Quick Links

  • Increase Font Size
  • Decrease Font Size
  • View as PDF

Recommendations Summary

HF: Coordination of Care (2017)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    HF: Coordination of Care for Adults with Heart Failure (NYHA Classes I-IV/AHA Stages B, C and D)

    For adults with heart failure (NYHA Classes I - IV/AHA Stages B, C and D), the registered dietitian nutritionist (RDN) should implement medical nutrition therapy (MNT) for heart failure and coordinate care as part of an interdisciplinary health care team. Every patient with heart failure should have a clear, detailed, and evidence-based plan of care that ensures the achievement of guideline determined medical therapy (GDMT) goals, effective management of comorbid conditions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease. This plan of care should be updated regularly and made readily available to all members of each patient’s healthcare team.

    Rating: Fair
    Imperative

    HF: Consult with Interdisciplinary Health Care Team Regarding Vitamin, Mineral and Herbal Supplementation in Heart Failure (NYHA Classes I - IV/AHA Stages B, C and D)

    For adults with heart failure (NYHA Classes I - IV/AHA Stages B, C and D), the registered dietitian nutritionist (RDN) should consult with others on the interdisciplinary health care team regarding vitamin, mineral and herbal supplementation. Due to the many interactions between various supplements and common medications, it is unclear whether certain supplements, such as omega-3 fatty acids, coenzyme Q10, vitamin D, iron and thiamin, are appropriate for patients with heart failure.

    Rating: Weak
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      None.

    • Potential Costs Associated with Application

      Costs of medical nutrition therapy (MNT) sessions and reimbursement vary; however, MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      From the evidence analysis regarding Coenzyme Q10 Supplementation in Heart Failure:

      Heart Failure (NYHA Classes I - IV/AHA Stages B and C):

      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), research reported no hospital admissions or deaths during the three-month intervention period within or between groups receiving either 150 mg/day of oral Coenzyme Q10 or placebo. However, due to the interactions between Coenzyme Q10 and some common heart-failure medications (warfarin, statins and beta-blockers), it is unclear whether this dose and duration of Coenzyme Q10 would be appropriate for patients with heart failure. Research is needed regarding the effect of Coenzyme Q10 supplementation on quality measures in patients with heart failure. Grade III
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), research reported mixed results regarding the effect of Coenzyme Q10 supplementation on quality of life, signs and symptoms. One study reported that the group receiving 150 mg/day of oral Coenzyme Q10 had a significant improvement of 0.5 units in NYHA functional class after three months compared to the placebo group, which had no significant change; one study reported that 75% of study subjects reported no change in symptoms. However, due to the interactions between Coenzyme Q10 and some common heart-failure medications (warfarin, statins and beta-blockers), it is unclear whether this dose and duration of Coenzyme Q10 would be appropriate for patients with heart failure. Research is needed regarding the effect of Coenzyme Q10 supplementation on quality of life in patients with heart failure. Grade III
      • In patients with heart failure (NYHA Classes I-IV/AHA Stages B and C), research reported no significant differences in creatinine levels after three months within or between groups receiving either 150 mg/day of oral Coenzyme Q10 or placebo. Research is needed regarding the effect of Coenzyme Q10 supplementation on BUN, BNP and serum sodium in patients with heart failure. Grade III
      Advanced Heart Failure (NYHA Class IV/AHA Stage D):
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of Coenzyme Q10 supplementation on quality measures. Grade V
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), research reported that patients with end-stage heart failure awaiting cardiac transplantation receiving 60 mg U/day of Ultrasome-CoQ10 for three months had improved quality of life and significant decreases in frequency of nocturia, severity of fatigue, severity in dyspnea and NYHA functional classification, compared to those receiving placebo. However, due to the interactions between Coenzyme Q10 and some common heart-failure medications (warfarin, statins and beta-blockers), it is unclear whether this dose and duration of Coenzyme Q10 would be appropriate for patients with advanced heart failure. Further research is needed regarding the effect of Coenzyme Q10 supplementation on quality of life, signs and symptoms. Grade III
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of Coenzyme Q10 supplementation on renal function labs and clinical labs. Grade V
      From the evidence analysis regarding Omega-3 Fatty Acid Supplementation in Heart Failure:

      Heart Failure (NYHA Classes I - IV/AHA Stages B and C):
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), research reported that omega-3 fatty acid supplementation had no significant effect on mortality rates, but the effect of 2 g/day for six months to one year showed mixed results on hospitalization rates. However, since omega 3 fatty acid supplementation may increase the effects of blood thinning agents such as warfarin, aspirin, clopedigrel, and vitamin E, it is unclear whether this dose and duration of omega-3 fatty acids would be appropriate for patients with heart failure. Research is needed regarding the effect of omega-3 fatty acid supplementation on length of stay in patients with heart failure. Grade III
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), research reported that the group receiving 2 g/day of omega-3 polyunsaturated fatty acids for one year had a significant decrease in NYHA functional class compared to an increase in the placebo group. However, since omega 3 fatty acid supplementation may increase the effects of blood thinning agents such as warfarin, aspirin, clopedigrel, and vitamin E, it is unclear whether this dose and duration of omega-3 fatty acids would be appropriate for patients with heart failure. Research is needed regarding the effect of omega-3 fatty acid supplementation on quality of life in patients with heart failure. Grade III
      • In patients with heart failure (NYHA Classes I-IV/AHA Stages B and C), research reported that omega-3 fatty acid supplementation, at the level of 2 g/day for three to six months, resulted in significant decreases in BNP levels. However, since omega 3 fatty acid supplementation may increase the effects of blood thinning agents such as warfarin, aspirin, clopedigrel, and vitamin E, it is unclear whether this dose and duration of omega-3 fatty acids would be appropriate for patients with heart failure. Research is needed regarding the effect of omega-3 fatty acid supplementation on BUN, creatinine and serum sodium in patients with heart failure. Grade III
      Advanced Heart Failure (NYHA Class IV/AHA Stage D):
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of omega-3 fatty acid supplementation on quality measures. Grade V
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of omega-3 fatty acid supplementation on quality of life, signs and symptoms. Grade V
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of omega-3 fatty acid supplementation on renal function labs and clinical labs. Grade V
      From the evidence analysis regarding Vitamin D Supplementation in Heart Failure:

      Heart Failure (NYHA Classes I - IV/AHA Stages B and C):
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), research reported that among patients randomized to either the intervention group receiving 2, 000 IU oral vitamin D3 daily for six weeks or the control group, the two adverse events that occurred during the course of the study (one death and one hospitalization) were not associated with the vitamin D supplementation. However, due to the interactions between vitamin D and some common medications (oral corticosteroids, thyroxin, anti-epileptics, tetracyclines, and quinolones), it is unclear whether this dose and duration of vitamin D would be appropriate for patients with heart failure. Research is needed regarding the effect of vitamin D supplementation on quality measures in patients with heart failure. Grade III
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), there were no studies identified that reported on the effect of vitamin D supplementation on quality of life, signs and symptoms. Grade V
      • In patients with heart failure (NYHA Classes I-IV/AHA Stages B and C), research reported no significant differences in N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels after six weeks within or between groups receiving either 2, 000 IU oral vitamin D3 daily or no supplementation. Research is needed regarding the effect of vitamin D supplementation on renal function labs and clinical labs in patients with heart failure. Grade III
      Advanced Heart Failure (NYHA Class IV/AHA Stage D):
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of vitamin D supplementation on quality measures. Grade V
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of vitamin D supplementation on quality of life, signs and symptoms. Grade V
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of vitamin D supplementation on renal function labs and clinical labs. Grade V
      From the evidence analysis regarding Iron Supplementation in Heart Failure:

      Heart Failure (NYHA Classes I - IV/AHA Stages B and C):
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), there were no studies identified that reported on the effect of iron supplementation on quality measures. Grade V
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), there were no studies identified that reported on the effect of iron supplementation on quality of life, signs and symptoms. Grade V
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), there were no studies identified that reported on the effect of iron supplementation on renal function labs and clinical labs. Grade V
      Advanced Heart Failure (NYHA Class IV/AHA Stage D):
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of iron supplementation on quality measures. Grade V
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of iron supplementation on quality of life, signs and symptoms. Grade V
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of iron supplementation on renal function labs and clinical labs. Grade V
      From the evidence analysis regarding Thiamin Supplementation in Heart Failure:

      Heart Failure (NYHA Classes I - IV/AHA Stages B and C):
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), there were no studies identified that reported on the effect of thiamin supplementation on quality measures. Grade V
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), there were no studies identified that reported on the effect of thiamin supplementation on quality of life, signs and symptoms. Grade V
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), there were no studies identified that reported on the effect of thiamin supplementation on renal function labs and clinical labs. Grade V
      Advanced Heart Failure (NYHA Class IV/AHA Stage D):
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of thiamin supplementation on quality measures. Grade V
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of thiamin supplementation on quality of life, signs and symptoms. Grade V
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of thiamin supplementation on renal function labs and clinical labs. Grade V
      From the 2013 ACCF/AHA Guideline for the Management of Heart Failure (HF):

      7.3. Stage C
      7.3.2. Pharmacological Treatment for Stage C HFrEF: Recommendations
      7.3.2.8. Other Drug Treatment

      7.3.2.8.3. Omega-3 Fatty Acids: Recommendation

      Class IIa
      • Omega-3 polyunsaturated fatty acid (PUFA) supplementation is reasonable to use as adjunctive therapy in patients with NYHA class II–IV symptoms and HFrEF (heart failure reduced ejection fraction) or HFpEF (heart failure preserved ejection fraction), unless contraindicated, to reduce mortality and cardiovascular hospitalizations. (Level of Evidence: B)
      7.3.2.9. Drugs of Unproven Value or That May Worsen HF: Recommendations

      Class III: No Benefit
      • Nutritional supplements as treatment for HF are not recommended in patients with current or prior symptoms of HFrEF. (Level of Evidence: B)
      • Hormonal therapies other than to correct deficiencies are not recommended for patients with current or prior symptoms of HFrEF. (Level of Evidence: C)
      8.9. Inpatient and Transitions of Care: Recommendations

      Class I
      • The use of performance improvement systems and/or evidence-based systems of care is recommended in the hospital and early postdischarge outpatient setting to identify appropriate HF patients for GDMT, provide clinicians with useful reminders to advance GDMT, and assess the clinical response. (Level of Evidence: B)
      • Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed (Level of Evidence: B):
        • initiation of GDMT if not previously established and not contraindicated;
        • precipitant causes of HF, barriers to optimal care transitions, and limitations in postdischarge support;
        • assessment of volume status and supine/upright hypotension with adjustment of HF therapy as appropriate;
        • titration and optimization of chronic oral HF therapy;
        • assessment of renal function and electrolytes where appropriate;
        • assessment and management of comorbid conditions;
        • reinforcement of HF education, self-care, emergency plans, and need for adherence;
        • and consideration for palliative care or hospice care in selected patients.
      • Multidisciplinary HF disease-management programs are recommended for patients at high risk for hospital readmission, to facilitate the implementation of GDMT, to address different barriers to behavioral change, and to reduce the risk of subsequent rehospitalization for HF. (Level of Evidence: B)
      Class IIa
      • Scheduling an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge are reasonable. (Level of Evidence: B)
      • Use of clinical risk-prediction tools and/or biomarkers to identify patients at higher risk for postdischarge clinical events are reasonable. (Level of Evidence: B)
      11.1. Coordinating Care for Patients With Chronic HF: Recommendations

      Class I
      • Effective systems of care coordination with special attention to care transitions should be deployed for every patient with chronic HF that facilitate and ensure effective care that is designed to achieve GDMT and prevent hospitalization. (Level of Evidence: B)
      • Every patient with HF should have a clear, detailed, and evidence-based plan of care that ensures the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease. This plan of care should be updated regularly and made readily available to all members of each patient’s healthcare team. (Level of Evidence: C)
      • Palliative and supportive care is effective for patients with symptomatic advanced HF to improve quality of life. (Level of Evidence: B)
      From the 2016 ESC Guideline for the Diagnosis and Treatment of Acute and Chronic Heart Failure:

      7.  Pharmacological Treatment of Heart Failure with Reduced Ejection Fraction
      7.4 Other Treatments With Less Certain Benefits in Symptomatic Patients with Heart Failure with Reduced Ejection Fraction
      7.4.2 n-3 Polyunsaturated Fatty Acids
      • An N-3 PUFA preparation may be considered in symptomatic HF patients to reduce the risk of cardiovascular hospitalization and cardiovascular death (applies only to preparation studied in cited trial, 850 mg of EPA/DHA). (No Class or Level provided)
      14. Multidisciplinary Team Management
      • It is recommended that patients with HF are enrolled in a multidisciplinary care management programme to reduce the risk of HF hospitalization and mortality. (Class I, Level A)

    • Recommendation Strength Rationale

      • Conclusion Statements in support of these recommendations were given Grades III and V
      • The 2013 ACCF/AHA Guidelines for the Management of Heart Failure received Levels of Evidence B and C
      • The 2016 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure received Class I, Level A

    • Minority Opinions

      Consensus reached.