HF who

have known atherosclerotic vascular disease,
healthcare providers should follow current
guidelines for secondary prevention.

I IIa IIb III

For patients with diabetes mellitus (who are all

at high risk for developing HF), blood sugar
should be controlled in accordance with
contemporary guidelines.

Stage A Therapy
Using Therapy Consistent with
Contemporary Guidelines
I IIa IIb III

Thyroid disorders should be treated in

accordance with contemporary guidelines in
patients at high risk for developing HF.

Stage A Therapy
Avoiding Behaviors That
Increase Risk
I IIa IIb III

Patients at high risk for developing HF should

be counseled to avoid behaviors that may
increase the risk of HF (e.g., smoking,
excessive alcohol consumption, and illicit
drug use).

Stage A Therapy
Periodic Evaluation for
Signs and Symptoms
I IIa IIb III

Healthcare providers should perform periodic

evaluation for signs and symptoms of HF in
patients at high risk for developing HF.

Stage A Therapy
Ventricular Rate Control or Sinus
Rhythm Restoration
I IIa IIb III

Ventricular rate should be controlled or sinus

rhythm restored in patients with
supraventricular tachyarrhythmias who are at
high risk for developing HF.

Stage A Therapy
Noninvasive Evaluation of
LV Function
I IIa IIb III

Healthcare providers should perform a

noninvasive evaluation of LV function (i.e.,
LVEF) in patients with a strong family history
of cardiomyopathy or in those receiving
cardiotoxic interventions.

Stage A Therapy
Angiotensin Converting Enzyme
Inhibitors (ACEI)
I IIa IIb III

ACEI can be useful to prevent HF in patients at

high risk for developing HF who have a history of
atherosclerotic vascular disease, diabetes
mellitus, or hypertension with associated
cardiovascular risk factors.

Stage A Therapy
Angiotension Receptor Blockers
(ARBs)
I IIa IIb III

ARBs can be useful to prevent HF in patients

at high risk for developing HF who have a
history of atherosclerotic vascular disease,
diabetes mellitus, or hypertension with
associated cardiovascular risk factors.

Stage A Therapy
Therapies NOT Recommended
I IIa IIb III

Routine use of nutritional supplements solely

to prevent the development of structural heart
disease should not be recommended for
patients at high risk for developing HF.

Stage B
Patients with Asymptomatic
LV Dysfunction

Stage B Therapy
Recommended Therapies:
General Measures as advised for Stage A
Drug therapy for all patients
ACEI or ARBs
Beta-Blockers
ICDs in appropriate patients
Coronary revascularization in appropriate patients
Valve replacement or repair in appropriate patients

Stage B Therapy
General Measures
I IIa IIb III

All Class I recommendations for Stage A

should apply to patients with cardiac
structural abnormalities who have not
developed HF. (Levels of Evidence: A, B, and
C as appropriate)

I IIa IIb III

Patients who have not developed HF

symptoms should be treated according to
contemporary guidelines after an acute MI.

Stage B Therapy
Angiotensin Converting Enzyme
Inhibitors (ACEI)
I IIa IIb III

I IIa IIb III

I IIa IIb III

Beta-blockers and ACEIs should be used in all

patients with a recent or remote history of MI
regardless of EF or presence of HF.
ACEI should be used in patients with a reduced EF
and no symptoms of HF, even if they have not
experienced MI.
ACEI or ARBs can be beneficial in patients with
hypertension and LVH and no symptoms of HF.

Stage B Therapy
Angiotensin Receptor Blockers
(ARBs)
I IIa IIb III

An ARB should be administered to post-MI patients

without HF who are intolerant of ACEIs and have a
low LVEF.
I IIa IIb III

I IIa IIb III

ACEIs or ARBs can be beneficial in patients with

hypertension and LVH and no symptoms of HF.
ARBs can be beneficial in patients with low EF and
no symptoms of HF who are intolerant of ACEIs.

Stage B Therapy
Beta-Blockers
I IIa IIb III

Beta-blockers and ACEIs should be used in all

patients with a recent or remote history of MI
regardless of EF or presence of HF.

I IIa IIb III

Beta-blockers are indicated in all patients

without a history of MI who have a reduced
LVEF with no HF symptoms.

Stage B Therapy
Internal Cardioverter Defibrillator (ICD)
I IIa IIb III

Placement of an ICD is reasonable in patients with

ischemic cardiomyopathy who are at least 40 days
post-MI, have an LVEF of 30% or less, are NYHA
functional class I on chronic optimal medical therapy,
and have reasonable expectation of survival with a
good functional status for more than 1 year.

I IIa IIb III

Placement of an ICD might be considered in patients

without HF who have nonischemic cardiomyopathy
and an LVEF less than or equal to 30% who are in
NYHA functional class I with chronic optimal medical
therapy and have a reasonable expectation of survival
with good functional status for more than 1 year.

Stage B Therapy
Coronary Revascularization
I IIa IIb III

Coronary revascularization should be

recommended in appropriate patients
without symptoms of HF in accordance
with contemporary guidelines (see
ACC/AHA Guidelines for the Management
of Patients With Chronic Stable Angina).

Stage B Therapy
Valve Replacement/Repair
I IIa IIb III

Valve replacement or repair should be

recommended for patients with
hemodynamically significant valvular
stenosis or regurgitation and no
symptoms of HF in accordance with
contemporary guidelines.

Stage B Therapy
Therapies NOT Recommended
I IIa IIb III

I IIa IIb III

I IIa IIb III

Digoxin should not be used in patients with low EF,

sinus rhythm, and no history of HF symptoms,
because in this population, the risk of harm is not
balanced by any known benefit.
Use of nutritional supplements to treat structural
heart disease or to prevent the development of
symptoms of HF is not recommended.
Calcium channel blockers with negative inotropic
effects may be harmful in asymptomatic patients
with low LVEF and no symptoms of HF after MI.

Stage C

Patients with Past or Current

Symptoms of Heart Failure

Stage C Therapy
(Reduced LVEF with Symptoms)

Recommended Therapies:
General measures as advised for Stages A and B
Drug therapy for all patients
Diuretics for fluid retention
ACEI
Beta-blockers
Drug therapy for selected patients
Aldosterone Antagonists
ARBs
Digitalis
Hydralazine/nitrates
ICDs in appropriate patients
Cardiac resynchronization in appropriate patients
Exercise Testing and Training

Stage C Therapy
(Reduced LVEF with Symptoms)

General Measures
I IIa IIb III

Measures listed as Class I recommendations for

patients in stages A and B are also appropriate for
patients in Stage C. (Levels of Evidence: A, B, and C as
appropriate)

I IIa IIb III

Drugs known to adversely affect the clinical status of

patients with current or prior symptoms of HF and
reduced LVEF should be avoided or withdrawn
whenever possible (e.g., nonsteroidal anti-inflammatory
drugs, most antiarrhythmic drugs, and most calcium
channel blocking drugs).

Stage C Therapy
(Reduced LVEF with Symptoms)

Diuretics
I IIa IIb III

Diuretics and salt restriction are indicated in

patients with current or prior symptoms of HF
and reduced LVEF who have evidence of fluid
retention.

Stage C Therapy
(Reduced LVEF with Symptoms)

Angiotensin Enzyme Converting

Inhibitors (ACEIs)
I IIa IIb III

I IIa IIb III

ACEIs are recommended for all patients with

current or prior symptoms of HF and reduced
LVEF, unless contraindicated.
Routine combined use of an ACEI, ARB, and
aldosterone antagonist is not recommended for
patients with current or prior symptoms of HF
and reduced LVEF.

Stage C Therapy
(Reduced LVEF with Symptoms)

Angiotensin Receptor Blockers (ARBs)

I IIa IIb III

ARBs approved for the treatment of HF are

recommended in patients with current or prior
symptoms of HF and reduced LVEF who are ACEIintolerant (see full text guidelines for information
regarding patients with angioedema).

I IIa IIb III

ARBs are reasonable to use as alternatives to ACEIs

as first-line therapy for patients with mild to
moderate HF and reduced LVEF, especially for
patients already taking ARBs for other indications.

Stage C Therapy
(Reduced LVEF with Symptoms)

ARBs (contd)
I IIa IIb III

I IIa IIb III

The addition of an ARB may be considered in

persistently symptomatic patients with reduced
LVEF who are already being treated with
conventional therapy.
Routine combined use of an ACEI, ARB, and
aldosterone antagonist is not recommended for
patientswith current or prior symptoms of HF and
reduced LVEF.

Stage C Therapy
(Reduced LVEF with Symptoms)

Aldosterone Antagonists
I IIa IIb III

I IIa IIb III

Addition of an aldosterone antagonist is recommended in

selected patients with moderately severe to severe
symptoms of HF and reduced LVEF who can be
carefully monitored for preserved renal function and
normal potassium concentration. Creatinine should be
less than or equal to 2.5 mg/dL in men or less than or
equal to 2.0 mg/dL in women and potassium should be
less than 5.0 mEq/L. Under circumstances where
monitoring for hyperkalemia or renal dysfunction is not
anticipated to be feasible, the risks may outweigh the
benefits of aldosterone antagonists.
Routine combined use of an ACEI, ARB, and aldosterone
antagonist is not recommended for patients with current
or prior symptoms of HF and reduced LVEF.

Stage C Therapy
(Reduced LVEF with Symptoms)

Beta-Blockers
I IIa IIb III

Beta-blockers (using 1 of the 3 proven to reduce

mortality, i.e., bisoprolol, carvedilol, and sustained
release metoprolol succinate) are recommended for
all stable patients with current or prior symptoms of
HF and reduced LVEF, unless contraindicated.

Stage C Therapy
(Reduced LVEF with Symptoms)

Digitalis
I IIa IIb III

Digitalis can be beneficial in patients with

current or prior symptoms of HF and reduced
LVEF to decrease hospitalizations for HF.

Stage C Therapy
(Reduced LVEF with Symptoms)

Hydralazine and Isosorbide Dinitrate

I IIa IIb III

The addition of a combination of hydralazine and a

nitrate is reasonable for patients with reduced
LVEF who are already taking an ACEI and betablocker for symptomatic HF and who have
persistent symptoms.

I IIa IIb III

A combination of hydralazine and a nitrate might be

reasonable in patients with current or prior
symptoms of HF and reduced LVEF who cannot be
given an ACEI or ARB because of drug intolerance,
hypotension, or renal insufficiency.

Stage C Therapy
(Reduced LVEF with Symptoms)

Implantable CardioverterDefibrillators (ICDs)

I IIa IIb III

I IIa IIb III

An ICD is recommended as secondary prevention to

prolong survival in patients with current or prior
symptoms of HF and reduced LVEF who have a history of
cardiac arrest, ventricular fibrillation, or hemodynamically
destabilizing ventricular tachycardia.
ICD therapy is recommended for primary prevention to
reduce total mortality by a reduction in sudden cardiac
death in patients with ischemic heart disease who are at
least 40 days post-MI, have an LVEF less than or equal to
30%, with NYHA functional class II or III symptoms while
undergoing chronic optimal medical therapy, and have
reasonable expectation of survival with a good functional
status for more than 1 year.

Stage C Therapy
(Reduced LVEF with Symptoms)

ICDs (contd)
I IIa IIb III

ICD therapy is recommended for primary prevention to

reduce total mortality by a reduction in sudden cardiac
death in patients with nonischemic cardiomyopathy who
have an LVEF less than or equal to 30%, with NYHA
functional class II or III symptoms while undergoing
chronic optimal medical therapy, and who have
reasonable expectation of survival with a good functional
status for more than 1 year.

I IIa IIb III

Placement of an ICD is reasonable in patients with LVEF

of 30% to 35% of any origin with NYHA functional class II
or III symptoms who are taking chronic optimal medical
therapy and who have reasonable expectation of survival
with good functional status of more than 1 year.

Stage C Therapy
(Reduced LVEF with Symptoms)

Cardiac Resynchronization
I IIa IIb III

Patients with LVEF less than or equal to 35%, sinus

rhythm, and NYHA functional class III or ambulatory
class IV symptoms despite recommended, optimal
medical therapy and who have cardiac
dyssynchrony, which is currently defined as a QRS
duration greater than 120 ms, should receive
cardiac
resynchronization therapy unless contraindicated.

Stage C Therapy
(Reduced LVEF with Symptoms)

Exercise Testing and Training

I IIa IIb III

Maximal exercise testing with or without

measurement of respiratory gas exchange is
recommended to facilitate prescription of an
appropriate exercise program for patients
presenting with HF.

I IIa IIb III

Exercise training is beneficial as an adjunctive

approach to improve clinical status in ambulatory
patients with current or prior symptoms of HF and
reduced LVEF.

Stage C Therapy
(Reduced LVEF with Symptoms)

Unproven/Not Recommended
Drugs and Interventions for HF
Nutritional

Supplements

Hormonal Therapies
Intermittent Intravenous
Positive Inotropic Therapy

Stage C Therapy
(Reduced LVEF with Symptoms)

Unproven/Not Recommended Drugs and Interventions

I IIa IIb III

Long-term use of an infusion of a positive inotropic

drug may be harmful and is not recommended for
patients with current or prior symptoms of HF and
reduced LVEF, except as palliation for patients with
end-stage disease who cannot be stabilized with
standard medical treatment (see recommendations
for Stage D).

I IIa IIb III

Use of nutritional supplements as treatment for HF

is not indicated in patients with current or prior
symptoms of HF and reduced LVEF.

Stage C Therapy
(Reduced LVEF with Symptoms)

Unproven/Not Recommended Drugs and Interventions

I IIa IIb III

Calcium channel blocking drugs are not indicated

as
routine treatment for HF in patients with current or
prior symptoms of HF and reduced LVEF.

I IIa IIb III

Hormonal therapies other than to replete

deficiencies are not recommended and may be
harmful to patients with current or prior symptoms
of HF and reduced LVEF.
I IIa IIb III

Routine combined use of an ACEI, ARB, and

aldosterone antagonist is not recommended for
patientswith current or prior symptoms of HF and
reduced LVEF.

Stage C Therapy
(Normal LVEF with Symptoms)

Recommended Therapies for Routine Use:

Treating known risk factor (hypertension) with therapy
consistent with contemporary guidelines
Ventricular rate control for all patients
Drugs for all patients Diuretics
Drugs for appropriate patients
ACEI
ARBs
Beta-Blockers
Digitalis
Coronary revascularization in selected patients
Restoration/maintenance of sinus rhythm in
appropriate patients

Differential Diagnosis in Patient with HF and

Normal LVEF with Symptoms

Incorrect diagnosis of HF
Inaccurate measurement of
LVEF
Primary valvular disease
Restrictive (infiltrative)
cardiomyopathies
Amyloidosis, sarcoidosis,
hemochromatosis
Pericardial constriction
Episodic or reversible LV
systolic dysfunction
Severe hypertension,
myocardial ischemia

HF associated with high

metabolic demand (highoutput states)
Anemia, thyrotoxicosis,
arteriovenous fistulae
Chronic pulmonary
disease with right HF
Pulmonary hypertension
associated with
pulmonary vascular
disorders
Atrial myxoma
Diastolic dysfunction of
uncertain origin
Obesity

Stage C Therapy
(Normal LVEF with Symptoms)

Treating known risk factors Hypertension

I IIa IIb III

Physicians should control systolic and

diastolic hypertension in patients with HF and
normal LVEF, in accordance with published
guidelines.

Stage C Therapy
(Normal LVEF with Symptoms)

Ventricular Rate Control

I IIa IIb III

Physicians should control ventricular rate in

patients with HF and normal LVEF and atrial
fibrillation.

Stage C Therapy
(Normal LVEF with Symptoms)

Diuretics
I IIa IIb III

Physicians should use diuretics to control

pulmonary congestion and peripheral edema in
patients with HF and normal LVEF.

Stage C Therapy
(Normal LVEF with Symptoms)

Coronary Revascularization
I IIa IIb III

Coronary revascularization is reasonable in

patients with HF and normal LVEF and
coronary artery disease in whom symptomatic
or demonstrable myocardial ischemia is
judged to be having an adverse effect on
cardiac function.

Stage C Therapy
(Normal LVEF with Symptoms)

Restoration/Maintenance
of Sinus Rhythm
I IIa IIb III

Restoration and maintenance of sinus rhythm

in patients with atrial fibrillation and HF and
normal LVEF might be useful to improve
symptoms.

Stage C Therapy
(Normal LVEF with Symptoms)

Angiotensin Enzyme Converting

Inhibitors (ACEIs)
I IIa IIb III

The use of beta-adrenergic blocking agents, ACEIs,

ARBs, or calcium antagonists in patients with HF
and normal LVEF and controlled hypertension might
be effective to minimize symptoms of HF.

Stage C Therapy
(Normal LVEF with Symptoms)

Angiotensin Receptor Blockers (ARBs)

I IIa IIb III

The use of beta-adrenergic blocking agents, ACEIs,

ARBs, or calcium antagonists in patients with HF
and normal LVEF and controlled hypertension might
be effective to minimize symptoms of HF.

Stage C Therapy
(Normal LVEF with Symptoms)

Beta-Blockers
I IIa IIb III

The use of beta-adrenergic blocking agents, ACEIs,

ARBs, or calcium antagonists in patients with HF
and normal LVEF and controlled hypertension might
be effective to minimize symptoms of HF.

Stage C Therapy
(Normal LVEF with Symptoms)

Digitalis
I IIa IIb III

The usefulness of digitalis to minimize

symptoms of HF in patients with HF and normal
LVEF is not well established.

Stage D
Patients with Refractory End-Stage HF

Stage D Therapy
Recommended Therapies Include:
Control of fluid retention
Referral to a HF program for appropriate pts
Discussion of options for end-of-life care
Informing re: option to inactivate defibrillator
Device use in appropriate patients
Surgical therapy
Cardiac transplantation
Mitral valve repair or replacement
Other
Drug Therapy
Positive inotrope infusion as palliation
in appropriate patients

Stage D Therapy
Control of Fluid
Retention
I IIa IIb III

Meticulous identification and control of fluid

retention is recommended in patients with
refractory end-stage HF.

Stage D Therapy
Referral to an HF Program
I IIa IIb III

Referral of patients with refractory end-stage

HF to an HF program with expertise in the
management of refractory HF is useful.

Stage D Therapy
Discussion of Options for
End-of-Life Care
I IIa IIb III

Options for end-of-life care should be

discussed with the patient and family when
severe symptoms in patients with refractory
end-stage HF persist despite application of all
recommended therapies.

Stage D Therapy
Inform on option to
inactivate defibrillation
I IIa IIb III

Patients with refractory end-stage HF and

implantable defibrillators should receive
information about the option to inactivate
defibrillation.

Stage D Therapy
Surgical Therapy
I IIa IIb III

Referral for cardiac transplantation in

potentially eligible patients is recommended for
patients with refractory end-stage HF.

I IIa IIb III

The effectiveness of mitral valve repair or

replacement is not established for severe
secondary mitral regurgitation in refractory
end-stage HF.

Stage D Therapy
Device Use
I IIa IIb III

I IIa IIb III

Consideration of an LV assist device as

permanentor destination therapy is
reasonable in highly selected patients with
refractory end-stage HF and an estimated
1-year mortality over 50% with medical therapy.
Pulmonary artery catheter placement may be
reasonable to guide therapy in patients with
refractory end-stage HF and persistently severe
symptoms.

Stage D Therapy
Medical Therapy
I IIa IIb III

Continuous intravenous infusion of a positive

inotropic agent may be considered for
palliation of symptoms in patients with
refractory end-stage HF.

I IIa IIb III

Routine intermittent infusions of positive

inotropic agents are not recommended for
patients with refractory end-stage HF.

Stage D Therapy
Therapies NOT Recommended
I IIa IIb III

I IIa IIb III

Partial left ventriculectomy is not

recommended inpatients with nonischemic
cardiomyopathy and refractory end-stage HF.
Routine intermittent infusions of positive
inotropic agents are not recommended for
patients with refractory end-stage HF.