1 Heart Failure - Adult - Inpatient/Ambulatory Clinical Practice Guideline Endorsement Note: Active Table of Contents – Click each header below to jump to the section of interest Table of Contents INTRODUCTION .................................................................................................................................3 SCOPE ................................................................................................................................................3 RECOMMENDATIONS .........................................................................................................................4 METHODOLOGY .................................................................................................................................5 RELATED TOOLS & RESOURCES ...........................................................................................................6 REFERENCES ......................................................................................................................................7 Effective 12/15/2022. Contact CCKM@uwhealth.org for previous versions. Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 01/2023 2 Content Experts: Name: Ravi Dhingra, MD - Cardiology Email Address: rdhingra@medicine.wisc.edu Name: Anne O’Connor, MD - Cardiology Email Address: aoconnor@medicine.wisc.edu Workgroup Members: Anne Rose, PharmD – Anticoagulation Stewardship Bethany Westerfeldt, NP- Cardiology David Pham, MD- Cardiology David Yang, MD - Pathology Elise Strycharske, NP- Cardiology Jamie Kling, MD - Family Medicine Kleitia Dida, MD – Internal Medicine Mackenzie McCauley, PharmD – Ambulatory Care Pharmacy Margaret Murray, RN – Cardiac Surgery Mark Micek, MD-Internal Medicine Peter Rahko, MD – Cardiology Theodore Berei, PharmD – Inpatient Services Contact for Changes: Center for Clinical Knowledge Management (CCKM) Email Address: CCKM@uwhealth.org Guideline Author: Lee Skrupky, PharmD, FCCM – CCKM Committee Approval(s): Clinical Knowledge Management Council (12/15/22) Effective 12/15/2022. Contact CCKM@uwhealth.org for previous versions. Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 01/2023 3 Introduction Heart failure (HF) is a significant cause of morbidity and mortality globally and in the US, with ~5.7 million Americans currently diagnosed with heart failure and an estimated 670,000 additional cases being identified each year.1 Some worrisome trends have recently been observed with respect to HF in the US, including increasing hospitalizations for heart failure, increasing age-adjusted death rate per capita, and an increasing incidence of heart failure with preserved ejection fraction (HFpEF) The increase in absolute number of patients with HF is thought to be related to the increasing number of older adults in the population, while the actual incidence of HF has reduced in recent years.2 It is therefore imperative to implement effective prevention, diagnostic, and management strategies to optimize outcomes for all patients across the spectrum of this complex disease sate. The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines provides up-to-date, evidence-based recommendations for the prevention, diagnosis and treatment of HF.2 This 2022 Guideline replaces both the “2013 ACCF/AHA Guideline for the Management of Heart Failure”3 and the “2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure.”4 Following a review of its content, this UW Health guideline workgroup agreed to endorse the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.2 Scope Intended User(s): Physicians, Advanced Practice Providers, Registered Nurses, Pharmacists Objective(s): To provide standardized, evidence-based recommendations for the management of heart failure. Target Population: Patients aged 18 years or older with pre-heart failure, heart failure with reduced ejection fraction (HFrEF), heart failure with improved ejection fraction (HFimpEF), heart failure with mildly reduced ejection fraction (HFmrEF), and heart failure with preserved ejection fraction (HFpEF). This guideline does not include recommendations for congenital heart lesions in adults. Clinical Questions Considered: • How should patients be evaluated for heart failure? • What are the stages of heart failure? • What are guideline-recommended therapies for the different stages of heart failure? Definitions American College of Cardiology (ACC)/American Heart Association (AHA) Stages of HF2 Stage A (At Risk for HEF) At high risk for HF but without structural heart disease of symptoms of HF B (Pre-HF) Structural heart disease but without signs or symptoms of HF C (Symptomatic HF) Structural heart disease with prior or current symptoms of HF D (Advanced HF) Refractory HF requiring specialized interventions New York Heart Association (NYHA) Functional Classifications of HF2 I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF. Effective 12/15/2022. Contact CCKM@uwhealth.org for previous versions. Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 01/2023 4 III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. IV Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest. Heart Failure Classification by Left Ventricular Ejection Fraction (LVEF)2 Classification Criteria HFrEF (HF with reduced EF) LVEF ≤ 40% HFimpEF (HF with improved EF) Previous LVEF ≤ 40% with subsequent measurement of LVEF > 40% HFmrEF (HF with mildly reduced EF) LVEF 41-49% and Evidence of spontaneous or provokable increased LV filling pressures* HFpEF (HF with preserved EF) LVEF ≥ 50% and Evidence of spontaneous or provokable increased LV filling pressures* *Examples of evidence of increased LV filling pressures include elevated natriuretic peptide, noninvasive and invasive hemodynamic measurement Recommendations UW Health endorses the recommendations found within the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.2 Directly below are links to helpful content found with the AHA/ACC/HFSA Guideline: • Definitions and stages of heart failure • Initial and serial evaluation • Management of patients with Stage B HF (Pre-HF) • Management of patients with Stage C HF (Symptomatic HF) o This section includes recommendations for HFmrEF, HFimpEF, and HFpEF • Management of patients with Stage D HF (Advanced HF) Effective 12/15/2022. Contact CCKM@uwhealth.org for previous versions. Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 01/2023 5 Disclaimer Clinical practice guidelines assist clinicians by providing a framework for the evaluation and treatment of patients. This guideline outlines the preferred approach for most patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish the only appropriate approach to a problem. Conflicts of Interest All guideline workgroup members are expected to follow institutional policies and procedures around conflicts of interest. Actions in which a guideline member discloses a conflict of interest relevant to the guideline topic may include, but is not limited to, abstaining from voting, dismissal during comment and voting period, or recusal from requesting and/or participation in the decision-making process. Methodology Development Process Each guideline is reviewed and updated approximately every 3 years, in consideration of the primary literature and relevant practice changes. All guidelines are developed using the guiding principles, standard processes, and styling outlined in the UW Health Clinical Practice Guideline Resource Guide. This includes expectations for workgroup composition and recruitment strategies, disclosure and management of conflict of interest for participating workgroup members, literature review techniques, evidence grading resources, required approval bodies, and suggestions for communication and implementation. Methods Used to Formulate the Recommendations: Following a review and discussion of the literature along with internal UW Health expert opinion, the workgroup members agreed to adopt recommendations developed by the American Heart Association (AHA), American College of Cardiology (ACC), and the Heart Failure Society of America (HFSA). All recommendations endorsed or developed by the guideline workgroup were reviewed and approved by other stakeholders or committees (as appropriate). As the AHA/ACC/HFSA HF Guideline is considered to represent the gold standard for guideline-directed medical therapy by UW Health internal experts, a formal guideline appraisal was not completed. Effective 12/15/2022. Contact CCKM@uwhealth.org for previous versions. Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 01/2023 6 Related Tools & Resources Metrics • Number of HF patients diagnosed with heart failure prescribed guideline directed medications • Number of HF exacerbation admissions in past 12 months • Percentage of orders placed from heart failure best practice alerts Related UW Health Clinical Practice Guidelines 1. Atrial Fibrillation Management – Adult – Inpatient/Ambulatory 2. Acute Coronary Syndrome (STEMI And Non-ST Elevation ACS) - Adult - Inpatient/Emergency Department 3. Mechanical Circulatory Device (MCD) – Adult – Inpatient/Ambulatory 4. Hypertension (HTN): Diagnosis and Management – Adult – Ambulatory 5. Diabetes - Adult/Pediatric - Inpatient/Ambulatory/Emergency Department 6. Tobacco Use or Secondhand Exposure: Assessment and Tobacco Cessation Interventions - Adult/Pediatric - Inpatient/Ambulatory Order Sets & Smart Sets IP- Heart Failure – Adult -Admission [688] IP- Heart Failure – Adult – Discharge [1411] Patient Resources 1. Health Facts for You #6078- Heart Failure Packet 2. Health Facts for You #6154 - Congestive Heart Failure for MCD Patients 3. Health Facts for You #5817- How to Lower Your Risk of CAD 4. Health Facts for You #5818 – Coronary Artery Plaque 5. Health Facts for You #180 – How to Lower Sodium in Your Diet 6. Health Facts for You #203 - Eating Healthy when Dining Out 7. Health Facts for You #302 – Using The Nutrition Label 8. Health Facts for You #3199- Heart Failure (KAB) Packet 9. Health Facts for You #7810- Heart Failure Zones 10. Health Facts for You #6885- Heart Failure and Depression 11. Health Facts for You #7727- Preventive Cardiology Cardiac Rehab for Heart Failure 12. Health Facts for You #8194- Your Heart Transplant Surgery 13. Health Facts for You #8164- Waiting for your heart transplant 14. UW Health - Heart Failure Protocols Heart Failure and Hypertension Lab Ordering in Cardiology – Adult – Ambulatory [78] Heart Failure Medication Titration – Adult – Ambulatory [82] Effective 12/15/2022. Contact CCKM@uwhealth.org for previous versions. Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 01/2023 7 References 1. Assocation AH. Target: HF. Accessed 11/17/22, 2022. https://www.heart.org/en/professional/quality-improvement/target-heart-failure 2. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. May 3 2022;145(18):e895-e1032. doi:10.1161/CIR.0000000000001063 3. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. Oct 15 2013;62(16):e147- 239. doi:10.1016/j.jacc.2013.05.019 4. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/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. Aug 8 2017;136(6):e137-e161. doi:10.1161/CIR.0000000000000509 Effective 12/15/2022. Contact CCKM@uwhealth.org for previous versions. Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 01/2023