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ACC/AHA guideline summary: Management of patients

with current or prior symptoms of heart failure (HF) and a
reduced left ventricular ejection fraction (LVEF) (HF stage
C)
Class I - There is evidence and/or general agreement
that the following approaches are effective in the
management of patients with current or prior symptoms
of HF and a reduced LVEF
Diuretics and salt restriction for fluid retention.
Angiotensin converting enzyme (ACE) inhibitors in all patients, unless
contraindicated.
Beta blockers in all stable patients, unless contraindicated. One of
the three beta blockers proven to reduce mortality should be used
(bisoprolol, carvedilol, and sustained release metoprolol succinate.
Angiotensin II receptor blockers (ARBs) in patients who do not
tolerate ACE inhibitors.
Drugs that can adversely affect the patient's clinical status should be
avoided or withdrawn, if possible. These include nonsteroidal
antiinflammatory drugs, most antiarrhythmic drugs, and most calcium
channel blockers.
Exercise training as an adjunctive approach to improve clinical status
in ambulatory patients.
An implantable cardioverter-defibrillator (ICD) for secondary
prevention to prolong survival in patients with a history of cardiac
arrest, ventricular fibrillation, or hemodynamically destabilizing
ventricular tachycardia.

An ICD for primary prevention to reduce total mortality by preventing

sudden cardiac death (SCD) in patients with non-ischemic or ischemic
heart disease who meet the following criteria: at least 40 days
post-myocardial infarction, an LVEF 35 percent, New York Heart
Association functional class II or III symptoms despite optimal chronic
medical therapy, and a reasonable expectation of survival with a good
functional status for more than one year.
Cardiac resynchronization therapy (CRT), with or without an ICD,
unless contraindicated, in patients who meet the following criteria:
cardiac dyssynchrony as defined by a QRS duration >120 msec, LVEF
35 percent, sinus rhythm, and New York Heart Association functional
class III or ambulatory class IV symptoms despite optimal medical
therapy.
Addition of an aldosterone antagonist is recommended in selected
patients with moderately severe to severe symptoms of HF and
reduced LVEF who can be carefully monitored for preserved renal
function and normal potassium concentration. Creatinine should be
2.5 mg per dl in men or 2.0 mg per dl in women and potassium
should be <5.0 mEq per liter. Under circumstances in which monitoring
for hyperkalemia and renal dysfunction is not anticipated to be
feasible, the risks may outweigh the benefits of aldosterone
antagonists.
The combination of hydralazine and nitrates is 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.

Class IIa - The weight of evidence and/or opinion is in

favor of the following approaches being effective in the
management of patients with current or prior symptoms
of HF and a reduced LVEF
It is reasonable to treat patients with atrial fibrillation and HF with a
strategy to maintain sinus rhythm or with a strategy to control
ventricular rate alone.
Maximal exercise testing with or without measurement of respiratory
gas exchange is reasonable to facilitate prescription of an appropriate
exercise program for patients presenting with HF.

ARBs as an alternative to ACE inhibitors as first-line therapy in

patients with mild to moderate HF, particularly those already taking an
ARB for other indications.
Digitalis in patients with current or prior symptoms of HF to reduce
hospitalization for HF.
The addition of the combination of hydralazine and a nitrate in
patients with persistent symptoms who are already taking an ACE
inhibitor and beta blocker.
CRT with or without an ICD is reasonable in patients with an LVEF of
35 percent, a QRS 0.12 seconds, and atrial fibrillation who have
New York Heart Association functional class III or ambulatory class IV
symptoms symptoms despite optimal chronic medical therapy.
CRT is reasonable in patients with an LVEF of
35 percent who have
New York Heart Association functional class III or ambulatory class IV
symptoms despite optimal medical therapy and who have frequent
dependence of ventricular pacing.

Class IIb - The weight of evidence and/or opinion is less

well established for the following approaches in the
management of patients with current or prior symptoms
of HF and a reduced LVEF
The combination of hydralazine and a nitrate in patients who cannot
be given an ACE inhibitor or ARB because of drug intolerance,
hypotension, or renal insufficiency.
Addition of an ARB in patients with persistent symptoms who are
already being treated with an ACE inhibitor, beta blocker, and diuretics.

Class III - There is evidence and/or general agreement

that the following approaches are not effective and may
be harmful in the management of patients with current
or prior symptoms of HF and a reduced LVEF
Routine use of triple therapy with an ACE inhibitor, an ARB, and an
aldosterone receptor antagonist is not recommended.
Routine administration of calcium channel blockers are not indicated.

Long-term infusion of a positive inotropic drug may be harmful and is

not recommended, except as palliation for end-stage disease that
cannot be stabilized with standard medical therapy.
Nutritional supplements are not indicated.
Hormonal therapies may be harmful and are not recommended
unless given to replete hormone deficiencies.

Data from Hunt, SA, Abraham, WT, Chin, MH, et al. 2009 focused
update incorporated into the ACC/AHA 2005 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. Circulation 2009; 119:e391.

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