Researchers examined in the American College of Cardiology (ACC) has released an expert consensus decision pathway document to optimize the treatment of heart failure (HF) with reduced ejection fraction. The ACC and American Heart Association have established clinical practice guidelines as the foundation for HF care. This research got published in the Journal of the American College of Cardiology.

To accelerate uptake of guidelines into practice and tackle existing evidence gaps, the writing committee adopted a practical approach and organized the document into 10 pivotal issues that remain unresolved in the guidelines.

They are:

1.       How to initiate, add, or switch therapy

2.       How to achieve optimal therapy given multiple HF drugs

3.       When to refer to an HF specialist

4.       How to address the challenges of care coordination

5.       How to improve adherence

6.       How to best address special populations: African Americans, the frail, and older adults

7.       How to manage the cost of HF care

8.       How to manage the increasing complexity of HF

9.       How to manage common comorbidities

10.    How to integrate palliative care and transition to hospice care

"Many physicians are aware of the multiple new therapies for heart failure, but with multiple choices it is now a challenge to know in what order and how best to construct a medical regimen for the patient with heart failure," Yancy said. "The algorithms provided offer clarity that should enable all practitioners to accomplish optimal therapy for patients with heart failure."

And for each guideline-directed medical therapy, it addresses the "significant challenge in how to titrate these drugs to optimal levels, something so very much needed in the care of patients with heart failure," Dr James Januzzi (Massachusetts General Hospital, Boston), vice-chair of the writing committee and chair of the ACC task force on expert consensus pathways, said in an email.

The committee also places heavy emphasis on recognizing how to longitudinally monitor patients with HF, and when to recognize it is time to refer such a patient for advanced HF care. Januzzi said, "On the other end of the spectrum, we also emphasize the growing need for involvement of our palliative care colleagues in the journey of our patients with more advanced heart failure, recognizing the optimal care of our patients includes optimal management of the end of their journey."

An opinion from Yancy observed that the way in which helpful clinical tips were provided to recognize which patient is ill and needs more aggressive therapy, while also understanding which patient might benefit most from palliative care. He continued, "Some of my very best patient care experiences have come from shepherding patients through the advanced stages of heart failure. This is when a doctor is most needed."