ACC Expert Consensus Decision Pathway Research Articles

Emphasizing the value of non-invasive imaging in the diagnosis and treatment of heart failure with preserved ejection fraction: an interpretation based on 2023 ACC expert consensus decision pathway on management of HFpEF

Emphasizing the value of non-invasive imaging in the diagnosis and treatment of heart failure with preserved ejection fraction: an interpretation based on 2023 ACC expert consensus decision pathway on management of HFpEF

Impact of a Cardiometabolic Clinic in Addressing Residual Cardiovascular Risk

BackgroundDespite the significant impact of statin therapy, patients continue to face substantial residual cardiovascular risk. These risks are particularly prominent in patients with both type 2 diabetes (T2D) and atherosclerotic cardiovascular disease (ASCVD). We examine the effectiveness of a cardiometabolic clinic, embedded within a suburban cardiology private practice, in identifying and managing several of these multifaceted risks. MethodsWe collated interventions for the first 100 patients with T2D and ASCVD who attended a minimum of two appointments at the clinic. ResultsFollowing an average of 2.4 clinic visits, 44 of 100 patients had undergone intensification of lipid-lowering therapy, with 16 initiated on PCSK9-directed therapies. This resulted in 85 of 100 patients achieving LDL-C levels below the 2022 ACC Expert Consensus Decision Pathway recommendations for intensification. Lipoprotein(a) was measured in 80 patients, revealing elevated levels in 22. At baseline, 18 and 32 patients were on glucagon-like peptide-1 receptor agonists (GLP1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i), respectively. This increased to 80 and 66 patients on GLP1RA and SGLT2i, respectively, with 94 patients on either class and 52 patients on both. Figure 1 presents baseline and follow-up use of cardiometabolic therapies. ConclusionThe cardiometabolic clinic effectively identified and intensified management of several residual cardiovascular risks in patients with T2D and ASCVD. Extensive use of combination lipid-lowering therapies substantially addressed cholesterol-related risk, and initial experiences support the feasibility of high-volume implementation of GLP1RA and SGLT2i therapies in this population.

Initial Evaluation and Management of Patients Presenting with Acute Chest Pain in the Emergency Department.

To review the initial evaluation of chest pain in the emergency department (ED), with a focus on coronary artery disease (CAD) and acute coronary syndromes (ACS), using consensus statements from major cardiovascular disease organizations. Major cardiovascular organizations have released consensus statements on this topic, notably the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain and the 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. Also, recent studies have evaluated the use of high sensitivity troponin (hs-cTn) to safely rule out myocardial infarction (MI), with the development of rule-out pathways designed to be utilized in the ED. This review highlights the comprehensive differential diagnoses of chest pain in the ED and urgent management of these etiologies, with a focus on cardiovascular etiologies. There exist a few rule-out pathways recommended by major cardiovascular organizations, notably the high-STEACS and the ESC 0/1 and 0/2 pathways that can safely and quickly discharge patients with low risk of MI.

HFpEF mimics: hypertrophic cardiomyopathy in light of the 2023 ACC Expert Consensus Decision Pathway on Management of Heart Failure with Preserved Ejection Fraction

HFpEF mimics: hypertrophic cardiomyopathy in light of the 2023 ACC Expert Consensus Decision Pathway on Management of Heart Failure with Preserved Ejection Fraction

Interpretation of the 2022 ACC expert consensus decision pathway on cardiovascular sequelae of COVID-19 in adults: myocarditis and other myocardial involvement, post-acute sequelae of SARS-CoV-2 infection, and return to play

2019年新型冠状（新冠）病毒疫情在全球流行。临床上新冠肺炎患者除了呼吸系统受损表现外，心肌损伤也比较常见。部分感染新冠病毒的患者在患病后数月存在心脏症状（如胸痛、呼吸短促和心悸），实验室和影像学检查也观察到心肌损伤和受累的证据。2022年美国心脏病学会公布了《2022年美国心脏病学会成年COVID-19心血管后遗症（心肌炎和其他心肌受累、SARS-CoV-2感染的急性后遗症）及恢复运动的临床决策路径专家共识》，试图解决成年人新冠病毒感染后出现心脏症状管理方面的常见问题。该文从新冠病毒感染后心肌炎、新冠病毒感染的急性后遗症和运动康复3方面对共识进行解读，同时结合中国方案，更好地评估和管理新冠感染心血管后遗症的患者。.

Closing the window on COVID-19 case-control studies.

Closing the window on COVID-19 case-control studies.

Clinical Perspectives on Cardiac Rehabilitation After Heart Failure in Elderly Patients with Frailty: A Narrative Review.

The purpose of this narrative review is to examine rehabilitation modalities for patients with heart failure and Frailty who require comprehensive intervention. Ischemic heart disease is the leading cause of death worldwide, accounting for 16% of global mortality. Due to population growing and aging, the total number of heart failure patients continues to rise, a condition known as the heart failure pandemic. Furthermore, frailty has been associated with an increased risk for heart failure and increased morbidity and mortality. The 2021 update of the 2017 ACC expert consensus decision pathway for optimization of HF treatment has become more concerning, citing frailty as one of the 10 most important issues associated with heart failure with reduced ejection fraction (HFrEF). Frailty and heart failure share common pathological mechanisms and are associated with poor clinical outcomes. Most studies of frailty in patients with heart failure primarily focus on physical frailty, and associations between psycho-psychological and social factors such as cognitive dysfunction and social isolation have also been reported. These results suggest that a more comprehensive assessment of frailty is important to determine the risk in patients with heart failure. Therefore, mechanisms of the three domains, including not only physical frailty but also cognitive, psychological, spiritual, and social aspects, should be understood. In addition to interventions in these three domains, nutritional and pharmacological interventions are also important and require tailor-made interventions for the widely varied conditions associated with heart failure and frailty. Although several studies have shown a relationship between frailty and prognosis in patients with heart failure, interventions to improve the prognosis have not yet been established. Further information is needed on frailty intervention by a multidisciplinary team to improve the prognosis.

Multidisciplinary Approach To Incorporating Sodium-glucose Co-transporter 2 Inhibitors In Ambulatory Heart Failure Patients

<h3>Introduction</h3> : In recent years, sodium-glucose co-transporter 2 inhibitors (SGLT2i) gained an indication in heart failure (HF) with reduced ejection fraction. With reduced cardiovascular mortality and HF hospitalizations, SGLT2i are now recommended and incorporated into the 2021 Update of the 2017 ACC Expert Consensus Decision Pathway for Optimization of HF Treatment. <h3>Hypothesis</h3> Multidisciplinary screening of patients in the ambulatory setting can identify qualified patients and facilitate SGLT2i initiation. <h3>Methods</h3> A SGLT2i initiation pilot program was started at the REX HF Clinic. During the pilot, a Clinical Pharmacist (CP) screened candidates based on select baseline demographics that included primary indications and contraindications to SGLT2i. It was decided that preference would be given to titration of traditional guideline-directed medical therapy (GDMT) over SGLT2i initiation. The CP screened all patients, identified those that qualified, and shared findings with the HF providers. Recommendations were made with consideration of SGLT2i cost and insurance-preferred agent. The HF provider and patient discussed medication changes as part of the clinic visit. When a SGLT2i was prescribed, the CP provided education to the patient, facilitated affordability by providing manufacturer coupon cards or assistance program applications, and monitored patient response and safety. <h3>Results</h3> : Two hundred forty-one unique patients were screened from October 2020 to April 2021, of which 112 patients (46.4%) qualified for SGLT2i (see TABLE 1). Sixty-four of the 112 patients had titration of other GDMT (57.1%). Of the remaining 48 patients, 12 were started on SGLT2i, while 7 had a contraindication. No medication changes were made in 15 patients, mostly due to patient preference or cost concerns.

Mechanical support for the failing single ventricle after Fontan

Mechanical support for the failing single ventricle after Fontan

2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction

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Implementing Nonphysician Provider Guideline-Directed Medical Therapy Heart Failure Clinics: A Multi-National Imperative

Heart failure (HF) is a global epidemic, with more than 60 million patients living with HF worldwide. 1 Lippi G Sanchis-Gomar F. Global epidemiology and future trends of heart failure. AME Med J. 2020; 5 Crossref Google Scholar With an ageing population, this number is projected to continue to increase and will result in significant economic and resource strain on health care systems. Despite recent advances in pharmacotherapy, morbidity and mortality related to HF remains high. This, in part, may be related to a significant portion of patients receiving sub-optimal, guideline-directed medical pharmacotherapy (GDMT). Greene et al 2 Greene SJ Butler J Albert NM et al. Medical therapy for heart failure with reduced ejection fraction: the champ-hf registry. J Am Coll Cardiol. 2018; 72: 351-366 Crossref PubMed Scopus (270) Google Scholar highlighted this trend in the United States through the Change the Management of Patients with Heart Failure (CHAMP-HF) registry. Among patients with HF with reduced ejection fraction (HFrEF) eligible for angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors (ARNi), beta blockers (BB), and mineralocorticoid receptor antagonists, these therapies were, concerningly, only prescribed in 27%, 33%, and 67% of eligible patients. Only a small portion of patients started on these foundational therapies were receiving target doses. Most notably, only 1% of the 3518 patients (approximately 35 patients) were simultaneously receiving target doses of all 3 therapies. The picture is similar internationally, with British registry data showing that failure to prescribe all 3 disease-modifying therapies is negatively associated with mortality in patients discharged after a recent HF hospitalization. It should also be mentioned that current registry data was collected before the release of recent sodium-glucose transport protein 2 inhibitor data, which has now led to an additional class of medications being recommended as part of the therapeutic backbone for HFrEF. 3 Maddox TM Januzzi JL et al. 2021 update to the 2017 acc expert consensus decision pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction: a report of the American College of Cardiology solution set oversight committee. J Am Coll Cardiol. 2021; 77: 772-810 Crossref PubMed Scopus (83) Google Scholar Furthermore, recent data from CONNECT-HF continues to reveal suboptimal dosing for patients with HFrEF, between 25% and 40% for ACEI, angiotensin receptor blocker, ARNI, BB, and mineralocorticoid receptor antagonist therapy. 4 CONNECT-HF: Can Additional HospitalPost-Discharge QI Interventions Improve HF Outcomes, Care?. American College of Cardiology, 2021https://www.acc.org/Latest-in-Cardiology/Articles/2021/05/12/19/40/Mon-8am-CONNECT-HF-acc-2021 Google Scholar

Medical Treatment of Heart Failure: Ignore the Ejection Fraction and Treat All?

The left ventricular ejection fraction (LVEF), the most widely used index of LV function, has an essential role in defining heart failure (HF) phenotypes and guiding treatment of chronic HF. 1 Maddox TM Januzzi JL Allen LA Breathett K Butler J Davis LL et al. 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2021; 77: 772-810 Crossref PubMed Scopus (83) Google Scholar

Achieving Successful Longitudinal Titration of Evidence Based Heart Failure Medical Therapy at a Newly Established Multidisciplinary Program in the Middle East Gulf Region

Background The 2017 ACC expert consensus decision pathway for optimization of heart failure (HF) treatment emphasizes the fact that target doses of medications are associated with the best outcomes. It has been reported that a significant portion of HFrEF patients are not on optimal doses of medical therapy, and gaps exist in longitudinal medication titration. The objective of this retrospective study is to describe medical therapy after 12 months of follow up in a newly established multidisciplinary HF program in the Middle East Gulf region. Methods A retrospective outpatient chart review was conducted on HF patients after initial outpatient clinic enrollment between October 2015 and July 2017. All patients with EF ≤ 40 were included. We documented baseline and follow-up evidence based HF medications including beta blockers, RAAS inhibitors, and MRA. Results Out of 305 enrolled patients, only 186 had a 12 month follow up appointment, out of which 139 had HFrEF and were included in this analysis. At baseline, 25.2%, 13.7%, and 42.4% of patients were receiving target doses of beta-blocker, ACEI/ARB/ARNI, and MRA, respectively. Only 2.9% were on target doses of all 3 classes of evidence based therapies. At 12 months, percentage of patients on target doses significantly increased to 51.8% for beta blockers and 31.7% for ACEI/ARB/ARNI, while there was no significant change in patients on target dose MRA (36.7%). More patients (10.1%) were on target doses of all 3 evidence based therapies (table 1). A significant increase was observed in the rate of adoption of ARNI from baseline to follow-up (10.1% vs 48.9%, p Conclusion Close follow up of patients with HFrEF was associated with statistically significant increase in those on target doses of both beta blockers and ACE/ARB/ARNI and patients on simultaneous target doses of all evidence based medications. Compared to recent western outpatient registries, our study shows that the success of longitudinal titration of evidence based medications and adoption of new ones can be enhanced when patients are followed by a specialized multidisciplinary program.

Initiation of Sacubitril/Valsartan (S/V) in Patients with Heart Failure with Reduced Ejection Fraction (HFrEF) and Compliance with Guideline-Directed (GD) Concomitant Medical Therapy for Heart Failure

Background The 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure (HF) Treatment guides healthcare providers on treatment plans and discussions with patients with HFrEF. Data on concomitant GD medical therapy for HF pre and post S/V initiation in the real world is limited. Objective To assess concomitant GD medical therapy for HF pre and post S/V initiation. Methods All adult patients with ≥1 claim for S/V or angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB) in 7/7/2015-5/31/2016 were identified from a large administrative claims database. Patients on S/V were assumed to have HFrEF based on its approved indication. Patients on ACEI/ARB had claims-based evidence of HFrEF. The index date was 1st claim for S/V (searched first) or ACEI/ARB. All patients had data for ≥24 months pre-index and ≥6 months post-index, unless inpatient death occurred. The uses of GD beta blockers (BB) and mineralocorticoid receptor antagonists (MRA) were assessed. Daily dose of the last fill of GD BB and MRA within 12-month pre S/V initiation and up to 4 fills post S/V was classified into 4 levels: 75% of GD target dose. McNemar's tests were conducted on % of patients with GD medications pre- and post-index; Cochran-Armitage tests were for the trend of target dose levels for all patients. Results A total of 956 patients had ≥1 claim for S/V (median age 64 years, 71% male) and 55,492 patients had ≥1 claim for ACEI/ARB (median age 70 years, 62% male). Compared to pre S/V initiation, fewer S/V patients had concomitant GD BB (post vs. pre: 84.1% vs 89.3%) or MRA (47.7% vs 52.1%) post S/V; both p 0.10). About 34-35% and >70% of patients received >75% of GD target daily dose for BB and MRA, respectively, across all fills ( Figure 1 ). Conclusions The majority of patients remained on GD BB or MRA with S/V; most continued at the same dose level of GD BB and MRA. Thus, in real-world practice, S/V is prescribed concomitantly with GD BB and MRA without the need for dose adjustment in the majority of cases.

Combination Lipid-Lowering Therapies for the Prevention of Recurrent Cardiovascular Events.

There has been confusion following the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Lipid guidelines on the role of non-statin medications for cardiovascular prevention. Several recent large trials have also now shown that lowering LDL with non-statins reduces cardiovascular events. In ASCVD patients on statins, adding ezetimibe or a PCSK9 inhibitor led to reductions in CV events in the IMPROVE IT, FOURIER, and most recently the ODYSSEY-OUTCOMES trials. Additional novel therapies reducing LDL and other atherogenic lipoproteins are in development during this exciting time in this field. With recent evidence, the 2017 ACC Expert Consensus Decision pathway calls for initial therapy with statins, monitoring LDL levels, and then adding ezetimibe and/or PCSK9 inhibitors to further lower LDL-C to targets based on the patient's risk.

Basic Principles of Periprocedural Management of Patients With Nonvalvular Atrial Fibrillation Receiving Anticoagulant Therapy: the Consensus Document of Experts of the American College of Cardiology

The article contains an outline of the 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. This document considers in detail problems of necessity and safety of temporary interrupting of anticoagulation for the period of procedure, main principles of interruption and restarting anticoagulant therapy after procedure, indications to the transitional (bridging) therapy in the periprocedural period, as well as possible strategies of periprocedural management of patients in dependence of risk of bleeding and thromboembolic complications. This Expert Consensus Decision Pathway refer to the periprocedural use of both oral (vitamin K antagonists, new oral anticoagulants) and parenteral (unfractionated and low-molecular-weight heparins) anticoagulants.

Author’s Reply to: Comment: Translating Guidelines Into Practice: Interpreting the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk

Author’s Reply to: Comment: Translating Guidelines Into Practice: Interpreting the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk

Translating Guidelines Into Practice: Interpreting the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk.

In 2016, the American College of Cardiology released a decision pathway, based on expert consensus, to guide use of non-statin agents in the management of atherosclerotic cardiovascular disease risk. The purpose of this article is to assist practitioners, health systems and managed care entities with interpreting this consensus statement in order to simplify implementation of the recommendations into patient care. Major themes from the consensus statement are briefly summarized and explained. Drug therapy recommendations are condensed into a single algorithm, while tables correlate each recommended regimen with the appropriate patient population from both a patient-level and systems-level perspective. Finally, a patient case with evidence-based decision support is explored. These tools allow practitioners to make appropriate patient-specific decisions about the use of non-statin pharmacotherapy and enable health systems and managed care entities to more readily identify guideline-appropriate use of these agents upon review of patient profiles or prescribing patterns. This article provides resources for healthcare providers that facilitate uptake of these recommendations into clinical practice.

Diagnosis of Myocarditis

Determining the etiology of cardiac dysfunction in patients with heart failure influences management and prognosis.1 Myocarditis, diagnosed by the current histopathological Dallas criteria, accounts for &10% of patients with new-onset cardiac dysfunction submitted to endomyocardial biopsy.1,2 Despite complete evaluation including history, physical examination, blood work, echocardiography, coronary angiography, and endomyocardial biopsy, &50% of patients with dilated cardiomyopathy have no etiology identified.1 Recent data suggest that patients in the “idiopathic” category may be suffering from myocardial inflammation due to persistent viral replication or autoimmune activation after a viral infection. These studies raise the question of whether the current histopathological criteria for myocardial inflammation (the Dallas criteria) are sensitive enough to identify the population with viral or autoimmune-related heart compromise. The Dallas criteria were proposed in 1986 and provided a histopathological categorization by which the diagnosis of myocarditis could be established. Dallas criteria myocarditis requires an inflammatory infiltrate and associated myocyte necrosis or damage not characteristic of an ischemic event. Borderline myocarditis requires a less intense inflammatory infiltrate and no light microscopic evidence of myocyte destruction.3 These criteria have been used exclusively by American investigators over the last 2 decades. Sampling error, variation in expert interpretation, variance with other markers of viral infection and immune activation in the heart, and variance with treatment outcomes all suggest that the Dallas criteria are no longer adequate. Chow et al and Hauck et al4,5 demonstrated by biopsying postmortem hearts of patients who had died with myocarditis that, from a single endomyocardial biopsy, histological myocarditis could be demonstrated in only 25% of samples. With >5 biopsies, Dallas criteria myocarditis could be diagnosed in approximately two thirds of subjects. A recent MRI study used focal imaging abnormalities to guide heart biopsy investigation of possible myocarditis. The authors showed that the earliest myocardial …