10 key updates from new American College of Cardiology inpatient heart failure recommendations
The American College of Cardiology (ACC) has published new recommendations designed to help cardiologists and other healthcare providers provide optimal care to patients hospitalized with heart failure. The new expert consensus decision pathway (ECDP) replaces a similar document from 2019 and is to be used in conjunction with heart failure guidelines published in 2022 by the ACC, American Heart Association and Heart Failure Society of America.
Inpatient hospital admissions related to heart failure symptoms are associated with high mortality rates—it is one reason so many clinical studies track heart failure hospitalizations when monitoring the safety and effectiveness of a new drug or medical device.
“Clinicians should be assessing and optimizing therapy during a hospital stay to not only provide a good clinical response in the hospital, but also to address a patient’s long-term trajectory after discharge,” Steven Hollenberg, MD, director of cardiac intensive care at the Emory Heart and Vascular Center and ECDP writing committee chair, said in a statement. “The updated ECDP places increased emphasis on establishing all four pillars of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) in the hospital, when possible, along with ensuring appropriate follow-up to monitor tolerance and continue medication.”
The new ECDP was published in full in the Journal of the American College of Cardiology, the ACC’s flagship journal.[1]. Because the document covers so much ground, the writing committee provided a list of 10 key changes in these new recommendations compared to the 2019 ECDP.
10 important updates in the American College of Cardiology’s 2024 expert consensus decision pathway about patients hospitalized with heart failure
1. The writing committee emphasized the importance of sodium-glucose cotransporter (SGLT) inhibitor therapy during heart failure hospitalizations. Regardless of a patient’s left ventricular ejection fraction, the group wrote, SGLT inhibitors can be started at any time, and the other pillars can be brought in after the patient is stabilized.
2. Hospital admissions for a new diagnosis of heart failure when the patient is already in the emergency department should occur when there are “rapidly progressive symptoms, severe congestion or higher complexity of disease.” Some low-risk patients, meanwhile, may be able to receive care in an observation unit or even from the comfort of home.
3. The typical routes that end with heart failure hospital admission include “newly diagnosed heart failure, chronic heart failure with previous therapy or advanced heart failure with chronic Class IV symptoms despite previously recommended therapies.”
4. Daily trajectory reviews may reveal that the patient is progressing toward effective decongestion and stabilization for the initiation of neurohormonal therapies.
5. Daily trajectory reviews may indicate a patient is “stalling” after an initial response to therapy, failing to respond at all or exhibiting worsening symptoms. This could warrant “diuretic agent therapies, reconsideration of etiology, physiology and comorbidities, possible escalation to other therapies and re-evaluation of goals of care.”
6. SGLT inhibitors and mineralocorticoid antagonists can be initiated at any time and continued after discharge, unless a specific patient’s medical history suggests otherwise.
7. Any strategies focused on neurohormonal therapies of beta-adrenergic blocking agents and angiotensin receptor-neprilysin inhibitors (ARNIs)/ angiotensin-converting enzyme (ACE) inhibitor/angiotensin II receptor blockers (ARBs) should examine the patient’s history with each therapy as well as all relevant hemodynamic data and the patient’s kidney function.
8. The selection of an ARNI/ACE inhibitor/ARB or switching from an ACE inhibitor/ARB to ARNI are both indicated for treating HFrEF, and can “generally be initiated” in combination with beta-blockers after the patient has been stabilized. Steps should be taken to minimize the patient’s risk of hypotension or kidney dysfunction.
9. Detailed plans related to diagnoses, discharge and other helpful information should be provided to patients and their referring physicians. These documents can then be reviewed during follow-up phone calls and other appointments.
10. The writing committee highlighted the substantial role palliative care can play when helping patients “recognize progressive disease and re-evaluate goals of care.”
These updates represent just the tip of the iceberg. The full document is now available in the Journal of the American College of Cardiology.
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.