Understanding the HF Decision Pathways Report
Author:
James Januzzi, MD
Massachusetts General Hospital, Boston, MA
Harvard Medical School, Boston, MA
The American College of Cardiology (ACC) Expert Consensus Decision Pathway on the Management of Chronic Heart Failure With Reduced Ejection Fraction is a multidisciplinary, collaborative effort supported by the ACC that was published in December 2017, so it is essentially hot off the press[MOU1] .
As a matter of framing the background of this, about 2 years ago now, the ACC started an entirely new approach to the production of consensus documents, moving away from the more monolithic, almost guideline-like consensus documents. The college felt that it was important to produce documents that provided actionable clinical knowledge at the point of care, often focusing on topics that might be well-supported by the guidelines but also topics that may have information that are not yet incorporated into guidelines. So, one area of clear potential utility for a document such as this was for the management of chronic heart failure (HF).
The document contains many different topics that are very germane to the everyday management of patients with HF with reduced ejection fraction, including how to properly select medications, titrate medications, longitudinally monitor patients over time with a goal to optimize their medical therapy, optimize their quality of life, and involve advanced HF options, including the possibility of transplantation, mechanical circulatory support, and palliative care for those patients with more advanced HF.
One area that we highlight in this document—which really is like a toolbox that offers different potential tools for the clinician to think about their patients and how to follow them and manage them optimally—is the increasing role of biomarker testing in patients with HF.
We note that recent data clearly support the use of measurements of both BNP and NT-proBNP, not only for their established role of diagnosing HF and as prognostication tools in HF, but also to longitudinally monitor patients.
So, rather than simply measuring these values, for example, in a patient with shortness of breath in the emergency department, where they clearly have strong data supporting their role, we now endorse the use of NT-proBNP (or BNP management) in the office for monitoring patients’ stability. Because we recognize well that biomarkers afford us an objective window into the underlying biology and the prognosis in HF—often above and beyond the presence of symptoms.
For example, for the measurement of NT-proBNP in chronic HF, the closer to a threshold of 1000 pg/mL—or better if lower—the better the prognosis. Certainly, patients with concentrations of NT-proBNP below 1000 pg/mL are much less likely to have clinical events, and when measured over time, we found—for example, in studies at the Massachusetts General Hospital heart center—that values of NT-proBNP below 1000 pg/mL also predict improvement in ejection fraction and left ventricular size, so-called reverse remodeling, in the face of HF therapy. Whereas, a rising value over time identifies patients likely to be remodeling and worsening their ejection fraction.
Taken together, one could envision utilizing biomarkers to monitor patients’ stability, and in the presence of a low and stable BNP or NT-proBNP one might feel the need to do routine cardiographic surveillance—something that is not often viewed as appropriate use. Whereas in those patients with rising concentrations of these biomarkers, you might want to think about earlier or more frequent imaging to monitor left ventricular size and function along with consideration of referral for more advanced HF management.
James Januzzi, MD, is a cardiologist at the Massachusetts General Hospital and is the Hutter Family Professor of Medicine at Harvard Medical School. He is also a clinical trialist at the Bayne Institute for Clinical Research and is the chair of the expert consensus decision pathways taskforce at the American College of Cardiology.