By AMERICAN HEART ASSOCIATION NEWS
Doctors may now be able to test people early and prevent them from developing heart failure, according to an updated guideline published Friday by three leading U.S. heart organizations.
“For the first time, we really believe the data are in hand to inform how we might best prevent this disease,” said Clyde Yancy, M.D. chair of the guideline’s writing committee, which included representatives of the American College of Cardiology, American Heart Association and the Heart Failure Society of America.
“Preventing the progression to symptomatic heart failure is incredibly important.”
Heart failure occurs when the heart cannot pump enough blood through the body. The condition can develop slowly over time or it can appear suddenly. It can result from a heart attack, high blood pressure, heart valve disease or coronary heart disease.
One way physicians can prevent heart failure in people at risk is through a blood test for natriuretic peptides, substances released by the body when the heart is damaged. The test, along with a physical exam and supplemental testing, can guide early treatments that may help prevent problems with the left ventricle and heart failure symptoms. “Once patients have any symptoms of heart failure, their prognosis is fundamentally different,” said Yancy, a heart failure expert and chief of cardiology at Northwestern University Feinberg School of Medicine in Evanston, Illinois.
Only half of all people diagnosed with heart failure survive more than five years.
Another recommendation to prevent acute heart failure calls for lowering high blood pressure below 130/80 mm Hg. Nearly a quarter of people diagnosed with acute heart failure, which requires hospitalization, die within one year.
Heart failure is on the rise. Nearly 6 million U.S. adults live with it now, and by 2030 the number could grow to more than 8 million.
“The aging U.S. population plays a part, with heart failure doubling with each decade of life,” said Kenneth Margulies, M.D. professor of medicine at the Hospital of the University of Pennsylvania in Philadelphia. “This is because more patients with various cardiovascular diseases are living longer, including people with established heart failure.”
The guideline update, which published Friday in the online edition of the AHA journal Circulation, recommends tests and medications to better manage patients already diagnosed with heart failure, a complex condition that can be difficult to treat.
“There are many important and complicated aspect(s) to the evaluation and management of patients with advanced heart failure,” said Margulies, also director of Heart Failure and Transplant Research at Penn. “These patients have high symptom burdens and disability along with high rates of hospitalization and mortality.”
Several recent studies have led to updates to evidence-based guidelines that will clearly influence practice and ultimately improve outcomes for patients, he said.
One change, originally published by the ACC/AHA/HFSA last year, resulted from a 2014 research trial that found that a drug that combines an angiotensin blocker and neprilysin inhibitor lowered the risk of hospitalization and death by 20 percent in heart failure patients with reduced ejection fraction, compared to those who took a common heart failure drug alone. The ejection fraction is the amount of blood the heart pumps out during each heartbeat. The FDA approved the combination drug, sold as ENTRESTO, in 2015.
A test for natriuretic peptides: either B-type natriuretic peptide or N-terminal pro-B-type natriuretic peptide can also be used to track the severity of heart failure.
Treating underlying high blood pressure, sleep disorders and anemia are beneficial to the well-being of heart failure patients, according to the guidelines.
The guidelines recommend lowering systolic blood pressure to less than 130 mm Hg. Systolic blood pressure, the top number of a blood pressure reading, reflects the pressure blood exerts against the artery walls when the heart beats.
Controlling anemia with intravenous iron injections is also recommended to improve patient function and quality of life.
For those with heart failure and excessive sleepiness, a sleep study is recommended, along with a device that provides continuous positive airway pressure, commonly known as CPAP, for obstructive sleep apnea. CPAP will improve sleep quality, which is important to quality of life for heart failure patients. But it won’t necessarily help their heart failure symptoms. Sleep disorders affect obesity, high blood pressure, Type 2 diabetes and overall cardiovascular disease, according to a 2016 statement.
According to guidelines, it’s important to distinguish OSA from central sleep apnea, when the brain doesn’t send signals to the muscles to breathe. Central sleep apnea can result from heart failure. The use of adaptive servo-ventilation, a type of breathing support device used to treat central sleep apnea, can be harmful to heart failure patients and should not be used, according to the guideline.
In addition to the new, evidence-based recommendations, the expedited process used to create the guideline update is noteworthy, said Yancy.
A new fast-paced approach helped guideline developers drastically reduce the amount of time needed to translate research results into practical recommendations — from years to months.
Yancy said most guidelines take at least two years from start to finish, including the previous 2013 heart failure guidelines. Keeping the focus on several, very specific objectives allowed the group to develop the current update in only eight months, he said.
“It demonstrates that indeed what we always hoped is possible: that the guideline process can be nimble, it can be dynamic, it can accommodate important new information in a timely way,” he said. This means patients can benefit sooner.
“If there is an intent of the guidelines process to be clear, to represent strong consensus viewpoints, either in the view of the data or the opinions about clinical care, I won’t say mission accomplished, but mission pretty close to being accomplished,” Yancy said.