2019 ACC Expert Consensus Decision Pathway for HF

Transcript: Deepak L. Bhatt, MD, MPH: Nancy, if you could just give us a brief overview of the 2019 American College of Cardiology Consensus Decision Pathway for Heart Failure Hospitalizations? And equally important, how does it apply to clinical practice, in your opinion?

Nancy M. Albert, PhD, CCNS: The 2019 document was a very interesting paper. It really focused on the trajectories that patients go through when they’re in the hospital for decompensation. We all know that the majority of patients who come in have fluid overload. The document really talks about decongesting patients, making sure that we’re giving the right dose of diuretic and that we continue that therapy to get them back to a euvolemic state.

It also reviews 3 trajectories, and it provides helpful hints to clinicians to guide them through the process. For example, the first trajectory is improving toward the goal. You just heard Scott talk about the different therapies we have out there. We want to make sure patients get back on guideline-directed medical therapy. We want to make sure we know that their diuresis is continuing during their hospitalization. What is their BNP [B-type natriuretic peptide]? Are they losing weight? What are their signs and symptoms? What other measures can we look at, whether it’s objective or subjective, to help us really understand that patients are moving toward that goal?

But more importantly, we have a certain number of patients who stall when they’re getting those treatments during hospitalization. The guidelines do a really nice job of saying, “What do we need to do? Do we need to escalate the dose of diuretic? Do we need to consider other medical therapies?” That’s where previously, if somebody was taken off an ACE [angiotensin-converting enzyme] inhibitor or an ARB [angiotensin receptor blocker] or an ARNI [angiotensin receptor—neprilysin inhibitor], maybe they need to be placed back on. Maybe they need to have MRA [mineralocorticoid receptor antagonist] therapy.

Look at the renal function. Look at their potassium. Make sure we’re being safe so we can really escalate care appropriately versus just using a diuretic, not getting where we need to go, and then continuing in that stalled pattern.

The last trajectory are patients who actually don’t improve in the hospital and get worse over time. When we think about patients getting worse, of course we can think about starting an intravenous inotropic agent. We can think about VADs [ventricular assist devices] and other advanced therapies, etc. But the document really focuses on reminding us that some patients are at end of life and we do need to consider palliative care. So they kind of push us to think about the whole movement—from the time somebody comes into the hospital, to getting transitioned back into their home, to how they take care of themselves at home so we can keep them out of the hospital. The guidelines, from a clinical standpoint, are really to help clinicians understand that heart failure is chronic. Patients do not go in and out of heart failure. Once they have it, they have it. As providers, we need to do a better job of keeping patients at that maintenance level.

I think Javed said something very interesting earlier—that patients are in control of their health. As providers, we really need to do a better job of helping them understand what they have to do to stay out of trouble. We see them 1% of the time. The other 99% of the time, they’re at home and maybe with their family. So we need to train them, educate them, and make sure they understand why they need to do what they need to do.

Transcript Edited for Clarity