New Heart Failure Guidelines Emphasize Prevention

New guidelines have been published to help providers treat patients who have heart failure as well as patients who are at risk for the disease.

The update was a joint effort by experts from the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Failure Society of America (HFSA). The guidelines were last updated in 2017.

The new changes highlight the importance of prevention, adds a new class of medication to the treatment options, and promotes a multidisciplinary care approach for people diagnosed with symptomatic heart failure.

“These new recommendations are timely and incorporate recent developments for treating heart failure,” Jeffrey Teuteberg, MD, associate professor of cardiovascular medicine at Stanford Hospital and Clinics, told Verywell. “They give the community a sense of what is going on.”

What Is Heart Failure?

Heart failure happens when a person’s heart is weak and cannot pump blood and oxygen to the rest of the body as well as it should.

According to the Centers for Disease Control and Prevention (CDC), heart failure affects 6.2 million American adults.

While there is not a cure for heart failure, it can be managed through medication, lifestyle changes, and other treatments (like devices or surgery).

Who Is At Risk for Heart Failure?

People with certain underlying medical conditions are at a higher risk of developing heart failure, including people with:

• Diabetes
• High blood pressure (hypertension)
• Coronary artery disease (CAD)
• Obesity
• Valvular heart disease

Other factors like being sedentary, dietary patterns, genetics, and smoking are also linked to cardiovascular disease, including heart failure.

Heart Failure Stages 

The American Heart Association (AHA) classifies the levels of heart failure as:

• Stage A: At Risk for Heart Failure: There is no evidence of structural heart disease and muscle injury, nor are there any symptoms or evidence of heart muscle injury. Heart failure risks include disease, such as diabetes, metabolic syndrome, or hypertension; heredity; and treatments that may cause heart damage, such as cancer chemotherapy.
  
• Stage B: Pre-Heart Failure: There is evidence of structural heart disease and muscle injury, but there are no symptoms.
• Stage C: Symptomatic Heart Failure: There is structural heart disease with symptoms such as shortness of breath, coughing, swelling in arms, legs, or abdomen.
• Stage D: Advanced Heart Failure: There is structural heart disease with symptoms that interfere with daily activities, and usually include recurrent hospitalizations.

Ejection Fraction

The updated heart failure guidelines also made changes to the four left ventricular ejection fraction (LVEF) classifications.

The ejection fraction shows how well the left ventricle of the heart can squeeze to pump blood. The metric is used to see how the disease is progressing and whether it’s responding to treatment.

The updated levels of ejection fraction (normal range is 50%–55%) are:

• HFrEF (reduced ejection fraction): less than or equal to 40%
• HFimpEF (improved ejection fraction): improved from less than 40% to above 40%
• HFmrEF (mildly reduced ejection fraction): between 41%–49%
• HFpEF (preserved ejection fraction): above 50% but with increased filling pressures

Highlights of New Recommendations

There were a few key updates to the guidance that will change how providers work with patients who have various stages of heart failure, including medication and goals of treatment.

SGLT-2

One key part of the update is that it addresses a commonly overlooked group of patients who are showing early signs of heart failure with mildly reduced or preserved ejection fraction.

Experts have recommended that a new class of medications, along with other prevention measures, be used to reduce complications, hospitalizations, and death caused by heart failure for patients with HFmrEF and HFpEF.

Teuteberg said that the addition is “a real boon” as “there are fewer medications and therapies for people with that category of heart failure.”

The class of medication—sodium-glucose transport protein 2 (SGLT-2) inhibitors—is also recommended as a treatment option for patients with symptomatic and advanced-stage heart failure.

SGLT-2 is mainly used to treat type 2 diabetes because it lowers blood sugar levels and can even improve heart health.

In fact, clinical trials have shown that an SGLT-2 inhibitor can lower the risk of hospitalization by 30%. That evidence is why the experts decided to add the drug to the new heart failure management guidelines.

Pre-Heart Failure

Giving more attention to “pre-heart failure” (stage B) is also an important goal of the new guidelines.

Experts want to shift the focus to emphasize the progressive nature of the disease and hopefully lead to more effective communication between patients and providers.

The primary treatment goal for patients in stage B is controlling their blood pressure, lowering their cholesterol, and managing their blood sugar levels to help prevent the disease from progressing.

Prevention

Making sure that heart failure patients—especially those who are in the latter stages of the disease—have a multidisciplinary care team is another key part of the updated recommendations.

For example, many of these patients will benefit from working with cardiac medicine professionals who specialize in late-stage heart failure, transplant surgery, implantable cardiac devices, and palliative care.

While the guidelines address how to help the patients with advanced disease, they also stress the importance of prevention—be it through identifying at-risk patients sooner or using a new class of medications to treat patients in stages A and B.

Much cardiovascular disease prevention can be achieved by making lifestyle changes—but patients still need support from their medical providers to make those changes and stick with them.

With a focus on prevention, the hope is that millions of people who are at risk for heart failure might be able to stop the progression of the disease and live a healthy, symptom-free life.