This is the current release of the guideline.

This guideline updates a previous version: Heart Failure Society of America. Heart Failure Society of America (HFSA) practice guidelines. HFSA guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction--pharmacological approaches. J Card Fail 1999 Dec;5(4):357-82.

Hypertension and heart failure

Management
Treatment

Cardiology
Family Practice
Internal Medicine

Physicians

To provide recommendations for managing patients with hypertension and heart failure

Patients with hypertension and heart failure

1. Aggressive treatment of blood pressure to target resting levels (<130/<80 mm Hg)
2. Medications used alone or in combination:
   • Angiotensin-converting enzyme inhibitor
   • Angiotensin receptor blocker
   • Diuretic
   • Beta-blocker
   • Calcium antagonist
   • Aldosterone inhibitors
   • Isosorbide dinitrate/hydralazine

Relationship of blood pressure to outcome in heart failure

Searches of Electronic Databases
Searches of Unpublished Data

Databases searched included Medline and Cochrane. In addition, the guideline developers polled experts in specific areas for data.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Level A: Randomized, Controlled, Clinical Trials
May be assigned based on results of a single trial

Level B: Cohort and Case-Control Studies
Post hoc, subgroup analysis, and meta-analysis
Prospective observational studies or registries

Level C: Expert Opinion
Observational studies – epidemiologic findings
Safety reporting from large-scale use in practice

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

The Heart Failure Society of America (HFSA) Guideline Committee sought resolution of difficult cases through consensus building. Written documents were essential to this process, because they provided the opportunity for feedback from all members of the group. On occasion, consensus of Committee opinion was sufficient to override positive or negative results of almost any form or prior evidence.

"Is recommended": Part of routine care
Exceptions to therapy should be minimized.

"Should be considered": Majority of patients should receive the intervention.
Some discretion in application to individual patients should be allowed.

"May be considered": Individualization of therapy is indicated

"Is not recommended": Therapeutic intervention should not be used

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

The process of moving from ideas of recommendations to a final document includes many stages of evaluation and approval. Every section, once written, had a lead reviewer and 2 additional reviewers. After a rewrite, each section was assigned to another review team, which led to a version reviewed by the Committee as a whole and then the Heart Failure Society of America (HFSA) Executive Council, representing 1 more level of expertise and experience. Out of this process emerged the final document.

The strength of evidence (A, B, C) and strength of recommendations are defined at the end of the "Major Recommendations" field.

Asymptomatic or Symptomatic Left Ventricular (LV) Hypertrophy or LV Dysfunction without LV Dilation (Preserved Ejection Fraction [EF])

• It is recommended that blood pressure be aggressively treated to lower systolic and usually diastolic levels. Target resting levels should be <130/<80 mm Hg, if tolerated. (Strength of Evidence = C)
• Treatment with several drugs should be considered, usually including an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB), a diuretic and often a beta-blocker or calcium antagonist. (Strength of Evidence = A)

Asymptomatic LV Dysfunction with LV Dilation and a Low EF

• Prescription of an ACE inhibitor (dose equivalent to 20 mg daily enalapril) is recommended (Strength of Evidence = A)
• Addition of a beta-blocker (dose equivalent to heart failure [HF] trials) is recommended even if blood pressure is controlled. (Strength of Evidence = C)
• If blood pressure remains >130/80 mm Hg then the addition of a diuretic is recommended, followed by a calcium antagonist or other antihypertensive drugs. (Strength of Evidence = C)

Symptomatic LV Dysfunction with LV Dilation and Low EF

• Prescription of target doses of ACE inhibitors, ARBs, beta-blockers, aldosterone inhibitors, and isosorbide dinitrate/hydralazine in various combinations (with a diuretic if needed) is recommended, based on doses used in large-scale outcome trials. (Strength of Evidence = A)
• If blood pressure remains >130/80 mm Hg, a noncardiac depressing calcium antagonist (e.g., amlodipine) may be considered or other antihypertensive medication doses increased. (Strength of Evidence = C)

Definitions:

Strength of Evidence

Level A: Randomized, Controlled, Clinical Trials
May be assigned based on results of a single trial

Level B: Cohort and Case-Control Studies
Post hoc, subgroup analysis, and meta-analysis
Prospective observational studies or registries

Level C: Expert Opinion
Observational studies – epidemiologic findings
Safety reporting from large-scale use in practice

Strength of Recommendations

"Is recommended": Part of routine care
Exceptions to therapy should be minimized.

"Should be considered": Majority of patients should receive the intervention.
Some discretion in application to individual patients should be allowed.

"May be considered": Individualization of therapy is indicated

"Is not recommended": Therapeutic intervention should not be used

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations").

The recommendations are supported by randomized controlled clinical trials, cohort and case-control studies, and expert opinion.

Appropriate treatment/management of hypertension to prevent the development and progression of left ventricular (LV) dysfunction

Not stated

It must be recognized that the evidence supporting recommendations is based largely on population responses that may not always apply to individuals within the population. Therefore, data may support overall benefit of 1 treatment over another but cannot exclude that some individuals within the population may respond better to the other treatment. Thus guidelines can best serve as evidence-based recommendations for management, not as mandates for management in every patient. Furthermore, it must be recognized that trial data on which recommendations are based have often been carried out with background therapy not comparable to therapy in current use. Therefore, physician decisions regarding the management of individual patients may not always precisely match the recommendations. A knowledgeable physician who integrates the guidelines with pharmacologic and physiologic insight and knowledge of the individual being treated should provide the best patient management.

An implementation strategy was not provided.

Living with Illness

Effectiveness

Not applicable: The guideline was not adapted from another source.

1999 (revised 2006 Feb)

Heart Failure Society of America, Inc - Disease Specific Society

Heart Failure Society of America, Inc

Comprehensive Heart Failure Practice Guideline Committee

Committee Members: Kirkwood F. Adams, Jr, MD (Co-Chair); JoAnn Lindenfeld, MD (Co-Chair); J. Malcolm O. Arnold, MD; David W. Baker, MD; Denise H. Barnard, MD; Kenneth Lee Baughman, MD; John P. Boehmer, MD; Prakash Deedwania, MD; Sandra B. Dunbar, RN, DSN; Uri Elkayam, MD; Mihai Gheorghiade, MD; Jonathan G. Howlett, MD; Marvin A. Konstam, MD; Marvin W. Kronenberg, MD; Barry M. Massie, MD; Mandeep R. Mehra, MD; Alan B. Miller, MD; Debra K. Moser, RN, DNSc; J. Herbert Patterson, PharmD; Richard J. Rodeheffer, MD; Jonathan Sackner-Bernstein, MD; Marc A. Silver, MD; Randall C. Starling, MD, MPH; Lynne Warner Stevenson, MD; Lynne E. Wagoner, MD

HFSA Executive Council: Gary S. Francis, MD, President; Michael R. Bristow, MD, PhD; Jay N. Cohn, MD; Wilson S. Colucci, MD; Barry H. Greenberg, MD; Thomas Force, MD; Harlan M. Krumholz, MD; Peter P. Liu, MD; Douglas L. Mann, MD; Ileana L. Pina, MD; Susan J. Pressler, RN, DNS; Hani N. Sabbah, PhD; Clyde W. Yancy, MD

Committee members and reviewers from the Executive Council received no direct financial support from the Heart Failure Society of America (HFSA) or any other source for the development of the guideline. Administrative support was provided by the Heart Failure Society of America staff, and the writing of the document was performed on a volunteer basis by the Committee. Financial relationships that might represent conflicts of interest were collected for all members of the Guideline Committee and of the Executive Council, who were asked to disclose potential conflicts and recuse themselves from discussions when necessary. Current relationships are shown in Table 1.5 of the "Development and Implementation" companion document (see the "Availability of Companion Documents" field).

This is the current release of the guideline.

This guideline updates a previous version: Heart Failure Society of America. Heart Failure Society of America (HFSA) practice guidelines. HFSA guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction--pharmacological approaches. J Card Fail 1999 Dec;5(4):357-82.

None available

This NGC summary was completed by ECRI on July 31, 2006. The information was verified by the guideline developer on August 10, 2006.