© 2005 by the American College of Cardiology Foundation and the American Heart Association, Inc.
`
`ACC/AHA PRACTICE GUIDELINES—FULL TEXT
`
`ACC/AHA 2005 Guideline Update for the Diagnosis and
`Management of Chronic Heart Failure in the Adult
`A Report of the American College of Cardiology/American Heart Association Task
`Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for
`the Evaluation and Management of Heart Failure)
`
`Developed in Collaboration With the American College of Chest Physicians and the
`International Society for Heart and Lung Transplantation
`
`Endorsed by the Heart Rhythm Society
`
`WRITING COMMITTEE MEMBERS
`Sharon Ann Hunt, MD, FACC, FAHA, Chair
`
`William T. Abraham, MD, FACC, FAHA
`Marshall H. Chin, MD, MPH, FACP
`Arthur M. Feldman, MD, PhD, FACC, FAHA
`Gary S. Francis, MD, FACC, FAHA
`Theodore G. Ganiats, MD
`Mariell Jessup, MD, FACC, FAHA
`Marvin A. Konstam, MD, FACC
`
`Donna M. Mancini, MD
`Keith Michl, MD, FACP
`John A. Oates, MD, FAHA
`Peter S. Rahko, MD, FACC, FAHA
`Marc A. Silver, MD, FACC, FAHA
`Lynne Warner Stevenson, MD, FACC, FAHA
`Clyde W. Yancy, MD, FACC, FAHA
`
`TASK FORCE MEMBERS
`Elliott M. Antman, MD, FACC, FAHA, Chair
`Sidney C. Smith, Jr., MD, FACC, FAHA, Vice Chair
`Cynthia D. Adams, MSN, APRN-BC, FAHA
`Sharon Ann Hunt, MD, FACC, FAHA
`Jeffrey L. Anderson, MD, FACC, FAHA
`Alice K. Jacobs, MD, FACC, FAHA
`David P. Faxon, MD, FACC, FAHA*
`Rick Nishimura, MD, FACC, FAHA
`Valentin Fuster, MD, PhD, FACC, FAHA, FESC*
`Joseph P. Ornato, MD, FACC, FAHA
`Jonathan L. Halperin, MD, FACC, FAHA
`Richard L. Page, MD, FACC, FAHA
`Loren F. Hiratzka, MD, FACC, FAHA*
`Barbara Riegel, DNSc, RN, FAHA
`
`*Former Task Force Member
`
`This document was approved by the American College of Cardiology
`Foundation Board of Trustees in August 2005 and by the American Heart
`Association Science Advisory and Coordinating Committee in August 2005.
`
`When citing this document, the American College of Cardiology Foundation
`requests that the following citation format be used: Hunt SA, Abraham WT,
`Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA,
`Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy
`CW. ACC/AHA 2005 guideline update for the diagnosis and management of
`chronic heart failure in the adult: a report of the American College of
`Cardiology/American Heart Association Task Force on Practice Guidelines
`(Writing Committee to Update the 2001 Guidelines for the Evaluation and
`Management of Heart Failure). American College of Cardiology Web Site.
`Available at: http://www.acc.org/clinical/guidelines/failure//index.pdf.
`(incorporates errata)
`
`Copies: This document is available on the World Wide Web sites of the
`American College of Cardiology (www.acc.org) and the American Heart
`Association (www.my.americanheart.org). Single copies of this document are
`available by calling 1-800-253-4636 or writing the American College of
`Cardiology Foundation, Resource Center, at 9111 Old Georgetown Road,
`Bethesda, MD 20814-1699. Ask for reprint number 71-0327. To obtain a reprint
`of the Summary Article published in the September 20, 2005 issues of the
`Journal of the American College of Cardiology and Circulation, ask for reprint
`number 71-0328. To purchase bulk reprints (specify version and reprint num-
`ber): Up to 999 copies, call 1-800-611-6083 US only) or fax 413-665-2671;
`1000 or more copies, call 214-706-1789, fax 214-691-6342, or e-mail pub-
`auth@heart.org.
`
`Permissions: Multiple copies, modification, alteration, enhancement, and/or
`distribution of this document are not permitted without the express permission
`of the American College of Cardiology Foundation. Please direct requests to
`copyright_permissions@acc.org.
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`TABLE OF CONTENTS
`Preamble.................................................................................... e3
`1. Introduction............................................................................e3
`2. Characterization of HF as a Clinical Syndrome....................e7
`2.1. Definition of HF............................................................. e7
`2.2. HF as a Symptomatic Disorder...................................... e7
`2.3. HF as a Progressive Disorder......................................... e7
`
`3. Initial and Serial Clinical Assessment of Patients
`Presenting With HF................................................................e8
`3.1. Initial Evaluation of Patients........................................e10
`3.1.1. Identification of Patients.....................................e10
`3.1.2. Identification of a Structural and Functional
`Abnormality........................................................ e10
`3.1.3. Evaluation of the Cause of HF............................e11
`3.1.3.1. History and Physical Examination........e11
`3.1.3.2. Laboratory Testing................................ e11
`3.1.3.3. Evaluation of the Possibility of
`Coronary Artery Disease....................... e12
`3.1.3.4. Evaluation of the Possibility of
`Myocardial Disease............................... e13
`3.2. Ongoing Evaluation of Patients................................... e13
`3.2.1. Assessment of Functional Capacity.................... e13
`3.2.2. Assessment of Volume Status............................. e14
`3.2.3. Laboratory Assessment.......................................e14
`3.2.4. Assessment of Prognosis.................................... e15
`
`4. Therapy................................................................................ e15
`4.1. Patients at High Risk for Developing HF (Stage A)....e15
`4.1.1. Control of Risk................................................... e16
`4.1.1.1. Treatment of Hypertension....................e16
`4.1.1.2. Treatment of Diabetes........................... e17
`4.1.1.3. Management of the Metabolic
`Syndrome...............................................e17
`4.1.1.4. Management of Atherosclerotic
`Disease...................................................e17
`4.1.1.5. Control of Conditions That May Cause
`Cardiac Injury........................................e18
`4.1.1.6. Other Measures..................................... e18
`4.1.2. Early Detection of Structural Abnormalities...... e18
`4.2. Patients With Cardiac Structural Abnormalities or
`Remodeling Who Have Not Developed HF
`Symptoms (Stage B).......................................... e18
`4.2.1. Prevention of Cardiovascular Events................. e19
`4.2.1.1. Patients With an Acute MI.................... e19
`4.2.1.2. Patients With a History of MI but
`Normal LVEF........................................ e19
`4.2.1.3. Patients With Hypertension and LVH...e19
`4.2.1.4. Patients With Chronic Reduction of
`LVEF but No Symptoms.......................e19
`4.2.1.5. Patients With Severe Valvular Disease
`but No Symptoms..................................e20
`4.2.2. Early Detection of HF.........................................e20
`4.3. Patients With Current or Prior Symptoms of HF
`(Stage C).......................................................................e20
`4.3.1. Patients With Reduced LVEF............................. e20
`4.3.1.1. General Measures..................................e22
`4.3.1.2. Drugs Recommended for Routine
`Use.........................................................e22
`4.3.1.2.1. Diuretics................................ e23
`4.3.1.2.2. Inhibitors of the Renin-
`Angiotensin-Aldosterone
`System................................... e24
`
`ACC - www.acc.org
`AHA - www.americanheart.org
`
`4.3.1.2.2.1. Angiotensin
`Converting Enzyme
`Inhibitors.............e24
`4.3.1.2.2.2. Angiotensin
`Receptor
`Blockers.............. e27
`4.3.1.2.2.3. Aldosterone
`Antagonists......... e29
`4.3.1.2.3. Beta-Adrenergic Receptor
`Blockers.................................e30
`4.3.1.2.4. Digitalis................................. e33
`4.3.1.2.5. Ventricular Arrhythmias and
`Prevention of Sudden
`Death......................................e34
`4.3.1.3. Interventions to Be Considered for Use
`in Selected Patients............................... e37
`4.3.1.3.1. Isosorbide Dinitrate...............e37
`4.3.1.3.2. Hydralazine........................... e37
`4.3.1.3.3. Hydralazine and Isosorbide
`Dinitrate.................................e37
`4.3.1.3.4. Cardiac Resynchronization
`Therapy.................................. e37
`4.3.1.3.5. Exercise Training.................. e38
`4.3.1.4. Drugs and Interventions Under Active
`Investigation.......................................... e39
`4.3.1.4.1. Techniques for Respiratory
`Support.................................. e39
`4.3.1.4.2. External Counterpulsation.....e39
`4.3.1.4.3. Vasopressin Receptor
`Antagonists............................ e39
`4.3.1.4.4. Implantable Hemodynamic
`Monitors................................ e39
`4.3.1.4.5. Cardiac Support Devices.......e39
`4.3.1.4.6. Surgical Approaches Under
`Investigation.......................... e40
`4.3.1.4.7. Nesiritide............................... e40
`4.3.1.5. Drugs and Interventions of Unproved
`Value and Not Recommended...............e40
`4.3.1.5.1. Nutritional Supplements and
`Hormonal Therapies.............. e40
`4.3.1.5.2. Intermittent Intravenous
`Positive Inotropic Therapy.... e40
`4.3.2. Patients With HF and Normal LVEF.................. e41
`4.3.2.1. Identification of Patients....................... e41
`4.3.2.2. Diagnosis...............................................e42
`4.3.2.3. Principles of Treatment......................... e43
`4.4. Patients With Refractory End-Stage HF (Stage D)......e43
`4.4.1. Management of Fluid Status...............................e44
`4.4.2. Utilization of Neurohormonal Inhibitors............e44
`4.4.3. Intravenous Peripheral Vasodilators and Positive
`Inotropic Agents..................................................e45
`4.4.4. Mechanical and Surgical Strategies....................e45
`
`5. Treatment of Special Populations........................................e46
`5.1. Women and Men...........................................................e46
`5.2. Ethnic Considerations...................................................e47
`5.3. Elderly Patients.............................................................e48
`
`6. Patients With HF Who Have Concomitant Disorders.........e48
`6.1. Cardiovascular Disorders............................................. e49
`6.1.1. Hypertension, Hyperlipidemia, and Diabetes
`Mellitus...............................................................e49
`6.1.2. Coronary Artery Disease....................................e49
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`AHA - www.americanheart.org
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`6.1.3. Supraventricular Arrhythmias............................ e50
`6.1.4. Prevention of Thromboembolic Events............. e51
`6.2. Noncardiovascular Disorders......................................e52
`6.2.1. Patients With Renal Insufficiency...................... e52
`6.2.2. Patients With Pulmonary Disease...................... e52
`6.2.3. Patients With Cancer.......................................... e52
`6.2.4. Patients With Thyroid Disease...........................e53
`6.2.5. Patients With Hepatitis C and HIV.................... e53
`6.2.6. Patients With Anemia.........................................e53
`
`7. End-of-Life Considerations................................................. e53
`
`8. Implementation of Practice Guidelines............................... e55
`8.1. Isolated Provider Interventions...................................e55
`8.2. Disease-Management Systems....................................e55
`8.3. Performance Measures................................................e56
`8.4. Roles of Generalist Physicians and Cardiologists...... e56
`
`Appendix I. Relationships With Industry: Writing
`Committee............................................................e57
`
`Appendix II. Relationships With Industry: Peer
`Reviewers........................................................... e58
`
`Appendix III. Abbreviations.................................................... e62
`
`References................................................................................e62
`
`PREAMBLE
`It is important that the medical profession play a significant
`role in critically evaluating the use of diagnostic procedures
`and therapies as they are introduced and tested in the detec-
`tion, management, or prevention of disease states. Rigorous
`and expert analysis of the available data documenting rela-
`tive benefits and risks of those procedures and therapies can
`produce helpful guidelines that improve the effectiveness of
`care, optimize patient outcomes, and favorably affect the
`overall cost of care by focusing resources on the most effec-
`tive strategies.
`The American College of Cardiology (ACC) and the
`American Heart Association (AHA) have jointly engaged in
`the production of such guidelines in the area of cardiovascu-
`lar disease since 1980. This effort is directed by the
`ACC/AHA Task Force on Practice Guidelines, whose charge
`is to develop and revise practice guidelines for important car-
`diovascular diseases and procedures. Experts in the subject
`under consideration are selected from both organizations and
`charged with examining subject-specific data and writing or
`updating these guidelines. The process includes additional
`representatives from other medical practitioner and specialty
`groups where appropriate. Writing groups are specifically
`charged to perform a formal literature review, weigh the
`strength of evidence for or against a particular treatment or
`procedure, and include estimates of expected health out-
`comes where data exist. Patient-specific modifiers, comor-
`bidities, and issues of patient preference that might influence
`the choice of particular tests or therapies are considered, as
`are frequency of follow-up and cost-effectiveness. When
`available, information from studies on cost will be consid-
`ered; however, review of data on efficacy and clinical out-
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`comes will constitute the primary basis for preparing recom-
`mendations in these guidelines.
`The ACC/AHA Task Force on Practice Guidelines makes
`every effort to avoid any actual, potential, or perceived con-
`flicts of interest that might arise as a result of an outside rela-
`tionship or personal interest of a member of the writing com-
`mittee. Specifically, all members of the writing committee,
`as well as peer reviewers of the document, are asked to pro-
`vide disclosure statements of all such relationships that
`might be perceived as real or potential conflicts of interest.
`These statements are reviewed by the parent task force,
`reported orally to all members of the writing panel at each
`meeting, and updated and reviewed by the writing commit-
`tee as changes occur. Please see Appendix I for author rela-
`tionships with industry and Appendix II for peer reviewer
`relationships with industry.
`The practice guidelines produced are intended to assist
`healthcare providers in clinical decision making by describ-
`ing a range of generally acceptable approaches for the diag-
`nosis, management, or prevention of specific diseases or
`conditions. These guidelines attempt to define practices that
`meet the needs of most patients in most circumstances. These
`guideline recommendations reflect a consensus of expert
`opinion after a thorough review of the available, current sci-
`entific evidence and are intended to improve patient care. If
`these guidelines are used as the basis for regulatory/payer
`decisions, the ultimate goal is quality of care and serving the
`patient’s best interests. The ultimate judgment regarding care
`of a particular patient must be made by the healthcare
`provider and patient in light of all of the circumstances pre-
`sented by that patient.
`These guidelines were approved for publication by the gov-
`erning bodies of the ACC and the AHA and have been offi-
`cially endorsed by the American College of Chest
`Physicians, the International Society for Heart and Lung
`Transplantation, and the Heart Rhythm Society. The guide-
`lines will be reviewed annually by the ACC/AHA Task Force
`on Practice Guidelines and will be considered current unless
`they are updated, revised, or withdrawn from publication.
`The summary article including recommendations is pub-
`lished in the September 20, 2005 issues of both the Journal
`of the American College of Cardiology and Circulation. The
`full-text guideline is posted on the World Wide Web sites of
`the ACC (www.acc.org) and the AHA (www.my.american-
`heart.org). Copies of the full text and the summary article are
`available from both organizations.
`
`Elliott M. Antman, MD, FACC, FAHA
`Chair, ACC/AHA Task Force on Practice Guidelines
`
`1. INTRODUCTION
`Heart failure (HF) is a major and growing public health prob-
`lem in the United States. Approximately 5 million patients in
`this country have HF, and over 550 000 patients are diag-
`nosed with HF for the first time each year (1). The disorder
`is the primary reason for 12 to 15 million office visits and 6.5
`million hospital days each year (2). From 1990 to 1999, the
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`annual number of hospitalizations has increased from
`approximately 810 000 to over 1 million for HF as a primary
`diagnosis and from 2.4 to 3.6 million for HF as a primary or
`secondary diagnosis (3). In 2001, nearly 53 000 patients died
`of HF as a primary cause. The number of HF deaths has
`increased steadily despite advances in treatment, in part
`because of increasing numbers of patients with HF due to
`better treatment and “salvage” of patients with acute myocar-
`dial infarctions (MIs) earlier in life (1).
`Heart failure is primarily a condition of the elderly (4), and
`thus the widely recognized “aging of the population” also
`contributes to the increasing incidence of HF. The incidence
`of HF approaches 10 per 1000 population after age 65 (1),
`and approximately 80% of patients hospitalized with HF are
`more than 65 years old (5). Heart failure is the most common
`Medicare diagnosis-related group (i.e., hospital discharge
`diagnosis), and more Medicare dollars are spent for the diag-
`nosis and treatment of HF than for any other diagnosis (6). It
`has been estimated that in 2005, the total direct and indirect
`cost of HF in the US will be equal to $27.9 billion (1).
`The ACC and the AHA first published guidelines for the
`evaluation and management of HF in 1995 and published
`revised guidelines in 2001 (7). Since that time, a great deal
`of progress has been made in the development of both phar-
`macological and nonpharmacological approaches to treat-
`ment for this common, costly, disabling, and potentially fatal
`disorder. The number of available treatments has increased,
`but this increase has rendered clinical decision making far
`more complex. The timing and sequence of initiating treat-
`ments and the appropriateness of prescribing them in combi-
`nation are uncertain. The increasing recognition of the exis-
`tence of clinical HF in patients with a normal ejection frac-
`tion (EF) (see Section 4.3.2.1) has also led to heightened
`awareness of the limitations of evidence-based therapy for
`this important group of patients. For these reasons, the 2
`organizations believed that it was appropriate to reassess and
`update these guidelines, fully recognizing that the optimal
`therapy of HF remains a work in progress and that future
`advances will require that the guideline be updated again.
`The writing committee was composed of 15 members who
`represented the ACC and AHA, as well as invited partici-
`pants from the American College of Chest Physicians, the
`Heart Failure Society of America, the International Society
`for Heart and Lung Transplantation, the American Academy
`of Family Physicians, and the American College of
`Physicians. Both the academic and private practice sectors
`were represented. This document was reviewed by 3 official
`reviewers nominated by the ACC, 3 official reviewers nomi-
`nated by the AHA, 1 reviewer nominated by the American
`Academy of Family Physicians, 2 reviewers nominated by
`the American College of Chest Physicians, 1 reviewer nom-
`inated by the American College of Physicians, 4 reviewers
`nominated by the Heart Failure Society of America, and 1
`reviewer nominated by the International Society for Heart
`and Lung Transplantation. In addition, 9 content reviewers
`and the following committees reviewed the document:
`ACC/AHA Committee to Develop Performance Measures
`
`ACC - www.acc.org
`AHA - www.americanheart.org
`
`for Heart Failure, ACC/AHA Committee to Revise
`Guidelines for the Management of Patients With Acute
`Myocardial Infarction, ACC/AHA/ESC Committee to
`Update Guidelines on the Management of Patients with
`Atrial Fibrillation, ACC/AHA Committee to Update
`Guidelines on Coronary Artery Bypass Graft Surgery, ACC
`Committee to Develop Data Standards on Heart Failure,
`AHA Quality of Care and Outcomes Research
`Interdisciplinary Working Group Steering Committee, and
`AHA Council on Clinical Cardiology Committee on Heart
`Failure and Transplantation.
`The full-text guidelines are available in 2 versions on the
`ACC and AHA Web sites: a version that highlights the
`change in recommendations (i.e., deleted text is struck
`through; new text is underlined) from the 2001 guideline to
`the 2005 guideline and a “clean” version that incorporates all
`changes in the recommendations. (The “track changes” ver-
`sion only highlights changes to the recommendations; it does
`not show changes to supporting text, tables, or figures.)
`In formulating the 2001 document, the writing committee
`developed a new approach to the classification of HF, one
`that emphasized both the development and progression of the
`disease. In doing so, the 2001 document identified 4 stages
`involved in the development of the HF syndrome. The first 2
`stages (A and B) are clearly not HF but are an attempt to help
`healthcare providers with the early identification of patients
`who are at risk for developing HF. Stages A and B patients
`are best defined as those with risk factors that clearly predis-
`pose toward the development of HF. For example, patients
`with coronary artery disease, hypertension, or diabetes mel-
`litus who do not yet demonstrate impaired left ventricular
`(LV) function, hypertrophy, or geometric chamber distortion
`would be considered Stage A, whereas patients who are
`asymptomatic but demonstrate LV hypertrophy (LVH)
`and/or impaired LV function would be designated as Stage B.
`Stage C then denotes patients with current or past symptoms
`of HF associated with underlying structural heart disease (the
`bulk of patients with HF), and Stage D designates patients
`with truly refractory HF who might be eligible for special-
`ized, advanced treatment strategies, such as mechanical cir-
`culatory support, procedures to facilitate fluid removal, con-
`tinuous inotropic infusions, or cardiac transplantation or
`other innovative or experimental surgical procedures, or for
`end-of-life care, such as hospice.
`This classification recognizes that there are established risk
`factors and structural prerequisites for the development of
`HF and that therapeutic interventions introduced even before
`the appearance of LV dysfunction or symptoms can reduce
`the population morbidity and mortality of HF. This classifi-
`cation system is intended to complement but in no way to
`replace the New York Heart Association (NYHA) functional
`classification, which primarily gauges the severity of symp-
`toms in patients who are in Stage C or Stage D. It has been
`recognized for many years that the NYHA functional classi-
`fication reflects a subjective assessment by a healthcare
`provider and can change frequently over short periods of
`time. It has also been recognized that the treatments used
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`may not differ significantly across the classes. Therefore, the
`committee believed that a staging system was needed that
`would reliably and objectively identify patients during the
`course of their developing disease and that would be linked
`to treatments uniquely appropriate at each stage of illness.
`According to this new staging approach, patients would only
`be expected to either not advance at all or to advance from
`one stage to the next, unless progression of the disease was
`slowed or stopped by treatment, and spontaneous reversal of
`this progression would be considered unusual. For instance,
`although symptoms (NYHA class) might vary widely over
`time (in response to therapy or to progression of disease) in
`a patient who has already developed the clinical syndrome of
`HF (Stage C), the patient could never return to Stage B
`(never had HF), and therapies recommended for Stage C will
`be appropriate even if this patient is in NYHA class I. This
`new classification scheme adds a useful dimension to our
`thinking about HF that is similar to that achieved by staging
`or risk assessment systems for other disorders (e.g., those
`used in the approach to cancer).
`Classification of Recommendations and Level of Evidence
`are expressed in the ACC/AHA format as follows and
`described in more detail in Table 1.
`
`Classification of Recommendations
`Class I: Conditions for which there is evidence and/or
`general agreement that a given procedure or
`treatment is beneficial, useful, and effective.
`
`Class II: Conditions for which there is conflicting evi-
`dence and/or a divergence of opinion about
`the usefulness/efficacy of a procedure or treat-
`ment.
`
`Class IIa: Weight of evidence/opinion is in
`favor of usefulness/efficacy.
`
`Class IIb: Usefulness/efficacy is less well
`established by evidence/opinion.
`
`Class III: Conditions for which there is evidence and/or
`general agreement that a procedure/treat-
`ment is not useful/effective and in some cases
`may be harmful.
`
`Level of Evidence
`(cid:129) Level of Evidence A: Data derived from multiple random-
`ized clinical trials or meta-analyses.
`(cid:129) Level of Evidence B: Data derived from a single random-
`ized trial, or nonrandomized studies.
`(cid:129) Level of Evidence C: Only consensus opinion of experts,
`case studies, or standard-of-care.
`
`The recommendations listed in this document are evidence-
`based whenever possible. Pertinent medical literature in the
`English language was identified through a series of comput-
`erized literature searches (including Medline and EMBASE)
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`and a manual search of selected articles. References selected
`and published in this document are representative but not all-
`inclusive. Recommendations relevant to a class of drugs
`specify the use of the drugs shown to be effective in clinical
`trials unless there is reason to believe that such drugs have a
`broad class effect.
`The committee elected to focus this document on the pre-
`vention of HF and on the diagnosis and management of
`chronic HF in the adult patient with normal or low LVEF. It
`specifically did not consider acute HF, which might merit a
`separate set of guidelines and is addressed in part in the
`ACC/AHA Guidelines for the Management of Patients With
`ST-Elevation Myocardial Infarction (8) and the ACC/AHA
`2003 Update of the Guidelines for the Management of
`Unstable Angina and Non-ST Elevation Myocardial
`Infarction (9). We have also excluded HF in children, both
`because the underlying causes of HF in children differ from
`those in adults and because none of the controlled trials of
`treatments for HF have included children. We have not con-
`sidered the management of HF due to primary valvular dis-
`ease [see ACC/AHA Guidelines on the Management of
`Patients With Valvular Heart Disease (10)] or congenital
`malformations, and we have not included recommendations
`for the treatment of specific myocardial disorders (e.g.,
`hemochromatosis, sarcoidosis, or amyloidosis).
`These practice guidelines are intended to assist healthcare
`providers in clinical decision making by describing a range
`of generally acceptable approaches for the prevention, diag-
`nosis, and management of HF. The guidelines attempt to
`define practices that meet the needs of most patients under
`most circumstances. However, the ultimate judgment regard-
`ing the care of a particular patient must be made by the
`healthcare provider in light of all of the circumstances that
`are relevant to that patient. These guidelines do not address
`cost-effectiveness from a societal perspective. The guide-
`lines are not meant to assist policy makers faced with the
`necessity to make decisions regarding the allocation of finite
`healthcare resources. In fact, these guidelines assume no
`resource limitation. They do not provide policy makers with
`sufficient information to be able to choose wisely between
`options for resource allocation. The various therapeutic
`strategies described in this document can be viewed as a
`checklist to be considered for each patient in an attempt to
`individualize treatment for an evolving disease process.
`Every patient is unique, not only in terms of his or her cause
`and course of HF, but also in terms of his or her personal and
`cultural approach to the disease. Guidelines can only provide
`an outline for evidence-based decisions or recommendations
`for individual care; these guidelines are meant to provide that
`outline.
`
`2. CHARACTERIZATION OF HF AS A
`CLINICAL SYNDROME
`2.1. Definition of HF
`Heart failure is a complex clinical syndrome that can result
`from any structural or functional cardiac disorder that
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`Hunt et al. 2005
`ACC/AHA Practice Guidelines
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`e6
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`ACC - www.acc.org
`AHA - www.americanheart.org
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`intent of the recommendation. It is hoped that this will increase readers’comprehension of the guidelines and will allow queries at the individual recommendation level.
`that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full
`†In 2003, the ACC/AHATask Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All recommendations in this guideline have been written in full sentences
`
`*Data available from clinical trials or registries about the usefulness/efficacy in different sub-populations, such as gender, age, history of diabetes, history of prior MI, history of heart failure, and prior aspirin use.
`
`“Size of Treatment Effect”
`
`Table 1.Applying Classification of Recommendations and Level of Evidence
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`Ex. 2025-0006
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`

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`ACC - www.acc.org
`AHA - www.americanheart.org
`
`impairs the ability of the ventricle to fill with or eject blood.
`The cardinal manifestations of HF are dyspnea and fatigue,
`which may limit exercise tolerance, and fluid retention,
`which may lead to pulmonary congestion and peripheral
`edema. Both abnormalities can impair the functional capaci-
`ty and quality of life of affected individuals, but they do not
`necessarily dominate the clinical picture at the same time.
`Some patients have exercise intolerance but little evidence of
`fluid retention, whereas others complain primarily of edema
`and report few symptoms of dyspnea or fatigue. Because not
`all patients have volume overload at the time of initial or sub-
`sequent evaluation, the term “heart failure” is preferred over
`the older term “congestive heart failure.”
`The clinical syndrome of HF may result from disorders of
`the pericardium, myocardium, endocardium, or great vessels,
`but the majority of patients with HF have symptoms due to
`an impairment of LV myocardial function. Heart failure may
`be associated with a wide spectrum of LV functional abnor-
`malities, which may range from patients with normal LV size
`and preserved EF to those with severe dilatation and/or
`markedly reduced EF. In most patients, abnormalities of sys-
`tolic and diastolic dysfunction coexist, regardless of EF.
`Patients with normal EF may have a different natural history
`and may require different treatment strategies than patients
`with reduced EF, although such differences remain contro-
`versial (see Section 4.3.2.1).
`Coronary artery disease, hypertension, and dilated car-
`diomyopathy are the causes of HF in a substantial proportion
`of patients in the Western world. As many as 30% of patients
`with dilated cardiomyopathy may have a genetic cause (11).
`Valvular heart disease is still a common cause of HF. In fact,
`nearly any form of heart disease may ultimately lead to the
`HF syndrome.
`It should be emphasized that HF is not equivalent to car-
`diomyopathy or to LV dysfunction; these latter terms
`describe possible structural or functional reasons for the
`development of HF. Instead, HF is defined as a clinical syn-
`drome that is characterized by specific symptoms (dyspnea
`and fatigue) in the medical history and signs (edema, rales)
`on the physical examination. There is no single diagnostic
`test for HF because it is largely a