Development and Implementation of a Comprehensive Heart Failure Practice Guideline
Heart failure (HF) is a syndrome characterized by high mortality, frequent hospitalization, poor quality of life, and multiple comorbidities. As a result, heart failure management inevitably involves both a multidimensional assessment process and a complex therapeutic regimen. Knowledge about the pathophysiology and treatment of HF continues to accumulate very rapidly so that individual clinicians may be unable to readily and adequately synthesize new information into effective principles of care for patients with this syndrome. Trial data, though valuable, often do not give adequate direction for individual patient management.
Given the complex and changing picture of HF and the accumulation of evidence-based HF therapy, it is not possible for the clinician to rely solely on personal experience and observation to guide therapeutic decisions. This situation is exacerbated because HF is now a chronic condition in most patients, meaning that the outcome of therapeutic decisions might not be apparent for several years. The natural history and prognosis of individual patients differs considerably, making it difficult to generalize. Treatments might not dramatically improve symptoms of the disease process, yet might prevent of delay its progression and the occurrence of morbid events and deaths. The assessment of specific therapeutic outcomes is complicated by the potential differential impact of various cotherapies.
The complexity of HF, its high prevalence, and the availability of many therapeutic options make it an ideal area for practice guidelines. Additional assumptions driving the development of HF guidelines are presented in Table 1.1.
The first HF guideline developed by the Heart Failure Society of America (HFSA) had a narrow scope, concentrating on the pharmacologic treatment of chronic, symptomatic left ventricular dysfunction.1 It did not consider subsets of the clinical syndrome of HF, such as acute decompensated HF and "diastolic dysfunction," or issues such as prevention. The subsequent comprehensive clinical practice guideline published in 2006 addressed a full range of topics including prevention, evaluation, disease management, and pharmacologic and device therapy for patients with HF.2 The 2010 guideline updates and expands each of these areas and adds a section on the Genetic Evaluation of Cardiomyopathy published separately in 2009.3 The discussion of end of life management has also been considerably expanded.
Table 1.1: Assumptions Underlying HFSA Practice Guideline
Clinical decisions must be made.
Correct course of action may not be readily apparent.
Multiple non-pharmacologic, pharmacologic, and device therapies are available.
Reasonably valid methods exist to address knowledge base and evaluate medical evidence.
Data beyond randomized clinical trials exist that enhance medical decision making.
Uncertainties remain concerning approaches to treatment after review of totality of medical evidence.
Expert opinion has a role in management decisions when Strength of Evidence A data are not available to guide management.
A consensus of experts remains the best method of management recommendations when Strength of Evidence A data are not available