Implementation of the 2022 ACC/AHA/HFSA Heart Failure Guideline: A Call to Action
2022; Elsevier BV; Volume: 28; Issue: 5 Linguagem: Inglês
10.1016/j.cardfail.2022.04.001
ISSN1532-8414
Autores Tópico(s)Cardiac Structural Anomalies and Repair
ResumoI have been privileged to be a member of the Writing Committee for several iterations of the American College of Cardiology/American Heart Association/Heart Failure Society of America ACC/AHA/HFSA Management of Heart Failure guidelines, including those released in April 2022.1Heidenreich PA Bozkurt B Aguilar D Allen LA Byun JJ et al.2022 ACC/AHA/HFSA guideline for the management of heart failure.J Cardiac Fail. 2022; 28: e1-e167Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Participating in this herculean process, one cannot help but be impressed by the thought and effort that goes into their development. The committee systematically gathers data, writes easily digestible recommendations, and rigorously discusses each recommendation to reach consensus. Further, safeguards are in place to minimize the potential influence of conflicts of interest throughout each of these steps. After that lengthy process, the guideline document then undergoes extensive external peer review, which results in significant revision. Additionally, the 3 sponsoring national organizations, as well as endorsing cardiovascular societies, provide input, ultimately culminating in the final document now published. And yet, after this long journey, much work remains as the recommendations in the guidelines must now be translated into clinical practice if patients are to benefit from these efforts. Based on historical experiences, I am concerned about what might now happen. A survey of primary care and cardiology practices in the United States demonstrated that fewer than 25% of patients with heart failure and reduced ejection fraction (HFrEF) were receiving the 3 foundational therapies promoted by prior guidelines (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, beta-blocker, and mineralocorticoid receptor antagonist), and only 1% of eligible patients were on target doses of all 3 therapies.2Greene SJ Butler J Albert NM DeVore AD Sharma PP Duffy CI et al.Medical therapy for heart failure with reduced ejection fraction: the CHAMP-HF registry.J Am Coll Cardiol. 2018; 72: 351-366Crossref PubMed Scopus (458) Google Scholar This lack of translation of guideline recommendations into clinical practice is not unique to the heart failure community. It is estimated that, on average, it takes 17 years for innovative therapies to be adopted by the medical community.3Bauer MS Kirchner J. Implementation science: what is it and why should I care?.Psychiatry Res. 2020; 283112376Crossref Scopus (145) Google Scholar Many steps are necessary to translate the guidelines into clinical practice. As with a leaky pipeline, multiple exit points can contribute to a low rate of success. Some of the attrition is related to clinicians, such as a lack of knowledge or acceptance of the evidence base or an inability to implement it, and some to patients, for example, not starting recommended therapies as they experience barriers to adherence.4Frantsve-Hawley J DB Rindal Translational research: bringing science to the provider through guideline implementation.Dent Clin North Am. 2019; 63: 129-144Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,5Glasziou P Haynes B. The paths from research to improved health outcomes.Evid Based Nurs. 2005; 8: 36-38Crossref PubMed Scopus (90) Google Scholar Methods to improve translation of evidence into clinical practice are the focus of the burgeoning field of implementation science. As defined in the inaugural issue of Implementation Science, a journal devoted to this field, implementation science is "the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practice into routine practice, and, hence, to improve the quality and effectiveness of health services and care."6Eccles MP Mittman BS. Welcome to implementation science.Implement Sci. 2006; 1: 1Crossref Scopus (838) Google Scholar In the new guideline, it is worthwhile highlighting the Class 1 (level of evidence A) recommendation for sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with HFrEF, irrespective of the presence of diabetes, to decrease heart failure hospitalizations and cardiovascular deaths. This recommendation represents a paradigm shift, such that quadruple, rather than triple therapy, is now the standard of care for patients with HFrEF. The adoption of this new recommendation may be facilitated because SGLT2 inhibitors do not require uptitration and are beneficial even in patients with decompensated heart failure. In contrast, their uptake may be hindered by any perception that these compounds are therapies to treat diabetes and thus not under the purview of cardiovascular clinicians. SGLT2 inhibitors can also lead to genitourinary infections, which could disincentivize cardiovascular clinicians who may not be comfortable in addressing such conditions, from prescribing these agents. Additionally, the cost of SGLT2 inhibitors may impede their widespread adoption. How can we best achieve the widespread implementation of the key recommendations in the new guidelines? First, educational efforts are needed to disseminate its content. The HFSA, ACC, and AHA are well-positioned to accomplish that goal. The dissemination of knowledge, although a necessary step, does not guarantee successful implementation, as described above. Indeed, the "know–do gap"4Frantsve-Hawley J DB Rindal Translational research: bringing science to the provider through guideline implementation.Dent Clin North Am. 2019; 63: 129-144Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar is a large hurdle that needs to be overcome. My personal implementation strategy is a mental checklist for HFrEF used at every applicable patient encounter to ensure that high level, Class 1 recommendations are followed (Fig. 1). Screening for iron deficiency so that it can be treated via intravenous repletion, the latter a Class 2a recommendation in the new guidelines, may soon join this list as further evidence accrues regarding its benefits. I recognize that, although this checklist strategy works for me, and is supported by others,7Gawande A. The checklist manifesto: how to get things right. Picador, London2010Google Scholar broader initiatives will be needed if we are to achieve success in the large population of patients with heart failure in the United States. Educational efforts directed toward patients to "activate" and empower them in this process have proven effective.8Allen LA Venechuk G McIlvennan CK Page RL Knoepke CE Helmkamp LJ et al.An electronically delivered patient-activation tool for intensification of medications for chronic heart failure with reduced ejection fraction: the EPIC-HF trial.Circulation. 2021; 143: 427-437Crossref PubMed Scopus (30) Google Scholar Other potential strategies include public reporting of guideline-directed medical therapy scorecards for health systems, group practices, and individual clinicians, the latter as done with procedural operators; the establishment of clinics devoted to the implementation of guideline recommendations9Balakumaran K Patil A Marsh S Ingrassia J Kuo CL Jacoby DL et al.Evaluation of a guideline directed medical therapy titration program in patients with heart failure with reduced ejection fraction.Int J Cardiol Heart Vasc. 2019; 22: 1-5PubMed Google Scholar; or an enhancement of the electronic health record with meaningful clinical decision support tools.10Ghazi L Yamamoto Y Riello RJ Coronel-Moreno C Martin M O'Connor KD et al.Electronic alerts to improve heart failure therapy in outpatient practice: a cluster randomized trial.J Am Coll Cardiol. 2022 Apr 3; (S0735-1097(22)04489-8. Online ahead of print)https://doi.org/10.1016/j.jacc.2022.03.338Crossref PubMed Scopus (17) Google Scholar Investing in implementation science research, including clinical trials of novel implementation strategies, has great potential to increase the likelihood of translational success. Incorporating implementation science methodology into the developmental phase of future guidelines may lead to earlier translation of their recommendations into clinical practice.11Sarkies MN Jones LK SS Gidding Watts GF. Improving clinical practice guidelines with implementation science.Nat Rev Cardiol. 2022; 19: 3-4Crossref PubMed Scopus (6) Google Scholar The publication of the "2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure" represents a milestone accomplishment and the culmination of the efforts of many in the field. However, this event really signifies a beginning, as we now start the work necessary to implement the recommendations in the guideline. My call to action is that we, professionals dedicated to significantly reducing the burden of heart failure, lead that charge. Our patients deserve nothing less.
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