ACC/AHA 2009 focused update of HF guidelines

2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and
Management of Heart Failure in Adults: A Report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines Developed in Collaboration With the International Society for
Heart and Lung Transplantation
Mariell Jessup, William T. Abraham, Donald E. Casey, Arthur M. Feldman, Gary S.
Francis, Theodore G. Ganiats, Marvin A. Konstam, Donna M. Mancini, Peter S.
Rahko, Marc A. Silver, Lynne Warner Stevenson, and Clyde W. Yancy
J. Am. Coll. Cardiol. 2009;53;1343-1382; originally published online Mar 26, 2009;

doi:10.1016/j.jacc.2008.11.009
This information is current as of December 28, 2011
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://content.onlinejacc.org/cgi/content/full/53/15/1343

Downloaded from content.onlinejacc.org by on December 28, 2011

Journal of the American College of Cardiology Vol. 53, No. 15, 2009
© 2009 by the American College of Cardiology Foundation and the American Heart Association, Inc. ISSN 0735-1097/09/$36.00
Published by Elsevier Inc. doi:10.1016/j.jacc.2008.11.009

PRACTICE GUIDELINE: FOCUSED UPDATE

2009 Focused Update: ACCF/AHA Guidelines for the
Diagnosis and Management of Heart Failure in Adults
A Report of the American College of Cardiology Foundation/American Heart Association Task Force
on Practice Guidelines
Developed in Collaboration With the International Society for Heart and Lung Transplantation

2009 Writing Group to Review New Evidence and Update the
2005 Guideline for the Management of Patients With Chronic Heart Failure
Writing on Behalf of the 2005 Heart Failure Writing Committee

Mariell Jessup, MD, FACC, FAHA, Chair* Marc A. Silver, MD, FACC, FAHA**
Lynne Warner Stevenson, MD, FACC, FAHA†
William T. Abraham, MD, FACC, FAHA† Clyde W. Yancy, MD, FACC, FAHA††
Donald E. Casey, MD, MPH, MBA‡
Arthur M. Feldman, MD, PHD, FACC, FAHA§ *International Society for Heart and Lung Transplantation Representative; †Amer-
ican College of Cardiology Foundation/American Heart Association Representative;
Gary S. Francis, MD, FACC, FAHA§ ‡American College of Physicians Representative; §Heart Failure Society of America
Theodore G. Ganiats, MD Representative; American Academy of Family Physicians Representative; ¶American
College of Cardiology Foundation/American Heart Association Performance Mea-
Marvin A. Konstam, MD, FACC¶
sures Liaison; #Content Expert; **American College of Chest Physicians Represen-
Donna M. Mancini, MD# tative; ††American College of Cardiology Foundation/American Heart Association
Peter S. Rahko, MD, FACC, FAHA† Task Force on Practice Guidelines Liaison

2005 Writing Sharon Ann Hunt, MD, FACC, FAHA, Mariell Jessup, MD, FACC, FAHA
Committee Chair Marvin A. Konstam, MD, FACC
Members
Donna M. Mancini, MD
William T. Abraham, MD, FACC, FAHA Keith Michl, MD, FACP
Marshall H. Chin, MD, MPH, FACP John A. Oates, MD, FAHA
Arthur M. Feldman, MD, PHD, FACC, Peter S. Rahko, MD, FACC, FAHA
FAHA Marc A. Silver, MD, FACC, FAHA
Gary S. Francis, MD, FACC, FAHA Lynne Warner Stevenson, MD, FACC, FAHA
Theodore G. Ganiats, MD Clyde W. Yancy, MD, FACC, FAHA

This document is a limited update to the 2005 guideline update and is based on a failure in adults: a report of the American College of Cardiology/American Heart
review of certain evidence, not a full literature review. This document was approved Association Task Force on Practice Guidelines. J Am Coll Cardiol 2009;53:1343– 82.
by the American College of Cardiology Foundation Board of Trustees and by the This article has been copublished in the April 14, 2009, issue of Circulation.
American Heart Association Science Advisory and Coordinating Committee in Copies: This document is available on the World Wide Web sites of the
October 2008. American College of Cardiology (www.acc.org) and American Heart Association
The American College of Cardiology Foundation requests that this document be (my.americanheart.org). For copies of this document, please contact Elsevier Inc.
cited as follows: Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Reprint Department, fax (212) 633-3820, e-mail reprints@elsevier.com.
Ganiats TG, Konstam MA, Mancini DM, Rahko PS, Silver MA, Stevenson LW, Permissions: Multiple copies, modiﬁcation, alteration, enhancement, and/or dis-
Yancy CW, writing on behalf of the 2005 Guideline Update for the Diagnosis and tribution of this document are not permitted without the express permission of the
Management of Chronic Heart Failure in the Adult Writing Committee. 2009 American College of Cardiology Foundation. Please contact Elsevier’s permission
focused update: ACCF/AHA guidelines for the diagnosis and management of heart department at healthpermissions@elsevier.com.


1344 Jessup et al. JACC Vol. 53, No. 15, 2009
2009 Guideline Focused Update on Heart Failure April 14, 2009:1343–82

Task Force Sidney C. Smith, JR, MD, FACC, FAHA, Chair Bruce W. Lytle, MD, FACC, FAHA‡‡
Members Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair Rick A. Nishimura, MD, FACC, FAHA
Richard L. Page, MD, FACC, FAHA
Christopher E. Buller, MD, FACC Lynn G. Tarkington, RN
Mark A. Creager, MD, FACC, FAHA Clyde W. Yancy, MD, FACC, FAHA
Steven M. Ettinger, MD, FACC
‡‡Former Task Force member during the writing effort
Harlan M. Krumholz, MD, FACC, FAHA
Frederick G. Kushner, MD, FACC, FAHA

6. Patients With Heart Failure Who Have
TABLE OF CONTENTS Concomitant Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1369

Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1344 6.1.3. Supraventricular Arrhythmias . . . . . . . . . . . . . . . . . . . . . . .1369
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1370
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1346
Appendix 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1379
1.1. Evidence Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1346
1.2. Organization of Committee and Relationships
Appendix 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1380
With Industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1347
1.3. Review and Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1347
1.4. Stages of Heart Failure: Information
From the 2005 Guideline . . . . . . . . . . . . . . . . . . . . . . . . . .1347 Preamble
3. Initial and Serial Clinical Assessment of Patients
Presenting With Heart Failure . . . . . . . . . . . . . . . . . . . . . . . .1348 A primary challenge in the development of clinical practice
guidelines is keeping pace with the stream of new data on
3.1. Initial Evaluation of Patients . . . . . . . . . . . . . . . . . . . . .1350 which recommendations are based. In an effort to respond
3.1.1. Identification of Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . .1350 more quickly to new evidence, the American College of
3.1.2. Identification of a Structural and Functional Cardiology Foundation/American Heart Association
Abnormality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1350
3.1.3.2. LABORATORY TESTING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1351 (ACCF/AHA) Task Force on Practice Guidelines has
3.2.3. Laboratory Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1352 created a “focused update” process to revise the existing
3.2.4. Assessment of Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .1352 guideline recommendations that are affected by the evolving
4. Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1353 data or opinion. Prior to the initiation of this focused
approach, periodic updates and revisions of existing guidelines
4.3.1. Patients With Reduced Left Ventricular Ejection required up to 3 years to complete. Now, however, new
Fraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1353
4.3.1.1. GENERAL MEASURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1356 evidence is reviewed in an ongoing fashion to more efficiently
4.3.1.2.5. VENTRICULAR ARRHYTHMIAS AND PREVENTION OF respond to important science and treatment trends that could
SUDDEN DEATH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1357 have a major impact on patient outcomes and quality of care.
4.3.1.3.3. HYDRALAZINE AND ISOSORBIDE DINITRATE . . . . . . . . . . . . . .1359 Evidence is reviewed at least twice a year, and updates will be
4.3.1.3.4. CARDIAC RESYNCHRONIZATION THERAPY . . . . . . . . . . . . . . . .1359
4.3.1.5.2. INTERMITTENT INTRAVENOUS POSITIVE
initiated on an as-needed basis as quickly as possible, while
INOTROPIC THERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1360 maintaining the rigorous methodology that the ACCF and
AHA have developed during their more than 20 years of
4.4. Patients With Refractory End-Stage Heart
Failure (Stage D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1360 partnership.
4.4.3. Intravenous Peripheral Vasodilators and Positive These updated guideline recommendations reflect a con-
Inotropic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1362 sensus of expert opinion after a thorough review primarily of
4.5. The Hospitalized Patient (New Section). . . . . . . . .1362 late-breaking clinical trials identified through a broad-based
4.5.1. Diagnostic Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1364 vetting process as important to the relevant patient popu-
4.5.2. Treatment in the Hospital . . . . . . . . . . . . . . . . . . . . . . . . . .1365 lation, as well as of other new data deemed to have an
4.5.2.1. DIURETICS: THE PATIENT WITH VOLUME OVERLOAD . . . . . . . . . . .1365
4.5.2.2. VASODILATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1366
impact on patient care (see Section 1.1., Evidence Review,
4.5.2.3. INOTROPES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1366 for details regarding this focused update). It is important to
4.5.2.4. OTHER CONSIDERATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1367 note that this focused update is not intended to represent
4.5.3. The Hospital Discharge. . . . . . . . . . . . . . . . . . . . . . . . . . . . .1367 an update based on a full literature review from the date
5. Treatment of Special Populations . . . . . . . . . . . . . . . . . . .1368 of the previous guideline publication. Specific criteria/
considerations for inclusion of new data include the following:

JACC Vol. 53, No. 15, 2009 Jessup et al. 1345
April 14, 2009:1343–82 2009 Guideline Focused Update on Heart Failure

Table 1. Applying Classification of Recommendations and Level of Evidence

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart
failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not
lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. †In 2003, the
ACC/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express
a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the
full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow quires at the individual recommendation level.

• Publication in a peer-reviewed journal how the grading system provides an estimate of the size of
• Large randomized, placebo-controlled trial(s) the treatment effect and an estimate of the certainty of the
• Nonrandomized data deemed important on the basis of treatment effect. Note that a recommendation with Level of
results affecting current safety and efficacy assumptions Evidence B or C does not imply that the recommendation
• Strength/weakness of research methodology and findings is weak. Many important clinical questions addressed in
• Likelihood of additional studies influencing current findings guidelines do not lend themselves to clinical trials. Although
• Impact on current performance measure(s) and/or like- randomized trials may not be available, there may be a very
lihood of need to develop new performance measure(s) clear clinical consensus that a particular test or therapy is
• Requests and requirements for review and update from the useful and effective. Both the class of recommendation and
practice community, key stakeholders, and other sources level of evidence listed in the focused updates are based on
free of relationships with industry or other potential bias consideration of the evidence reviewed in previous iterations
• Number of previous trials showing consistent results of the guideline as well as the focused update. Of note, the
• Need for consistency with a new guideline or guideline implications of older studies that have informed recommen-
revision dations but have not been repeated in contemporary settings
In analyzing the data and developing updated recommen- are carefully considered.
dations and supporting text, the focused update writing The ACCF/AHA practice guidelines address patient
group used evidence-based methodologies developed by the populations (and healthcare providers) residing in North
ACCF/AHA Task Force on Practice Guidelines, which are America. As such, drugs that are not currently available
described elsewhere (1). in North America are discussed in the text without a
The schema for class of recommendation and level of specific class of recommendation. For studies performed
evidence is summarized in Table 1, which also illustrates in large numbers of subjects outside of North America,


each writing committee reviews the potential impact of canheart.org) Web sites. A revised version of the ACC/AHA
different practice patterns and patient populations on the 2005 Guideline Update for the Diagnosis and Management of
treatment effect and on the relevance to the ACCF/AHA target Chronic Heart Failure in the Adult (2) full-text guideline that
population to determine whether the findings should inform a incorporates the focused update has also been e-published in
specific recommendation. these issues and is available on the respective Web sites (3). For
The ACCF/AHA practice guidelines are intended to easy reference, that online-only version denotes sections that
assist healthcare providers in clinical decision making by have been updated.
describing a range of generally acceptable approaches for the Sidney C. Smith, Jr, MD, FACC, FAHA
diagnosis, management, and prevention of specific diseases Chair, ACCF/AHA Task Force on Practice Guidelines
or conditions. The guidelines attempt to define practices
that meet the needs of most patients in most circumstances. Alice K. Jacobs, MD, FACC, FAHA
The ultimate judgment regarding care of a particular patient Vice-Chair, ACCF/AHA Task Force on Practice Guidelines
must be made by the healthcare provider and patient in light of
all the circumstances presented by that patient. Thus, there are 1. Introduction
circumstances in which deviations from these guidelines may
be appropriate. Clinical decision making should consider the
1.1. Evidence Review
quality and availability of expertise in the area where care is
provided. These guidelines may be used as the basis for Late-breaking clinical trials presented at the 2005, 2006,
regulatory or payer decisions, but the ultimate goals are quality and 2007 annual scientific meetings of the ACCF, AHA,
of care and serving the patient’s best interests. and European Society of Cardiology, as well as selected
Prescribed courses of treatment in accordance with these other data, were reviewed by the standing guideline writing
recommendations are effective only if they are followed by committee along with the parent task force and other
the patient. Because lack of patient adherence may adversely experts to identify those trials and other key data that might
affect treatment outcomes, healthcare providers should impact guideline recommendations. On the basis of the
make every effort to engage the patient in active participa- criteria/considerations noted earlier, recent trial data and
tion with prescribed treatment. other clinical information were considered important
The ACCF/AHA Task Force on Practice Guidelines enough to prompt a focused update of the ACC/AHA 2005
makes every effort to avoid actual, potential, or perceived Guideline Update for the Diagnosis and Management of
conflict of interest that may arise as a result of industry Chronic Heart Failure in the Adult (2). In addition, the
relationships or personal interests among the writing com- guidelines writing committee thought that a new section on
mittee. Specifically, all members of the writing committee, the management of the hospitalized patient with heart failure
as well as peer reviewers of the document, are asked to (HF) should be included in this update. A number of recent
disclose all such relationships pertaining to the trials and HF trials reviewed for this update, were, in fact, performed on
other evidence under consideration (see Appendixes 1 and hospitalized patients, and a number of newer therapies are
2). Final recommendations were balloted to all writing under development for this population. Moreover, there is
committee members. Writing committee members with sig- increasing government and other third-party payer interest in
nificant (greater than $10 000) relevant relationships with the prevention of HF hospitalizations, and rehospitalizations.
industry were required to recuse themselves from voting on Quality indicators about the process of discharging the HF
that recommendation. Writing committee members who did patient have already been developed, and data about rehospi-
not participate are not listed as authors of this focused update. talizations for HF by hospital have already been made public.
With the exception of the recommendations presented Thus, the committee thought that a new section about this
here, the full guideline remains current. Only the recom- important aspect of HF care should be added to this update.
mendations from the affected section(s) of the full guideline When considering the new data for this focused update,
are included in this focused update. For easy reference, all the writing group faced the task of weighing evidence from
recommendations from any section of a guideline affected by studies enrolling large numbers of subjects outside North
a change are presented with notation as to whether they America. While noting that practice patterns and the rigor
remain current, are new, or have been modified. When applied to data collection, as well as the genetic makeup of
evidence affects recommendations in more than 1 set of subjects, might influence the observed magnitude of a
guidelines, those guidelines are updated concurrently. treatment’s effect, the writing group believed that the data
The recommendations in this focused update are considered were relevant to formulation of recommendations for the
current until they are superseded by another focused update or management of HF in North America.
the full-text guidelines are revised. This focused update is Policy on clinical areas not covered by the present
published in the April 14, 2009, issues of the Journal of the focused update can be found in the 2009 Focused Update
American College of Cardiology and Circulation as an update to Incorporated into the ACC/AHA 2005 Guidelines for
the full-text guideline and is also posted on the ACCF the Diagnosis and Management of Heart Failure in
(www.acc.org, www.cardiosource.com) and AHA (my.ameri- Adults (3).


Figure 1. Stages in the Development of Heart Failure/Recommended Therapy by Stage

ACEI indicates angiotensin-converting enzyme inhibitors; ARB, angiotensin II receptor blocker; EF, ejection fraction; FHx CM, family history of cardiomyopathy; HF, heart fail-
ure; LVH, left ventricular hypertrophy; and MI, myocardial infarction.

1.2. Organization of Committee and was collected and distributed to the writing committee
Relationships With Industry and is published in this document (see Appendix 2 for
For this focused update, all members of the 2005 HF details).
writing committee were invited to participate; those who This document was approved for publication by the govern-
agreed (referred to as the 2009 Focused Update Writing ing bodies of the ACCF and the AHA and endorsed by the
Group) were required to disclose all relationships with International Society for Heart and Lung Transplantation.
industry relevant to the data under consideration (1). Each
1.4. Stages of Heart Failure:
recommendation required a confidential vote by the writing
Information From the 2005 Guideline
group members before and after external review of the
document. Writing group members who had a significant The HF writing committee previously developed a new
(greater than $10 000) relationship with industry relevant to approach to the classification of HF (2), one that empha-
a recommendation were required to recuse themselves from sized both the development and progression of the disease.
voting on that recommendation. In doing so, they identified 4 stages involved in the
development of the HF syndrome (Figure 1). The first 2
1.3. Review and Approval stages (A and B) are clearly not HF but are an attempt to
This document was reviewed by 2 external reviewers nom- help healthcare providers with the early identification of
inated by the ACCF and 2 external reviewers nominated by patients who are at risk for developing HF. Stages A and B
the AHA, as well as a reviewer from the ACCF/AHA Task patients are best defined as those with risk factors that
Force on Practice Guidelines, 10 organizational reviewers clearly predispose toward the development of HF. For
representing the American College of Chest Physicians, the example, patients with coronary artery disease, hyperten-
American College of Physicians, the American Academy sion, or diabetes mellitus who do not yet demonstrate
of Family Physicians, the Heart Failure Society of Amer- impaired left ventricular (LV) function, hypertrophy, or
ica, and the International Society for Heart and Lung geometric chamber distortion would be considered Stage A,
Transplantation, and 14 individual content reviewers. All whereas patients who are asymptomatic but demonstrate
information about reviewers’ relationships with industry LV hypertrophy and/or impaired LV function would be


designated as Stage B. Stage C then denotes patients with 3. Initial and Serial Clinical Assessment of
current or past symptoms of HF associated with underlying Patients Presenting With Heart Failure
structural heart disease (the bulk of patients with HF), and
Stage D designates patients with truly refractory HF who The changes in this section are made to clarify the role of
might be eligible for specialized, advanced treatment strat- functional assessment of the HF patient, beyond the New York
egies, such as mechanical circulatory support, procedures to Heart Association (NYHA) classification, and to expand on the
facilitate fluid removal, continuous inotropic infusions, or use of B-type natriuretic peptide (BNP) and N-terminal
cardiac transplantation or other innovative or experimental pro-B-type natriuretic peptide (NT-proBNP) testing within
surgical procedures, or for end-of-life care, such as hospice. the context of the overall evaluation of the patient (Table 2).

Table 2. Updates to Section 3. Initial and Serial Clinical Assessment of Patients Presenting With Heart Failure
2005 Guideline Recommendations 2009 Focused Update Recommendations Comments
3. Recommendations for the Initial Clinical Assessment of Patients Presenting With Heart Failure
Class I
A thorough history and physical examination should be 1. A thorough history and physical examination should be 2005 recommendation remains
obtained/performed in patients presenting with HF to obtained/performed in patients presenting with HF to current in the 2009 update.
identify cardiac and noncardiac disorders or behaviors that identify cardiac and noncardiac disorders or behaviors
might cause or accelerate the development or progression of that might cause or accelerate the development or
HF. (Level of Evidence: C) progression of HF. (Level of Evidence: C)
A careful history of current and past use of alcohol, illicit drugs, 2. A careful history of current and past use of alcohol, illicit 2005 recommendation remains
current or past standard or “alternative therapies,” and drugs, current or past standard or “alternative current in the 2009 update.
chemotherapy drugs should be obtained from patients therapies,” and chemotherapy drugs should be obtained
presenting with HF. (Level of Evidence: C) from patients presenting with HF. (Level of Evidence: C)
In patients presenting with HF, initial assessment should be 3. In patients presenting with HF, initial assessment should 2005 recommendation remains
made of the patient’s ability to perform routine and desired be made of the patient’s ability to perform routine and current in the 2009 update.
activities of daily living. (Level of Evidence: C) desired activities of daily living. (Level of Evidence: C)
Initial examination of patients presenting with HF should 4. Initial examination of patients presenting with HF should 2005 recommendation remains
include assessment of the patient’s volume status, include assessment of the patient’s volume status, current in the 2009 update.
orthostatic blood pressure changes, measurement of weight orthostatic blood pressure changes, measurement of
and height, and calculation of body mass index. (Level of weight and height, and calculation of body mass index.
Evidence: C) (Level of Evidence: C)
Initial laboratory evaluation of patients presenting with HF 5. Initial laboratory evaluation of patients presenting with HF 2005 recommendation remains
should include complete blood count, urinalysis, serum should include complete blood count, urinalysis, serum current in the 2009 update.
electrolytes (including calcium and magnesium), blood urea electrolytes (including calcium and magnesium), blood
nitrogen, serum creatinine, fasting blood glucose urea nitrogen, serum creatinine, fasting blood glucose
(glycohemoglobin), lipid profile, liver function tests, and (glycohemoglobin), lipid profile, liver function tests, and
thyroid-stimulating hormone. (Level of Evidence: C) thyroid-stimulating hormone. (Level of Evidence: C)
Twelve-lead electrocardiogram and chest radiograph (posterior to 6. Twelve-lead electrocardiogram and chest radiograph (PA 2005 recommendation remains
anterior [PA] and lateral) should be performed initially in all and lateral) should be performed initially in all patients current in the 2009 update.
patients presenting with HF. (Level of Evidence: C) presenting with HF. (Level of Evidence: C)
Two-dimensional echocardiography with Doppler should be 7. Two-dimensional echocardiography with Doppler should 2005 recommendation remains
performed during initial evaluation of patients presenting be performed during initial evaluation of patients current in the 2009 update.
with HF to assess left ventricular ejection fraction (LVEF), presenting with HF to assess LVEF, left ventricular size,
LV size, wall thickness, and valve function. Radionuclide wall thickness, and valve function. Radionuclide
ventriculography can be performed to assess LVEF and ventriculography can be performed to assess LVEF and
volumes. (Level of Evidence: C) volumes. (Level of Evidence: C)
Coronary arteriography should be performed in patients 8. Coronary arteriography should be performed in patients 2005 recommendation remains
presenting with HF who have angina or significant ischemia presenting with HF who have angina or significant current in the 2009 update.
unless the patient is not eligible for revascularization of any ischemia unless the patient is not eligible for
kind. (Level of Evidence: B) revascularization of any kind (4–8). (Level of Evidence: B)
Class IIa
Coronary arteriography is reasonable for patients presenting 1. Coronary arteriography is reasonable for patients 2005 recommendation remains
with HF who have chest pain that may or may not be of presenting with HF who have chest pain that may or current in the 2009 update.
cardiac origin who have not had evaluation of their coronary may not be of cardiac origin who have not had
anatomy and who have no contraindications to coronary evaluation of their coronary anatomy and who have no
revascularization. (Level of Evidence: C) contraindications to coronary revascularization. (Level of
Evidence: C)
Coronary arteriography is reasonable for patients presenting with 2. Coronary arteriography is reasonable for patients 2005 recommendation remains
HF who have known or suspected coronary artery disease but presenting with HF who have known or suspected current in the 2009 update.
who do not have angina unless the patient is not eligible for coronary artery disease but who do not have angina
revascularization of any kind. (Level of Evidence: C) unless the patient is not eligible for revascularization of
any kind. (Level of Evidence: C)



Table 2. Continued
Class IIa (Continued)
Noninvasive imaging to detect myocardial ischemia and 3. Noninvasive imaging to detect myocardial ischemia and 2005 recommendation remains
viability is reasonable in patients presenting with HF who viability is reasonable in patients presenting with HF who current in the 2009 update.
have known coronary artery disease and no angina unless have known coronary artery disease and no angina
the patient is not eligible for revascularization of any kind. unless the patient is not eligible for revascularization of
(Level of Evidence: B) any kind (9). (Level of Evidence: B)
Maximal exercise testing with or without measurement of 4. Maximal exercise testing with or without measurement 2005 recommendation remains
respiratory gas exchange and/or blood oxygen saturation is of respiratory gas exchange and/or blood oxygen current in the 2009 update.
reasonable in patients presenting with HF to help determine saturation is reasonable in patients presenting with HF
whether HF is the cause of exercise limitation when the to help determine whether HF is the cause of exercise
contribution of HF is uncertain. (Level of Evidence: C) limitation when the contribution of HF is uncertain.
(Level of Evidence: C)
Maximal exercise testing with measurement of respiratory gas 5. Maximal exercise testing with measurement of 2005 recommendation remains
exchange is reasonable to identify high-risk patients respiratory gas exchange is reasonable to identify high- current in the 2009 update.
presenting with HF who are candidates for cardiac risk patients presenting with HF who are candidates for
transplantation or other advanced treatments. (Level of cardiac transplantation or other advanced treatments
Evidence: B) (10–12). (Level of Evidence: B)
Screening for hemochromatosis, sleep-disturbed breathing, or 6. Screening for hemochromatosis, sleep-disturbed 2005 recommendation remains
human immunodeficiency virus is reasonable in selected breathing, or human immunodeficiency virus is current in the 2009 update.
patients who present with HF. (Level of Evidence: C) reasonable in selected patients who present with HF.
Diagnostic tests for rheumatologic diseases, amyloidosis, or 7. Diagnostic tests for rheumatologic diseases, 2005 recommendation remains
pheochromocytoma are reasonable in patients presenting amyloidosis, or pheochromocytoma are reasonable in current in the 2009 update.
with HF in whom there is a clinical suspicion of these patients presenting with HF in whom there is a clinical
diseases. (Level of Evidence: C) suspicion of these diseases. (Level of Evidence: C)
Endomyocardial biopsy can be useful in patients presenting 8. Endomyocardial biopsy can be useful in patients 2005 recommendation remains
with HF when a specific diagnosis is suspected that would presenting with HF when a specific diagnosis is current in the 2009 update.
influence therapy. (Level of Evidence: C) suspected that would influence therapy (13). (Level of
Evidence: C)
Measurement of BNP can be useful in the evaluation of 9. Measurement of natriuretic peptides (BNP and NT- Modified recommendation
patients presenting in the urgent care setting in whom the proBNP) can be useful in the evaluation of patients (added a caveat on
clinical diagnosis of HF is uncertain. (Level of Evidence: A) presenting in the urgent care setting in whom the natriuretic peptides and their
clinical diagnosis of HF is uncertain. Measurement of role as part of total
natriuretic peptides (BNP and NT-proBNP) can be useful evaluation, in both diastolic
in risk stratification (14–21). (Level of Evidence: A) and systolic dysfunction).
Class IIb
Noninvasive imaging may be considered to define the 1. Noninvasive imaging may be considered to define the 2005 recommendation remains
likelihood of coronary artery disease in patients with HF and likelihood of coronary artery disease in patients with HF current in the 2009 update.
LV dysfunction. (Level of Evidence: C) and LV dysfunction. (Level of Evidence: C)
Holter monitoring might be considered in patients presenting 2. Holter monitoring might be considered in patients 2005 recommendation remains
with HF who have a history of myocardial infarction (MI) and presenting with HF who have a history of MI and are current in the 2009 update.
are being considered for electrophysiologic study to being considered for electrophysiologic study to
document ventricular tachycardia (VT) inducibility. (Level of document VT inducibility. (Level of Evidence: C)
Evidence: C)
Class III
Endomyocardial biopsy should not be performed in the routine 1. Endomyocardial biopsy should not be performed in the 2005 recommendation remains
evaluation of patients with HF. (Level of Evidence: C) routine evaluation of patients with HF (13). (Level of current in the 2009 update.
Evidence: C)
Routine use of signal-averaged electrocardiography is not 2. Routine use of signal-averaged electrocardiography is 2005 recommendation remains
recommended for the evaluation of patients presenting with not recommended for the evaluation of patients current in the 2009 update.
HF. (Level of Evidence: C) presenting with HF. (Level of Evidence: C)
Routine measurement of circulating levels of neurohormones 3. Routine measurement of circulating levels of 2005 recommendation remains
(e.g., norepinephrine or endothelin) is not recommended for neurohormones (e.g., norepinephrine or endothelin) is current in the 2009 update.
patients presenting with HF. (Level of Evidence: C) not recommended for patients presenting with HF.
3. Recommendations for Serial Clinical Assessment of Patients Presenting With Heart Failure
Class I
Assessment should be made at each visit of the ability of a 1. Assessment should be made at each visit of the ability 2005 recommendation remains
patient with HF to perform routine and desired activities of of a patient with HF to perform routine and desired current in the 2009 update.
daily living. (Level of Evidence: C) activities of daily living. (Level of Evidence: C)
Assessment should be made at each visit of the volume status 2. Assessment should be made at each visit of the volume 2005 recommendation remains
and weight of a patient with HF. (Level of Evidence: C) status and weight of a patient with HF. (Level of current in the 2009 update.
Evidence: C)
Careful history of current use of alcohol, tobacco, illicit drugs, 3. Careful history of current use of alcohol, tobacco, illicit 2005 recommendation remains
“alternative therapies,” and chemotherapy drugs, as well as drugs, “alternative therapies,” and chemotherapy drugs, current in the 2009 update.
diet and sodium intake, should be obtained at each visit of a as well as diet and sodium intake, should be obtained at
patient with HF. (Level of Evidence: C) each visit of a patient with HF. (Level of Evidence: C)



Table 2. Continued

Class IIa
Repeat measurement of ejection fraction (EF) and the severity 1. Repeat measurement of EF and the severity of structural 2005 recommendation remains
of structural remodeling can provide useful information in remodeling can be useful to provide information in current in the 2009 update.
patients with HF who have had a change in clinical status or patients with HF who have had a change in clinical
who have experienced or recovered from a clinical event or status or who have experienced or recovered from a
received treatment that might have had a significant effect clinical event or received treatment that might have had
on cardiac function. (Level of Evidence: C) a significant effect on cardiac function. (Level of
Evidence: C)

Class IIb
The value of serial measurements of BNP to guide therapy for 1. The value of serial measurements of BNP to guide 2005 recommendation remains
patients with HF is not well established. (Level of Evidence: C) therapy for patients with HF is not well established. current in the 2009 update.

3.1. Initial Evaluation of Patients ity and is insensitive to important changes in exercise capacity.
These limitations may be overcome by formal tests of exercise
3.1.1. Identification of Patients
tolerance. Measurement of the distance that a patient can walk
In general, patients with LV dysfunction or HF present to in 6 minutes may have prognostic significance and may help to
the healthcare provider in 1 of 3 ways: assess the level of functional impairment in the very sick, but
1. With a syndrome of decreased exercise tolerance. Most serial changes in walking distance may not parallel changes in
patients with HF seek medical attention with complaints of clinical status. Maximal exercise testing, with measurement of
a reduction in their effort tolerance due to dyspnea and/or peak oxygen uptake, has been used to identify appropriate
fatigue. These symptoms, which may occur at rest or during candidates for cardiac transplantation, to determine disability,
exercise, may be attributed inappropriately by the patient and to assist in the formulation of an exercise prescription, but
and/or healthcare provider to aging, other physiological its role in the general management of patients with HF has not
abnormalities (e.g., deconditioning), or other medical dis- been defined.
orders (e.g., pulmonary disease). Therefore, in a patient
whose exercise capacity is limited by dyspnea or fatigue, the 3.1.2. Identification of a Structural and Functional
healthcare provider must determine whether the principal Abnormality
cause is HF or another abnormality. Elucidation of the
A complete history and physical examination are the first steps
precise reason for exercise intolerance can be difficult
in evaluating the structural abnormality or cause responsible for
because several disorders may coexist in the same patient. A
the development of HF. Direct inquiry may reveal prior or
clear distinction can sometimes be made only by measure-
ments of gas exchange or blood oxygen saturation or by current evidence of MI, valvular disease, or congenital heart
invasive hemodynamic measurements during graded levels disease, whereas examination of the heart may suggest the
of exercise (see ACC/AHA 2002 Guideline Update for presence of cardiac enlargement, murmurs, or a third heart
Exercise Testing [22]). sound. Although the history and physical examination may
2. With a syndrome of fluid retention. Patients may present provide important clues about the nature of the underlying
with complaints of leg or abdominal swelling as their cardiac abnormality, identification of the structural abnormal-
primary (or only) symptom. In these patients, the impair- ity leading to HF generally requires invasive or noninvasive
ment of exercise tolerance may occur so gradually that it imaging of the cardiac chambers or great vessels.
may not be noted unless the patient is questioned carefully The single most useful diagnostic test in the evaluation of
and specifically about a change in activities of daily living. patients with HF is the comprehensive 2-dimensional echo-
3. With no symptoms or symptoms of another cardiac or cardiogram coupled with Doppler flow studies to determine
noncardiac disorder. During their evaluation for a whether abnormalities of myocardium, heart valves, or pericar-
disorder other than HF (e.g., abnormal heart sounds or dium are present and which chambers are involved. Three
abnormal electrocardiogram or chest x-ray, hypertension fundamental questions must be addressed: 1) Is the LV
or hypotension, diabetes mellitus, an acute myocardial ejection fraction (EF) preserved or reduced? 2) Is the structure
infarction (MI), an arrhythmia, or a pulmonary or of the LV normal or abnormal? 3) Are there other structural
systemic thromboembolic event), patients may be found abnormalities such as valvular, pericardial, or right ventricular
to have evidence of cardiac enlargement or dysfunction. abnormalities that could account for the clinical presentation?
A variety of approaches have been used to quantify the This information should be quantified with a numerical esti-
degree of functional limitation imposed by HF. The most mate of EF, measurement of ventricular dimensions and/or
widely used scale is the NYHA functional classification (23), volumes, measurement of wall thickness, and evaluation of
but this system is subject to considerable interobserver variabil- chamber geometry and regional wall motion.


Right ventricular size and systolic performance should be 3.1.3.2. LABORATORY TESTING
assessed. Atrial size should also be determined semiquantita- Laboratory testing may reveal the presence of disorders or
tively and left atrial dimensions and/or volumes measured. All conditions that can lead to or exacerbate HF. The initial
valves should be evaluated for anatomic and flow abnormalities evaluation of patients with HF should include a complete
to exclude the presence of primary valve disease. Secondary blood count, urinalysis, serum electrolytes (including cal-
changes in valve function, particularly the severity of mitral and cium and magnesium), glycohemoglobin, and blood lipids,
tricuspid valve insufficiency, should be determined. as well as tests of both renal and hepatic function, a chest
Noninvasive hemodynamic data acquired at the time of radiograph, and a 12-lead electrocardiogram. Thyroid func-
echocardiography are an important additional correlate for tion tests (especially thyroid-stimulating hormone) should
patients with preserved or reduced EF. Combined quantifica- be measured, because both hyperthyroidism and hypothy-
tion of the mitral valve inflow pattern, pulmonary venous roidism can be a primary or contributory cause of HF. A
inflow pattern, and mitral annular velocity provides data about fasting transferrin saturation is useful to screen for hemo-
chromatosis; several mutated alleles for this disorder are
characteristics of LV filling and left atrial pressure. Evaluation
common in individuals of Northern European descent, and
of the tricuspid valve regurgitant gradient coupled with mea-
affected patients may show improvement in LV function
surement of inferior vena caval dimension and its response
after treatment with phlebotomy and chelating agents.
during respiration provides an estimate of systolic pulmonary
Magnetic resonance imaging of the heart or liver may be
artery pressure and central venous pressure. Stroke volume may needed to confirm the presence of iron overload. Screening
be determined with combined dimension measurement and for human immunodeficiency virus (HIV) is reasonable and
pulsed Doppler in the LV outflow tract (24). However, should be considered for all high-risk patients. However,
abnormalities can be present in any of these parameters in the other clinical signs of HIV infection typically precede any
absence of HF. No single parameter necessarily correlates HF symptoms in those patients who develop HIV cardio-
specifically with HF; however, a totally normal filling pattern myopathy. Serum titers of antibodies developed in response
argues against clinical HF. to infectious organisms are occasionally measured in pa-
A comprehensive echocardiographic evaluation is impor- tients with a recent onset of HF (especially in those with a
tant, because it is common for patients to have more than 1 recent viral syndrome), but the yield of such testing is low,
cardiac abnormality that contributes to the development of and the therapeutic implications of a positive result are
HF. Furthermore, the study may serve as a baseline for uncertain (see a recent review of the role of endomyocardial
comparison, because measurement of EF and the severity of biopsy (13), and Section 3.1.3.4, Evaluation of the Possi-
structural remodeling can provide useful information in pa- bility of Myocardial Disease, in the full-text guideline.
tients who have had a change in clinical status or who have Assays for connective tissue diseases and for pheochromo-
experienced or recovered from a clinical event or received cytoma should be performed if these diagnoses are sus-
treatment that might have had a significant effect on cardiac pected, and serum titers of Chagas disease antibodies should
function. be checked in patients with nonischemic cardiomyopathy
Other tests may be used to provide information regarding who have traveled in or emigrated from an endemic region.
the nature and severity of the cardiac abnormality. Radio- Several recent assays have been developed for natriuretic
nuclide ventriculography can provide highly accurate mea- peptides (BNP and NT-proBNP). Several of the natriuretic
surements of LV function and right ventricular EF, but it is peptides are synthesized by and released from the heart.
unable to directly assess valvular abnormalities or cardiac Elevated plasma BNP levels have been associated with
reduced LVEF (27), LV hypertrophy, elevated LV filling
hypertrophy. Magnetic resonance imaging or computed
pressures, and acute MI and ischemia, although they can
tomography may be useful in evaluating chamber size and
occur in other settings, such as pulmonary embolism and
ventricular mass, detecting right ventricular dysplasia, or
chronic obstructive pulmonary disease.
recognizing the presence of pericardial disease, as well as in
Natriuretic peptides are sensitive to other biological factors,
assessing cardiac function and wall motion (25).
such as age, sex, weight, and renal function (28). Elevated
Magnetic resonance imaging may also be used to identify levels lend support to a diagnosis of abnormal ventricular
myocardial viability and scar tissue (26). Chest radiography can function or hemodynamics causing symptomatic HF (29).
be used to estimate the degree of cardiac enlargement and Trials with these diagnostic markers suggest use in the urgent-
pulmonary congestion or to detect the presence of pulmonary care setting, where they have been used in combination with
disease. A 12-lead electrocardiogram may demonstrate evi- clinical evaluation to differentiate dyspnea due to HF from
dence of prior MI, LV hypertrophy, cardiac conduction ab- dyspnea of other causes (4), and suggest that its use may reduce
normality (e.g., left bundle-branch block), or a cardiac arrhyth- both the time to hospital discharge and the cost of treatment
mia. However, because of their low sensitivity and specificity, (30). BNP levels tend to be less elevated in HF with preserved
neither the chest x-ray nor the electrocardiogram should form EF than in HF with low EF and are lower in obese patients
the primary basis for determining the specific cardiac abnor- (31,32). Levels of natriuretic peptides may be elevated mean-
mality responsible for the development of HF. ingfully in women and in people over 60 years of age who do


not have HF, and thus these levels should be interpreted Both improvement and deterioration may have important
cautiously in such individuals when distinguishing between implications for future care, although the recommended
cardiac and noncardiac causes of dyspnea. Elevated natriuretic medical regimen should be continued in most cases. Im-
peptide levels may lend weight to a suspected diagnosis of HF provement may reflect recovery from a previous condition,
or trigger consideration of HF when the diagnosis is unknown such as viral myocarditis or hypothyroidism, or may occur
but should not be used in isolation to confirm or exclude the after titration of recommended therapies for chronic HF.
presence of HF (30,33). Thus, it is appropriate to obtain a repeat EF after some
period of optimal medical therapy, typically 4 to 6 months,
3.2.3. Laboratory Assessment
to decide about the implantation of an implantable
Serum electrolytes and renal function should be monitored cardioverter-defibrillator (ICD). Deterioration may reflect
routinely in patients with HF. Of particular importance is gradual disease progression or a new event, such as recurrent
the serial measurement of serum potassium concentration, MI. Routine assessment of EF at frequent, regular, or
because hypokalemia is a common adverse effect of treat- arbitrary intervals is not recommended.
ment with diuretics and may cause fatal arrhythmias and There has been no established role for periodic invasive or
increase the risk of digitalis toxicity, whereas hyperkalemia noninvasive hemodynamic measurements in the manage-
may complicate therapy with angiotensin-converting en- ment of HF. Most drugs used for the treatment of HF are
zyme (ACE) inhibitors, angiotensin II receptor blockers prescribed on the basis of their ability to improve symptoms
(ARBs), and aldosterone antagonists. Worsening renal or survival rather than their effect on hemodynamic vari-
function may require adjustment of the doses of diuretics, ables. Moreover, the initial and target doses of these drugs
renin-angiotensin-aldosterone system antagonists, digoxin, are selected on the basis of experience in controlled trials
and noncardiac medications. Development of hyponatremia and are not based on the changes they may produce in
or anemia may be a sign of disease progression and is cardiac output or pulmonary wedge pressure. Nevertheless,
associated with impaired survival. invasive hemodynamic measurements may assist in the
Serum BNP levels have been shown to parallel the clinical determination of volume status and in distinguishing HF
severity of HF as assessed by NYHA class in broad from other disorders that may cause circulatory instability,
populations. Levels are higher in hospitalized patients and such as pulmonary diseases and sepsis. Measurements of
tend to decrease during aggressive therapy for decompen- cardiac output and pulmonary wedge pressure through a
sation (see Section 3.1.3.2. in the full-text guideline, Lab- pulmonary artery catheter have also been used in patients
oratory Testing) (29). Indeed, there is an increasing body of with refractory HF to assess pulmonary vascular resistance,
evidence demonstrating the power of the addition of BNP a determinant of eligibility for heart transplantation. Car-
(or NT-proBNP) levels in the assessment of prognosis in a diac output can also be measured by noninvasive methods.
variety of cardiovascular disorders. However, it cannot be
3.2.4. Assessment of Prognosis
assumed that BNP levels can be used effectively as targets
for adjustment of therapy in individual patients. Many Although both healthcare providers and patients may be
patients taking optimal doses of medications continue to interested in defining the prognosis of an individual patient
show markedly elevated levels of BNP, and some patients with HF, the likelihood of survival can be determined
demonstrate BNP levels within the normal range despite reliably only in populations and not in individuals. How-
advanced HF. The use of BNP measurements to guide the ever, some attempt at prognostication in HF may provide
titration of drug doses has not been shown conclusively to better information for patients and their families to help
improve outcomes more effectively than achievement of the them appropriately plan for their futures. It also identifies
target doses of drugs shown in clinical trials to prolong life patients in whom cardiac transplantation or mechanical
(34). Ongoing trials will help to determine the role of serial device therapy should be considered.
BNP (or other natriuretic peptides) measurements in both Multivariate analysis of clinical variables has helped to
diagnosis and management of HF. identify the most significant predictors of survival, and prog-
Serial chest radiographs are not recommended in the nostic models have been developed and validated (36). De-
management of chronic HF. Although the cardiothoracic creasing LVEF, worsening NYHA functional status, degree of
ratio is commonly believed to reflect the cardiac dilatation hyponatremia, decreasing peak exercise oxygen uptake, de-
that is characteristic of HF, enlargement of the cardiac creasing hematocrit, widened QRS on 12-lead electrocardio-
silhouette primarily reflects changes in right ventricular gram, chronic hypotension, resting tachycardia, renal insuffi-
volume rather than LV function, because the right ventricle ciency, intolerance to conventional therapy, and refractory
forms most of the border of dilated hearts on radiographs. volume overload are all generally recognized key prognostic
Similarly, changes in the radiographic assessment of pulmo- parameters, although the actual prognostic models incorporat-
nary vascular congestion are too insensitive to detect any but ing them are not widely used in clinical practice (36,37).
the most extreme changes in fluid status (35). Although elevated circulating levels of neurohormonal factors
Repeat assessment of EF may be most useful when the have also been associated with high mortality rates, the routine
patient has demonstrated a major change in clinical status. assessment of neurohormones such as norepinephrine or en-


dothelin is neither feasible nor helpful in clinical management. 4. Therapy
Likewise, elevated BNP (or NT-proBNP) levels predict higher
risk of HF and other events after MI, whereas marked
4.3.1. Patients With Reduced Left Ventricular
elevation in BNP levels during hospitalization for HF may
Ejection Fraction
predict rehospitalization and death. Nonetheless, the BNP
measurement has not been clearly shown to supplement careful Changes in this section focused on 3 areas: recommendations
clinical assessment for management. about electrical device therapy (e.g., cardiac resynchronization
Because treatment of HF has improved over the past 10 therapy [CRT] and ICDs), the use of a fixed dose combination
years, the older prognostic models need to be revalidated (38), of hydralazine and isosorbide dinitrate in self-identified African
and newer prognostic models may have to be developed. Americans, and the management of atrial fibrillation in pa-
Outcomes have been improved for most high-risk patients, tients with HF. The previous version of the guidelines had a
which has resulted in a shift in the selection process for patients number of possibly confusing recommendations about selection
referred for heart transplantation (38). Routine use of ambu- of patients for ICD implantation. The writing group has
latory electrocardiographic monitoring, T-wave alternans anal- tried to simplify the recommendations, and keep them con-
ysis, heart rate variability measurement, and signal-averaged cordant with the most recent guidelines covering the same
electrocardiography have not been shown to provide incremen- issue (39,40). Updated trial information has led to the
tal value in assessing overall prognosis, although ambulatory change in the recommendations about the use of hydralazine/
electrocardiographic monitoring can be useful in decision isosorbide dinitrate and about the management of atrial
making regarding placement of ICDs (39). fibrillation (Table 3).

Table 3. Updates to Section 4.3.1. Patients With Reduced Left Ventricular
Ejection Fraction
4.3.1. Patients With Reduced Left Ventricular Ejection Fraction
Class I
Measures listed as Class I recommendations for patients in 1. Measures listed as Class I recommendations for 2005 recommendation remains
stages A and B are also appropriate for patients in Stage patients in stages A and B are also appropriate for current in 2009 update.
C. (Levels of Evidence: A, B, and C as appropriate) patients in Stage C. (Levels of Evidence: A, B, and C as
appropriate)
Diuretics and salt restriction are indicated in patients with 2. Diuretics and salt restriction are indicated in patients 2005 recommendation remains
current or prior symptoms of HF and reduced LVEF who with current or prior symptoms of HF and reduced LVEF current in 2009 update.
have evidence of fluid retention (see Table 4). (Level of who have evidence of fluid retention (see Table 4 in the
Evidence: C) full-text guidelines). (Level of Evidence: C)
Angiotensin converting enzyme inhibitors are recommended 3. Angiotensin-converting enzyme inhibitors are 2005 recommendation remains
for all patients with current or prior symptoms of HF and recommended for all patients with current or prior current in 2009 update.
reduced LVEF, unless contraindicated (see text, Table 3 in symptoms of HF and reduced LVEF, unless
the full-text guidelines). (Level of Evidence: A) contraindicated (see text, Table 3 in the full-text
guidelines) (41–53). (Level of Evidence: A)
Beta blockers (using 1 of the 3 proven to reduce mortality, 4. Beta blockers (using 1 of the 3 proven to reduce 2005 recommendation remains
i.e., bisoprolol, carvedilol, and sustained release mortality, i.e., bisoprolol, carvedilol, and sustained current in 2009 update.
metoprolol succinate) are recommended for all stable release metoprolol succinate) are recommended for all
patients with current or prior symptoms of HF and stable patients with current or prior symptoms of HF
reduced LVEF, unless contraindicated (see text, Table 3 in and reduced LVEF, unless contraindicated (see text,
the full-text guidelines). (Level of Evidence: A) Table 3 in the full-text guidelines) (54–72). (Level of
Evidence: A)
Angiotensin II receptor blockers approved for the 5. Angiotensin II receptor blockers (see Table 3 in the full- 2005 recommendation remains
treatment of HF (see Table 3) are recommended in text guidelines) are recommended in patients with current but text modified to
patients with current or prior symptoms of HF and current or prior symptoms of HF and reduced LVEF who eliminate specific agents
reduced LVEF who are ACE inhibitor-intolerant (see text are ACE inhibitor-intolerant (see text for information tested.
for information regarding patients with angioedema). regarding patients with angioedema) (73–83). (Level of
(Level of Evidence: A) Evidence: A)
Drugs known to adversely affect the clinical status of 6. Drugs known to adversely affect the clinical status of 2005 recommendation remains
patients with current or prior symptoms of HF and patients with current or prior symptoms of HF and current in 2009 update.
reduced LVEF should be avoided or withdrawn whenever reduced LVEF should be avoided or withdrawn
possible (e.g., nonsteroidal anti-inflammatory drugs, most whenever possible (e.g., nonsteroidal anti-inflammatory
antiarrhythmic drugs, and most calcium channel blocking drugs, most antiarrhythmic drugs, and most calcium
drugs; see text). (Level of Evidence: B) channel blocking drugs; see text) (84–90). (Level of
Evidence: B)



Table 3. Continued
Class I (Continued)
Maximal exercise testing with or without measurement of 2005 recommendation no
respiratory gas exchange is recommended to facilitate longer current. See 2009
prescription of an appropriate exercise program for Class IIa No. 2
patients with HF. (Level of Evidence: C) recommendation below.
Exercise training is beneficial as an adjunctive approach to 7. Exercise training is beneficial as an adjunctive 2005 recommendation remains
improve clinical status in ambulatory patients with current approach to improve clinical status in ambulatory current in 2009 update.
or prior symptoms of HF and reduced LVEF. (Level of patients with current or prior symptoms of HF and
Evidence: B) reduced LVEF (90a–90d). (Level of Evidence: B)
An implantable cardioverter-defibrillator is recommended as 8. An implantable cardioverter-defibrillator is 2005 recommendation remains
secondary prevention to prolong survival in patients with recommended as secondary prevention to prolong current in 2009 update.
current or prior symptoms of HF and reduced LVEF who survival in patients with current or prior symptoms of
have a history of cardiac arrest, ventricular fibrillation, or HF and reduced LVEF who have a history of cardiac
hemodynamically destabilizing ventricular tachycardia. arrest, ventricular fibrillation, or hemodynamically
(Level of Evidence: A) destabilizing ventricular tachycardia (91–93). (Level of
Evidence: A)
Implantable cardioverter-defibrillator therapy is 9. Implantable cardioverter-defibrillator therapy is Modified recommendation to be
recommended for primary prevention to reduce total recommended for primary prevention of sudden consistent with the
mortality by a reduction in sudden cardiac death in cardiac death to reduce total mortality in patients with ACC/AHA/Heart Rhythm
patients with ischemic heart disease who are at least 40 non-ischemic dilated cardiomyopathy or ischemic heart Society (HRS) 2008 Device-
days post-MI, have an LVEF less than or equal to 30%, disease at least 40 days post-MI, a LVEF less than or Based Therapy guidelines.
with NYHA functional class II or III symptoms while equal to 35%, and NYHA functional class II or III
undergoing chronic optimal medical therapy, and have symptoms while receiving chronic optimal medical
reasonable expectation of survival with a good functional therapy, and who have reasonable expectation of
status for more than 1 year. (Level of Evidence: A) survival with a good functional status for more than 1
year (40,93–99). (Level of Evidence: A)
Implantable cardioverter-defibrillator therapy is 2005 recommendation no
recommended for primary prevention to reduce total longer current. See 2009
mortality by a reduction in sudden cardiac death in Class I No. 9
patients with nonischemic cardiomyopathy who have an recommendation above.
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. (Level of Evidence: B)
Patients with LVEF less than or equal to 35%, sinus rhythm, 10. Patients with LVEF of less than or equal to 35%, sinus Clarified recommendation
and NYHA functional class III or ambulatory class IV rhythm, and NYHA functional class III or ambulatory (includes therapy with or
symptoms despite recommended, optimal medical class IV symptoms despite recommended, optimal without an ICD).
therapy and who have cardiac dyssynchrony, which is medical therapy and who have cardiac dyssynchrony,
currently defined as a QRS duration greater than 120 ms, which is currently defined as a QRS duration greater
should receive cardiac resynchronization therapy unless than or equal to 0.12 seconds, should receive cardiac
contraindicated. (Level of Evidence: A) resynchronization therapy, with or without an ICD, unless
contraindicated (100–115). (Level of Evidence: A)
Addition of an aldosterone antagonist is reasonable in 11. Addition of an aldosterone antagonist is recommended 2005 recommendation remains
selected patients with moderately severe to severe in selected patients with moderately severe to severe current in 2009 update.
symptoms of HF and reduced LVEF who can be carefully symptoms of HF and reduced LVEF who can be
monitored for preserved renal function and normal carefully monitored for preserved renal function and
potassium concentration. Creatinine should be less than normal potassium concentration. Creatinine should be
or equal to 2.5 mg per dL in men or less than or equal to 2.5 mg per dL or less in men or 2.0 mg per dL or less
2.0 mg per dL in women and potassium should be less in women and potassium should be less than 5.0
than 5.0 mEq per liter. Under circumstances where mEq per liter. Under circumstances where
monitoring for hyperkalemia or renal dysfunction is not monitoring for hyperkalemia or renal dysfunction is
anticipated to be feasible, the risks may outweigh the not anticipated to be feasible, the risks may
benefits of aldosterone antagonists. (Level of Evidence: B) outweigh the benefits of aldosterone antagonists
(116–118). (Level of Evidence: B)
12. The combination of hydralazine and nitrates is New recommendation
recommended to improve outcomes for patients self-
described as African-Americans, with moderate-severe
symptoms on optimal therapy with ACE inhibitors,
beta blockers, and diuretics (119,120). (Level of
Evidence: B)
Class IIa
1. It is reasonable to treat patients with atrial fibrillation New recommendation
and HF with a strategy to maintain sinus rhythm or
with a strategy to control ventricular rate alone (121–
125). (Level of Evidence: A)
2. Maximal exercise testing with or without measurement Modified recommendation
of respiratory gas exchange is reasonable to facilitate (changed class of
prescription of an appropriate exercise program for recommendation from I to
patients presenting with HF. (Level of Evidence: C) IIa).


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