Recommendations Summary

HF: Monitor and Evaluate Effectiveness of Medical Nutrition Therapy (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: Monitor and Evaluate Effectiveness of Medical Nutrition Therapy (MNT) in Heart Failure (NYHA Classes I-IV/AHA Stages B, C and D)

  The registered dietitian nutritionist (RDN) should monitor and evaluate the following in adults with heart failure (NYHA Classes I–IV/AHA Stages B, C and D), to determine the effectiveness of medical nutrition therapy (MNT):

  • New York Heart Association (NYHA) functional classification, which describes the severity of symptoms and exercise intolerance as follows:
    • Class I: No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).
    • Class II: Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).
    • Class III: Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.
    • Class IV: Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.
  • Biochemical data, medical tests and medication usage:
    • Lipid profiles
    • Blood pressure or Doppler blood pressure
    • Echocardiogram (left ventricular ejection fraction 40% or less)
    • Complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function tests, thyroid-stimulating hormone, brain natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP)
    • Use of medications, prescription and other over-the-counter medications, herbal supplements and complementary or alternative medications.
  • Nutrition-focused physical findings:
    • Height, weight, body mass index (BMI) and waist circumference
    • Edema, congestion and shortness of breath
    • Cachexia and muscle wasting 
    • Hand grip strength testing
  • Client history:
    • General health and demographic information
    • Social history
    • Cultural preferences
    • Health literacy and numeracy
    • Education and occupation
    • Knowledge, beliefs, attitudes, motivation, readiness to change, self-efficacy, and willingness and ability to make behavioral changes
    • Physical activity, including activities of daily living
    • Patient or family nutrition-related medical and health history
    • Other medical or surgical treatments
    • Previous nutrition care services and medical nutrition therapy (MNT) recommendations.
  • Food and nutrition-related history:
    • Food, beverage and nutrient intake including energy intake, serving sizes, meal-snack patterns, carbohydrate, fiber, types and amounts of fat, protein, micronutrient intake and alcohol intake
    • Allergies and food intolerances
    • Early satiety
    • Altered sense of taste (hypogeusia or dysgeusia)
    • Dry mouth (xerostomia)
    • Gastrointestinal distress (nausea, vomiting, diarrhea, malabsorption, bloating, etc.)
    • Experience with food, previous and current food and nutrition history, eating environment, access to healthy foods and eating out.

  Every patient with HF should have a clear, detailed and continually updated 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.

  Rating: Strong
  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 2013 ACCF/AHA Guideline for the Management of Heart Failure (HF):
    
    6.1. Clinical Evaluation
    6.1.1. History and Physical Examination: Recommendations
    
    Class I

    • A thorough history and physical examination should be obtained or performed in patients presenting with HF to identify cardiac and non-cardiac disorders or behaviors that might cause or accelerate the development or progression of HF. (Level of Evidence: C)
    • In patients with idiopathic DCM, a three-generational family history should be obtained to aid in establishing the diagnosis of familial DCM. (Level of Evidence: C)
    • Volume status and vital signs should be assessed at each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venous pressure and the presence of peripheral edema or orthopnea. (Level of Evidence: B)

    6.1.2. Risk Scoring: Recommendation
    
    Class IIa

    • Validated multi-variable risk scores can be useful to estimate subsequent risk of mortality in ambulatory or hospitalized patients with HF. (Level of Evidence: B)

    6.2 Diagnostic Tests: Recommendations
    
    Class I

    • Initial laboratory evaluation of patients presenting with HF should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function tests and thyroid-stimulating hormone. (Level of Evidence: C)
    • Serial monitoring, when indicated, should include serum electrolytes and renal function. (Level of Evidence: C)
    • A 12-lead ECG should be performed initially on all patients presenting with HF. (Level of Evidence: C)

    Class IIa

    • Screening for hemochromatosis or HIV is reasonable in selected patients who present with HF. (Level of Evidence: C)
    • Diagnostic tests for rheumatologic diseases, amyloidosis or pheochromocytoma are reasonable in patients presenting with HF, in whom there is a clinical suspicion of these diseases. (Level of Evidence: C)

    6.3 Biomarkers: Recommendations
    
    A. Ambulatory/Outpatient
    
    Class I

    • In ambulatory patients with dyspnea, measurement of BNP or N-terminal pro-B-type natriuretic peptide (NT-proBNP) is useful to support clinical decision-making regarding the diagnosis of HF, especially in the setting of clinical uncertainty. (Level of Evidence: A)
    • Measurement of BNP or NT-proBNP is useful for establishing prognosis or disease severity in chronic HF. (Level of Evidence: A)

    Class IIa

    • BNP- or NT-proBNP-guided HF therapy can be useful to achieve optimal dosing of GDMT in select clinically euvolemic patients followed in a well-structured HF disease management program. (Level of Evidence: B)

    Class IIb

    • The usefulness of serial measurement of BNP or NT-proBNP to reduce hospitalization or mortality in patients with HF is not well established. (Level of Evidence: B)
    • Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in patients with chronic HF. (Level of Evidence: B)

    B. Hospitalized/Acute
    
    Class I

    • Measurement of BNP or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis. (Level of Evidence: A)
    • Measurement of BNP or NT-proBNP or cardiac troponin is useful for establishing prognosis or disease severity in acutely decompensated HF. (Level of Evidence: A)

    Class IIb

    • The usefulness of BNP- or NT-proBNP–guided therapy for acutely decompensated HF is not well established. (Level of Evidence: C)
    • Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in patients with acutely decompensated HF. (Level of Evidence: A)

    6.4. Non-Invasive Cardiac Imaging: Recommendations
    
    Class I

    • Patients with suspected or new-onset HF or those presenting with acute decompensated HF should undergo a chest X-ray to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary and other diseases that may cause or contribute to the patient’s symptoms. (Level of Evidence: C)
    • A two-dimensional echocardiogram with Doppler should be performed during initial evaluation of patients presenting with HF to assess ventricular function, size, wall thickness, wall motion and valve function. (Level of Evidence: C)
    • Repeat measurement of EF and measurement of the severity of structural remodeling are useful to provide information in patients with HF who have had a significant change in clinical status; who have experienced or recovered from a clinical event; who have received treatment, including GDMT, that might have had a significant effect on cardiac function; or who may be candidates for device therapy. (Level of Evidence: C)

    Class IIa

    • Non-invasive imaging to detect myocardial ischemia and viability is reasonable in patients presenting with de novo HF, who have known CAD and no angina, unless the patient is not eligible for re-vascularization of any kind. (Level of Evidence: C)
    • Viability assessment is reasonable in select situations when planning re-vascularization in HF patients with CAD. (Level of Evidence: B)
    • Radionuclide ventriculography or magnetic resonance imaging can be useful to assess LVEF and volume when echocardiography is inadequate. (Level of Evidence: C)
    • Magnetic resonance imaging is reasonable when assessing myocardial infiltrative processes or scar burden. (Level of Evidence: B)

    Class III: No Benefit

    • Routine repeat measurement of LV function assessment in the absence of clinical status change or treatment interventions should not be performed. (Level of Evidence: B)

    6.5. Invasive Evaluation: Recommendations
    
    Class I

    • Invasive hemodynamic monitoring with a pulmonary artery catheter should be performed to guide therapy in patients who have respiratory distress or clinical evidence of impaired perfusion, in whom the adequacy or excess of intra-cardiac filling pressures cannot be determined from clinical assessment. (Level of Evidence: C)

    Class IIa

    • Invasive hemodynamic monitoring can be useful for carefully selected patients with acute HF who have persistent symptoms despite empiric adjustment of standard therapies and:
      • Whose fluid status, perfusion, or systemic or pulmonary vascular resistance is uncertain;
      • Whose systolic pressure remains low, or is associated with symptoms, despite initial therapy;
      • Whose renal function is worsening with therapy;
      • Who require parenteral vasoactive agents; or
      • Who may need consideration for MCS or transplantation. (Level of Evidence: C)
    • When ischemia may be contributing to HF, coronary arteriography is reasonable for patients eligible for re-vascularization. (Level of Evidence: C)
    • Endomyocardial biopsy can be useful in patients presenting with HF when a specific diagnosis is suspected that would influence therapy. (Level of Evidence: C)

    Class III: No Benefit

    • Routine use of invasive hemodynamic monitoring is not recommended in normotensive patients with acute decompensated HF and congestion with symptomatic response to diuretics and vasodilators. (Level of Evidence: B)

    Class III: Harm

    • Endomyocardial biopsy should not be performed in the routine evaluation of patients with HF. (Level of Evidence: C)

    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)

  • Recommendation Strength Rationale

    The 2013 ACCF/AHA Guidelines for the Management of Heart Failure received Levels of Evidence A, B and C.

  • Minority Opinions

    Consensus reached.

• Supporting Evidence

  The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

  • References
  • References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

    Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013; 128: e240–e327.