Test your recall of the most recent amendments to the heart failure guidelines on prevention, treatment of hypertension, and comorbidities.
In early 2017, the American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) published the second of two focused updates to the 2013 ACCF/AHA Guideline for the Management of Heart Failure. Both amendments to the original 2013 document incorporate data released since the earlier publication on essential elements including HF prevention, hypertension management, and treatment of common comorbidities.
The three questions that follow are a quick test of your recall of the most recent update, published in Circulation in April, 2017.
1. You are seeing a patient who has NYHA Class II heart failure and a ferritin level of <100 ng/mL. Based on the recent update to the ACC/AHA/HFSA HF guideline, which of the following is true?
A. Oral iron replacement may be of benefit
B. Oral iron replacement likely has no benefit
C. Intravenous iron replacement may be of benefit
D. Intravenous iron replacement likely has no benefit
The correct answer is: C. Intravenous iron replacement may be of benefit.
According to 2017 ACC/AHA/HFSA updated guidelines on the management of HF, intravenous iron replacement is recommended in patients with NYHA class II and class III HF and iron deficiency anemia (ferritin <100 ng/mL or 100 to 300 ng/mL if transferrin saturation is < 20%). This is a newrecommendation, based on new evidence from clinical trials suggesting improvement in exercise, functional capacity, and LVEF with intravenous iron replacement. However, larger trials are needed before ACC/AHA/HFSA can make a strong recommendation on the matter. The evidence base for oral iron repletion is uncertain in this setting.1
2. A 78-year-old patient has a Framingham Risk Score of 20%. What is the optimal blood pressure for this patient in order to decrease the risk of developing HF?
A. <120/80 mmHg
B. <130/80 mmHg
C. <140/80 mmHg
D. Research does not support targeting systolic blood pressure to prevent HF in a patient like this.
The correct answer is: B. <130/80 mmHg
In the 2017 focused update, the ACC/AHA/HFSA newly recommended that the optimal blood pressure for the prevention of HF in patients at increased CV risk (age >75 years, established vascular disease, chronic renal disease, or a Framingham Risk Score >15%), should be 130/80 mm Hg. Targeting systolic blood pressure in patients with increased CV risk represents a new strategy for the prevention of HF. It is based on new RCT data suggesting that controlling systolic blood pressure to <120 mmHg was linked to significantly decreased HF and decreased CV death overall.2 Because blood pressure measured in a clinical setting is usually 5 to 10 mmHg higher compared to a research setting, the recommendation is to target blood pressure to <130/80 mmHg in clinical practice.1
3. Which of the following patients should not receive an angiotensin receptor neprilysin inhibitor (ARNI)?
A. A patient who is already on an ACE-I
B. A patient with a history of angioedema
C. A patient with HFrEF NYHA class II that remains symptomatic despite treatment with enalapril
D. Neither A or B
The correct answer is: D. Neither A or B
According to 2017 ACC/AHA/HFSA updated HF management guidelines, concomitant administration of an ACE-I and ARNI (or administering an ARNI <36 hours after stopping an ACE-I) is not recommended, based on the risk for for angioedema. Likewise, a patient with a history of angioedema should not receive an ARNI due to this risk. In patients with HFrEF NYHA class II or III who remain symptomatic despite tolerating an ACE-I or an ARB, ACC/AHA/HFSA recommends replacement with an ARNI. New clinical trial data suggests that replacing an ACE-I or ARB with an ARNI may decrease hospitalizations and mortality in such patients.
1. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017 Aug 8;136(6):e137-e161. doi: 10.1161/CIR.0000000000000509.
2. Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103–16.