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Heart Failure

HF: Introduction (2008)

Guideline Overview

Guideline Title

Heart Failure (2005) Evidence-Based Nutrition Practice Guideline

Guideline Narrative Overview

The focus of this guideline is on nutrition practice during the treatment of adult patients with heart failure, specifically left ventricular dysfunction.
According to the 2005 American College of Cardiology and American Heart Association (ACC/AHA) Practice Guidelines, the term "congestive heart failure" has been replaced by "heart failure" because it is a chronic disease and the patients may not exhibit congestion as a symptom. Heart failure develops from uncontrolled hypertension, coronary artery disease, myocardial infarction, valvular disease, idiopathic cardiomyopathy, and alcohol and/or drug abuse. Patients with heart failure experience fatigue, exercise intolerance, edema, and shortness of breath. Treatment of heart failure symptoms should be based on a comprehensive nutrition assessment to maximize adequate intake and control the symptoms of the disease. The goals of nutrition care include a reduction in sodium and fluid intake and the monitoring of calories, protein and nutrient needs.

Evidence-Based Nutrition Practice Guideline Development
This guideline is intended for use by dietetic practitioners involved in the nutrition care for patients with heart failure. It is expected that this knowledge will be integrated into providing individualized nutrition care with practical recommendations that are based on the current state of the science for nutrition and patients with a diagnosis of heart failure based on a left ventricular ejection fraction (LVEF) of 45% or less. This includes the following New York Heart Association Functional Classification (NYHA):

  • NYHA Class I: Asymptomatic; patient is not short of breath or fatigued with any activity
  • NYHA Class II: Patient is short of breath or fatigued after moderate activity (such as climbing two flights of stairs, golfing nine holes, or carrying a load of wash up from the basement)
  • NYHA Class III: Patient is short of breath or fatigued even after very mild exertion (such as walking around the house or up half a flight of stairs)
  • NYHA Class IV: Patient is exhausted, short of breath, or fatigued at rest (just sitting still or lying in bed).
This guideline outlines the most current information on nutrition and heart failure. The recommendations developed in this guideline were based upon a systematic review of the literature. Topics include:
  • Medical Nutrition Therapy
  • Sodium and Fluid Restriction
  • Energy and Protein Needs
  • Alcohol
  • Vitamin, Mineral, and Herbal Supplements
  • Caffeine
The recommendations involving nutrition and treatment for heart failure are based on the work performed by the ADA Heart Failure evidence analysis working group. The number of supporting documents for these topics is below:
  • Recommendations: 11
  • Conclusion Statements: 15
  • Evidence Summaries: 13 
  • Article worksheets: 33
To view the guideline development and review process, click here.

Application of the Guideline
This guideline will be accompanied by a set of companion documents (i.e., a toolkit) to assist the practitioner in applying the guideline. The toolkit will contain materials such as the Medical Nutrition Therapy protocol, documentation forms, outcomes management tools, client education resources and case studies. The toolkit is currently under development and will undergo pilot-testing through the ADA's Dietetic Practice-Based Research Network prior to publication.

The literature search will be repeated for each guideline topic on an annual basis to identify new research that has been published since the previous search was completed. Based on the quantity and quality of new research, a determination will be made about whether the information could change the published recommendation or rating.

If a revision is unwarranted, then the search is recorded, dated and saved until the next review and no further action is taken. If the determination is that there could be a change in the recommendation or rating, then the supporting evidence analysis question(s) will be re-analyzed following the standard ADA Evidence Analysis Process (see ADA Evidence Analysis Manual). When the analysis is completed, the expert workgoup will approve and re-grade the conclusion statements and recommendations. The guideline will undergo a complete revision every three to five years.

Medical Nutrition Therapy and Heart Failure
Scientific evidence supports the effectiveness of nutrition therapy to control the symptoms of heart failure and to improve the quality of life of patients with the disease. Topics included in this guideline:

  • Use of medical nutrition therapy and dietitian intervention
  • Sodium and fluid prescription
  • Determination of energy and protein needs
  • Use of vitamin, mineral, and herbal supplementation 
The registered dietitian plays an integral role on the multi-disciplinary healthcare team by preparing an individualized nutrition plan for patients with heart failure.

Populations to Whom This Guideline May Apply
This guideline applies to adult patients with heart failure who have been diagnosed with left ventricular dysfunction (LVEF 45% or less).

Other Guideline Overview Material
For more details on the guideline components, use the liks on the left to access:
  • Scope of Guideline
  • Statement of Intent and Patient Preference
  • Guideline Methods
  • Specific Topics Search Methods
  • Implementation of the Guideline
  • Benefits and Harms of Implementing the Recommendations.
Clinical judgment is critical. Careful consideration should be given to the application of these guidelines for patients classified NYHA class I and II, or those patients experiencing acute or chronic renal insufficiency.