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.

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

Education and Counseling

• It is recommended that patients with heart failure (HF) and their family members or caregivers receive individualized education and counseling that emphasizes self-care. This education and counseling should be delivered by providers using a team approach in which nurses with expertise in HF management provide the majority of education and counseling, supplemented by physician input and, when available and needed, input from dieticians, pharmacists, and other health care providers. All HF patients benefit from education and counseling, but patients in New York Heart Association (NYHA) functional class III or IV need the most intensive education, while patients in NYHA I or II need less intensive education. (Strength of Evidence = B)

  Teaching is not sufficient without skill building and specification of critical target behaviors. Essential elements of patient education to promote self-care with associated skills are shown in Table 8.1, below. (Strength of Evidence = B).

Table 8.1: Essential Elements of Patient Education With Associated Skills and Target Behaviors

• It is recommended that patients' literacy, cognitive status, psychologic state, culture, and access to social and financial resources be taken into account for optimal education and counseling. Because cognitive impairment and depression are common in HF and can seriously interfere with learning, patients should be screened for these. Appropriate interventions, such as supportive counseling and pharmacotherapy, are recommended for those patients found to be depressed. Patients found to be cognitively impaired need additional support to manage their HF. (Strength of Evidence = C)
• It is recommended that educational sessions begin with an assessment of current HF knowledge, issues about which the patient wants to learn, and the patient's perceived barriers to change. Address specific issues (e.g., medication nonadherence) and their causes (e.g., lack of knowledge vs cost vs forgetting) and employ strategies that promote behavior change, including motivational approaches. (Strength of Evidence = B)
• It is recommended that the frequency and intensity of patient education and counseling vary according to the stage of illness. Patients in advanced HF or with persistent difficulty adhering to the recommended regimen require the most education and counseling. Patients should be offered a variety of options for learning about HF according to their individual preferences:
  • Videotape
  • One-on-one or group discussion
  • Reading materials, translators, telephone calls, mailed information
  • Internet
  • Visits

  Repeated exposure to material is essential because a single session is never sufficient. (Strength of Evidence = B)

• It is recommended that during the care process patients be asked to:
  • Demonstrate knowledge of the name, dose, and purpose of each medication
  • Sort foods into high- and low-sodium categories
  • Demonstrate their preferred method for tracking medication dosing
  • Show provider daily weight log
  • Reiterate symptoms of worsening HF
  • Reiterate when to call the provider because of specific symptoms or weight changes (Strength of Evidence = B)
• During acute care hospitalization, only essential education is recommended, with the goal of assisting patients to understand HF, the goals of its treatment, and posthospitalization medication and follow-up regimen. Education begun during hospitalization should be supplemented and reinforced within 1-2 weeks after discharge, continued for 3-6 months, and reassessed periodically. (Strength of Evidence = B)

Disease Management Programs

• Patients recently hospitalized for HF and other patients at high risk should be considered for referral to a comprehensive HF disease management program that delivers individualized care. High-risk patients include those with renal insufficiency, low output state, diabetes, chronic obstructive pulmonary disease, persistent New York Heart Association class III or IV symptoms, frequent hospitalization for any cause, multiple active comorbidities, or a history of depression, cognitive impairment, or persistent non-adherence to therapeutic regimens. (Strength of Evidence = A)
• It is recommended that HF disease management programs include the components shown in Table 8.3, below, based on patient characteristics and needs. (Strength of Evidence = B)

Table 8.3: Recommended Components of a HF Disease Management Program

• It is recommended that HF disease management include integration and coordination of care between the primary care physician and HF care specialists and with other agencies, such as home health and cardiac rehabilitation. (Strength of Evidence = C).
• It is recommended that patients in a HF disease management program be followed until they or their family/caregiver demonstrate independence in following the prescribed treatment plan, adequate or improved adherence to treatment guidelines, improved functional capacity, and symptom stability. Higher risk patients with more advanced HF may need to be followed permanently. Patients who experience increasing episodes of exacerbation or who demonstrate instability after discharge from a program should be referred again to the service. (Strength of Evidence = B)

Advance Directives and End-of-life Care

• Patient and family or caregiver decisions about quality of life and prognosis are recommended as part of the disease management of HF. (Strength of Evidence = C)
• It is recommended that the patients' status be optimized medically and psychologically before discussing the possibility that end-of-life care is indicated. The decision to declare a patient as an appropriate candidate for end-of-life care should be made by physicians experienced in the care of patients with HF. End-of-life management should be coordinated with the patient's primary care physician. As often as possible, discussions regarding end-of-life care should be initiated while the patient is still capable of participating in decision-making. (Strength of Evidence = C)
• End-of-life care should be considered in patients who have advanced, persistent HF with symptoms at rest despite repeated attempts to optimize pharmacologic and nonpharmacologic therapy, as evidenced by 1 or more of the following:
  • Frequent hospitalization (3 or more per year)
  • Chronic poor quality of life with inability to accomplish activities of daily living
  • Need for intermittent or continuous intravenous support
  • Consideration of assist devices as destination therapy (Strength of Evidence = C)
• It is recommended that end-of-life care strategies be individualized, include effective symptom management and avoid unnecessary testing and interventions. (Strength of Evidence = C)
• It is recommended that, as part of end-of-life care, patients and their families/caregivers be given specific directions concerning their response to clinical events if they decide against resuscitation. Inactivation of an implantable defibrillation device should be discussed. (Strength of Evidence = C)
• It is recommended that patients with severe and unresponsive advanced HF have their wishes concerning treatment options and end-of-life care reassessed often, because decisions about resuscitation and palliative care may change over time. (Strength of Evidence = B)
• Patients with HF undergoing end-of-life care may be considered for hospice services that can be delivered in the home, a hospital setting, or a special hospice unit. (Strength of Evidence = C)
• Discussions about the possibility of sudden unexpected cardiac death are recommended for patients with HF. The extent and intensity of the discussion should vary according to the level of risk present. Discussions about the advance directives and cardiopulmonary resuscitation (CPR), including education for family members, should be provided on an individualized basis. (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.

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. Piña, 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.