1. l References Application to Clinical Practice The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have cooperatively produced guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines is in charge of developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, and also leads and supervises this effort. In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force. The guidelines assist primary healthcare providers in decision making by introducing an acceptable approach to the diagnosis, management and prevention of heart failure (ACCF/AHA, 2013). Introduction Summary of Research Synthesis of Guidelines The 2013 guidelines are intended to assist healthcare providers in selecting the best management by providing expert analysis of evidence based research on prevention, diagnosis, risk classification and treatment. For overall care of a HF patient, the guidelines emphasize the following: participation in performance improvement processes based on professionally developed clinical practice guidelines; care coordination and transitions of care from primary care physicians, to cardiologists to palliative care and hospice; shared decision making between patients and family members importance of education These guidelines can be used by the Advanced Practice Nurse to coordinate and assist in coordinating a plan of care in the newly diagnosed HF patient and can also assist the NP to have the patient information, labs and test for referral to the cardiologist. Largely, this is a comprehensive guide with useful algorithms, summary and evidence tables that will expected be very useful for all providers taking care of HF patients (Bozkurt, 2013). The University of California performed a study targeting patients at risk for developing HF, ACCF stages; stage A or B, to determine if using BNP measurements can assist in guiding referral and therapy to prevent LV dysfunction and HF. For the study, a patient with a BNP >50 the first step is to obtain an ECG, and a referral to a cardiologist, lifestyle counseling and management is recommended. For patients with BNP levels <50 patients received usual care. Results showed a reduction in LV dysfunction of 35% and a 52& reduction in HF. The study also demonstrated a 45% decrease in emergency hospitalization for major cardiovascular events. The study confirmed that BNP measurement in patients at risk of HF can predict the development of future LV dysfunction and that BNP guided therapy for patients at risk for HF appears to be a cost effective and practical strategy. This also agrees with the ACCF/AHA BNP classification as an “A” recommendation (Boyle, 2013).. The American College of Cardiology Foundation and The American Heart Association 2013 Guidelines for the Management of Heart Failure: Stage A & B Recommendations Jeannette Zelhart-Smith University of Saint Francis Nurs 510 The American College of Cardiology Foundation and the American Heart Association(2013). ACCF/AHA Heart Failure Guidelines [Algorithm]. United States: American College of Cardiology and American Heart Association American College of Cardiology Foundation and the American Heart Association. (2013). 2013 ADDF/AHA guideline for the management of heart failure. Dallas, TX: Author. Boyle, A. (2013). BNP guided heart failure prevention [Magazine]. Clinical Cardiology, 32(9). Retrieved from www.ahcmedia.com Bozkurt, B. (2013). What is new in the 2013 ACCF/AHA guidelines for the management of heart failure? Retrieved from http://my.americanheart.org/professional/ScienceNews/What-is-New-in-the- 2013-ACCF-AHA-Guidelines-for-the-Management-of-Heart- Failure_UCM_452903_Article.jsp http://my.americanheart.org/professional/ScienceNews/What-is-New-in-the- 2013-ACCF-AHA-Guidelines-for-the-Management-of-Heart- Failure_UCM_452903_Article.jsp Medscape. (Cartographer). (2013). NYHA/AHA heart failure classification [chart]. Retrieved from www.medscape.com National Institute for Health and Clinical Excellence. (2010). Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care (6). London: Author. Shah, K., Parekh, N., Clopton, P., Anand, I., Christenson, R., Daniels, L.,... Anker, S. (2013). Improved survival in patients with diastolic heart failure discharged on beta-blockers and ACE inhibitors [Magazine]. Journal of the American College of Cardiology, 61(10). The ACCF/AHA recommendations for diagnosing HF support a thorough H&P, 3 generation family history and with every visit weight, volume status and vital signs. Initial labs include the following: CBC, U/A, BMP, lipid panel, LFT and TSH. A 12 lead ECG and a chest x-ray to assess heart size and pulmonary congestion could also be ordered. In patients with dyspnea, a BNP can be useful to support clinical decision making and may be useful in deciphering severity in chronic HF and acutely decompensated HF. However, the usefulness of serial BNP measurement to reduce hospitalization or to guide therapy in acutely decompensated HF is not well established. STAGE A In accordance with the guidelines treatment and management of stage A begins with lowering the risk of HF by controlling or avoiding contributing factors such as HTN, lipid disorders, tobacco use, diabetes and obesity. An ACEi or ARB may be added if the patient has vascular disease or diabetes. A statin is recommended if there is a lipid disorder. STAGE B Stage A recommendation also apply to stage B and also include additions of medications. For stage B recommendation for patients with recent or remote history of MI and a decreased EF an ACE, BB and statin should be used to decrease mortality. In patients intolerant to ACEs ARBs may be used. The practitioner may decrease the risk of hypotension by administering ACE and BB at different times of the day. It should be noted that CCBs may be harmful in asymptomatic patients with decreased LVEF. Classification of Heart Failure (ACCF/AHA, 2013) Stage A At high risk for HF but without structural heart disease or symptoms of HF Structural heart disease Patients with: HTN Atherosclerotic disease DM Obesity Metabolic syndrome Or Patients Using cardiotoxins With family history of cardiomyopathy Therapy Goals Heart healthy lifestyle Prevent vascular, coronary disease Prevent LV structural abnormalities Drugs ACE or ARB in appropriate patients for vascular disease or DM Statins as appropriate Stage B Structural heart disease but without signs or symptoms of HF Patients with: Previous MI LV remodeling including LVH and EF Asymptomatic valvular disease Therapy Goals Prevent HF symptoms Prevent further cardiac remodeling Drugs ACE or ARB as appropriate Beta blockers as appropriate In selected patients ICD Revascularization or valvular surgery as appropriate Both the ACCF/AHA Stages of HF and the New York Heart Association Functional Classification provide useful information about the severity of HF. The ACCF/AHA concentrates on development and progression of disease and the NYHA focuses on exercise ability and the severity of symptoms of disease. The ACCF/AHA stages recognize once a patient moves to a higher stage regression to earlier stage is not observed. The NYHA functional class is subjective by the clinician and can change frequently over short periods of time. The NYHA is widely used in clinical practice and research for determining if patient is eligible for certain healthcare services (ACCF/AHA, 2013).. According to the National Institute for Health and Clinical Excellence (NICE), as with the ACCF/AHA, diagnosis of HF begins with the history and physical. If HF is suspected in patients with a previous MI, the recommended action is to measure the serum BNP first; and if there is a history of MI or the BNP is high obtain a ECG and refer to cardiologist within 2 weeks. If only the BNP levels are raised and there is no history of MI, the patient should see the specialist within 6 weeks. According to the NICE guidelines, treatment for a patient with a normal ejection fraction (EF) should begin with a diuretic and treatment of underlying conditions. Should the EF be decreased beta blockers (BB) and ACE inhibitors are recommended. Consuming a heart healthy diet and a supervised exercise program can decrease hospitalization and improve quality of life for patients with stable heart failure. The ACCF/AHA guidelines begin treatment with an ACE or ARB in contrast to the NICE guidelines that recommend beginning with a diuretic. However, both guidelines agree that heart healthy lifestyle is key (NICE, 2010).. Medical management of heart failure with preserved ejection fraction (HFPEF) remains unclear. A study was done to analyze the benefit of ACE-inhibitors (ACEi) and beta blockers (BB) in patients with HFPEF and in heart failure with reduced ejection fraction (HFREF). The study measured biomarkers in 1,641 patients presenting with dyspnea. The biomarkers were then measured again after pharmaceutical therapy with either an ACEi alone, a BB alone or combination of ACEi and BB, was initiated. Results showed that patients with a diagnosis of HF whom were discharged on a BB or an ACEI had improved survival in both HFPEF and HFREF. A model including all CHF patients and both beta blocker and ACEi, ACEi alone, and BB alone demonstrated the most protective effect with ACEi. The conclusion of this study was that patients with HFPEF and HFREF both demonstrate improved survival when being discharged on ACEi and BB, with ACEi possibly having more survival benefit (Shah et al., 2013) A correlation can be seen when comparing the results of this study to the current recommended guidelines. The ACCF/AHA guidelines recommend first line pharmaceutical treatment begin with an ACEi. However, the current guidelines recommend that every patient should receive both an ACEi and a BB. It should also be noted that carvedilol was the BB of choice for many of the studies.