Medical Care Line Executive, DeBakey VA Medical Center, Houston, TX, USA.
Department of Medicine at Baylor College of Medicine, Houston, TX, USA.
Curr Cardiol Rep. 2018 Apr 17;20(6):39. doi: 10.1007/s11886-018-0978-7.
The goal of this paper is to provide a summary of the new recommendations in the most recent 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. The intent is to provide the background and the supporting evidence for the recommendations and to provide practical guidance for management strategies in treatment of heart failure patients.
In the 2017 ACC/AHA/HFSA Focused Update of HF guidelines, important additions include new information on biomarkers, specifically on the topics of the diagnostic, prognostic role of natriuretic peptides in heart failure, and the role of natriuretic peptides in screening in patients high risk for HF and prevention of HF. There are important recommendations for treatment of patients with HF with reduced EF (HFrEF), including the beneficial role of angiotensin receptor blocker and neprilysin inhibition (ARNI) treatment in reducing outcomes including mortality, ivabradine in reducing heart failure hospitalizations in stable HFrEF patients with sinus rhythm and heart rate ≥ 70 bpm despite β-blockers. In patients with HF with preserved EF (HFpEF), though there are no studies demonstrating survival benefit, potential benefit with aldosterone antagonism in reducing HF hospitalizations is noted. In treatment of comorbidities, optimization of blood pressure control to less than 130 mmHg is recommended in hypertensive patients to prevent HF or in patients with hypertension and HFrEF or HFpEF. In addition to recognition on the potential role of treatment of iron deficiency anemia to improve symptoms and functional capacity, caution against use of adaptive servo-ventilation in patients with HFrEF and central sleep apnea and against use of erythropoietin stimulating agents in patients with HFrEF is provided. There are new treatment strategies that are associated with significant improvements in mortality and other outcomes in patients with HF. Successful management of HF requires recognition of indications, contraindications, benefits, safety, and risk of these new therapies. In addition to incorporation of these new treatment strategies, it is critical to focus also on patient education, care coordination, identification of goals of care, monitoring, management of comorbidities, and individualization of therapies. New treatment modalities increase the choices for treatment and provide the opportunity to implement individualized treatment strategies for our patients.
本文旨在总结 2017 年美国心脏病学会/美国心脏协会/心力衰竭学会（ACC/AHA/HFSA）对 2013 年 ACCF/AHA 心力衰竭管理指南的重点更新，该更新为美国心脏病学会（ACC）/美国心脏协会（AHA）临床实践指南工作组和心力衰竭学会（HFSA）的报告。目的是为建议提供背景和支持证据，并为心力衰竭患者的治疗管理策略提供实用指导。
在 2017 年 ACC/AHA/HFSA 心力衰竭指南重点更新中，新增加的内容包括生物标志物的新信息，特别是心力衰竭中利钠肽的诊断和预后作用，以及高危心力衰竭和心力衰竭预防患者中利钠肽筛查的作用。在射血分数降低的心力衰竭（HFrEF）患者治疗中，有重要的建议，包括血管紧张素受体阻滞剂和脑啡肽酶抑制剂（ARNI）治疗可降低死亡率等结局，伊伐布雷定可降低窦性心律且心率≥70 bpm 的稳定 HFrEF 患者的心力衰竭住院率。在射血分数保留的心力衰竭（HFpEF）患者中，虽然没有研究证明生存获益，但注意到醛固酮拮抗剂在减少心力衰竭住院率方面可能有获益。在治疗合并症方面，建议高血压患者血压控制在 130mmHg 以下，以预防心力衰竭或高血压合并 HFrEF 或 HFpEF。除了认识到治疗缺铁性贫血可改善症状和功能能力的潜在作用外，还提醒注意避免在 HFrEF 合并中枢性睡眠呼吸暂停患者中使用适应性伺服通气，并避免在 HFrEF 患者中使用促红细胞生成素刺激剂。新的治疗策略可显著改善心力衰竭患者的死亡率和其他结局。成功治疗心力衰竭需要认识这些新疗法的适应证、禁忌证、益处、安全性和风险。除了纳入这些新的治疗策略外，还必须关注患者教育、护理协调、确定护理目标、监测、合并症的管理和治疗的个体化。新的治疗方式增加了治疗选择，并为我们的患者提供了实施个体化治疗策略的机会。
