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Citation
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The Pharmacologic
Managment of Chronic Heart Failure. Washington, DC: Pharmacy Benefits
Management Strategic Healthcare Group and the Medical Advisory
Panel, Veterans Health Administration, Department of Veterans
Affairs; February, 2001. PRM-SHG Publication No. 00-0015.
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Completion
Date:
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February
2001
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Release
Date:
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February,
2001
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Source(s):
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The
Chronic Heart Failure Guideline was developed by and written for clinicians
by the Medical Advisory Panel (MAP) for Pharmacy Benefits Management and
specialists in cardiology. The MAP is comprised of practicing VA and
Department of Defense(DoD) physicians.
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Adaptation:
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Development
of the guidelines relied upon the following consensus documents: Advisory
Council to Improve Outcomes Nationwide in Heart Failure (ACTION-HF).
Consensus recommendations for the management of heart failure. Am J Cardiol
1999:83(2A):1A-38A, ACC/AHA Task Force Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines
(Committee on Evaluation and Management of Heart Failure). JACC
1995;26(5):1376-98 and Evaluation and care of patients with
left-ventricular systolic dysfunction. Clinical practice guideline No. 11
AHCPR publication no. 94-0612. Rockville, MD: Agency for Health Care Policy
and Research Public Health Service, U.S. Department of Health and Human
Services, 1994.
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Guideline
Status:
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This is
the current release of the guideline. An update is targeted for 2003.
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Developer(s):
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Veterans Health Administration (VHA), Department
of Veterans Affairs (VA) - Federal Government Agency [U.S.]
Department of Defense (DoD) - Federal Government Agency [U.S.]
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Funding
Source:
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United States Government
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Committee:
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Medical
Advisory Panel for Pharmacy Benefits Management -Strategic Health Group
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Group
Composition:
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list of contributors.
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Disease
Condition:
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Chronic
Heart Failure (CHF)
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Category:
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Diagnosis;
Treatment; Pharmacologic & Non Pharmacologic, Treatment of Co-morbid
Conditions, Management; and Follow Up
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Intended
Users:
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Designed
for use by primary care providers, cardiology, or by multidisciplinary HF
treatment teams. The guideline can also be used to coordinate, and
standardize care and as teaching tools for students and house staff.
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Target
Population:
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Any
person who is eligible for care in the VA or DoD health care delivery
system.
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VHA
Contact Person(s):
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Elaine
Furmaga, Pharm. D.
Pharmacist Specialist
Department of Veterans Affairs
6080 Champagne Ct, SE
Grand Rapids, MI 49546
Phone: 708-216-2079 ext 3598
Fax: 708-216-2136
Email: furmaga@flash.net
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GOALS/OBJECTIVES
- To promote evidence-based
management of individuals with Heart Failure
- To identify the critical
decision points in management of patients with Heart Failure
- To allow flexibility so that
local policies or procedures, such as those regarding referrals to or
consultation with specialists
- To improve local management
of patients with Heart Failure and thereby improve patient outcomes
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INTERVENTIONS AND PRACTICES
The guidelines are meant to focus on the pharmacologic
management of patients with HF. Other sections have been included that
highlight areas such as physical examination, diagnosis, nonpharmacologic
management.
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OUTCOMES CONSIDERED
Goals of
therapy for HF include improved symptoms, increased functional capacity,
improved quality of life, slowed disease progression, decreased need for
hospitalization, and prolonged survival. Early post-myocardial infarction
(MI) treatment with an angiotensin-converting enzyme inhibitor (ACEI) in
patients with left ventricular systolic dysfunction may prevent future
development of HF and improve overall survival.
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MAJOR RECOMMENDATIONS
The guideline is presented in an algorithmic format and
is intended to provide a systematic approach to the pharmacologic
management of patients with HF.
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CLINICAL ALGORITHMS
Algorhithm
section of the web page
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TYPE OF EVIDENCE
Critical
literature review focused on pharmacologic management of Heart Failure. The
annotations that include discussion on medical history, physical
examination, diagnosis and evaluation, nonpharmacologic intervention,
management of concomitant cardiac conditions, and treatment of underlying
causes were based on consensus and did not undergo critical literature
review. Where evidence was not available, expert opinion of the MAP was
used. After review and discussion by the PBM-MAP, the draft guideline was
sent to experts in the field of Cardiology for review. After the
Cardiologist reviewers' comments were considered and incorporated into the
document where appropriate, the draft was then circulated to practicing
clinicians (primarily cardiologists and primary care providers) for input
on clarity and applicability.
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DESCRIPTION OF METHODS TO
COLLECT EVIDENCE
The
algorithm and annotations are in part based on the HF guideline developed
in 1997. To update this information, the literature following the
publication of the 1997 document was searched (search queried articles
published 1995 to March 2000, and updated February 2001). A literature
search of MEDLINE was conducted including the following search terms: heart
failure, angiotensin-converting enzyme inhibitor, â -adrenergic blocker,
digoxin, spironolactone, angiotensin receptor blocker, calcium channel
blocker, anticoagulation, diastolic dysfunction, side effect, clinical
trial, review, meta-analysis. The literature was limited to adult human
subjects and articles published in the English language. The bibliographies
of articles and consensus documents were reviewed for additional relevant
literature. Literature known to the PBM-MAP on medical history, physical
examination, diagnosis and evaluation was also included in the document.
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METHODS TO ASSESS THE QUALITY
AND STRENGTH OF THE EVIDENCE
The literature was critically analyzed with evidence
grading. The rating scale used for this document was based on the evidence
rating used by U.S. Preventative Services Task Force (
http://text.nlm.nih.gov/cps/www/cps.3.html), adapted from the Canadian
Task Force on the Periodic Health Examination.
The Grading
Scheme Used for the Guideline
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Strength of Recommendation (SR)
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Recommendation
Grade = A
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Recommendation
Grade = B
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Recommendation
Grade = C
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Recommendation
Grade = D
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Recommendation
Grade = E
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There
is good evidence to support that the intervention be adopted.
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There
is fair evidence to support that the intervention be adopted.
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There
is insufficient evidence to recommend for or against the intervention,
but recommendations may be made on other grounds.
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There
is fair evidence to support that the intervention be excluded.
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There
is good evidence to support that the intervention be excluded.
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Quality of Evidence (QE)
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Grade
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Quality of Evidence
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I
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Evidence
obtained from at least one properly randomized controlled trial.
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II-1
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Evidence
obtained from well-designed controlled trials without randomization.
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II-2
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Evidence
obtained from well-designed cohort or case-control analytic studies,
preferably from more than one center or research group.
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II-3
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Evidence
obtained from multiple time series studies with or without the
intervention. Dramatic results in uncontrolled experiments (such as the
results of the introduction of penicillin treatment in the 1940s) could
also be regarded as this type of evidence.
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III
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Opinions
of respected authorities, based on clinical experience; descriptive
studies and case reports; or reports of expert committees.
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Recommendations were based on evidence published in the
medical literature. Critical literature review focused on pharmacologic
management of HF. The annotations that include discussion on medical
history, physical examination, diagnosis and evaluation, nonpharmacologic
intervention, management of concomitant cardiac conditions, and treatment
of underlying causes were based on consensus and did not undergo critical
literature review. Where evidence was not available, expert opinion of the
MAP was used. After review and discussion by the PBM-MAP, the draft
guideline was sent to experts in the field of Cardiology for review. After
the Cardiologist reviewers' comments were considered and incorporated into
the document where appropriate, the draft was then circulated to practicing
clinicians (primarily cardiologists and primary care providers) for input
on clarity and applicability.
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REVIEW METHODS
Peer
Review
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ENDORSER(S)
VHA 's
National Clinical Practice Guideline Council
DoD/VA Clinical Practice Guidelines Working Group
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QUALIFYING STATEMENTS
Clinical practice guidelines, which are increasingly
being used in health care, are seen by many as a potential solution to
inefficiency and inappropriate variations in care. Guidelines should be
evidenced-based as well as based upon explicit criteria to ensure consensus
regarding their internal validity. However, it must be remembered that the
use of guidelines must always be in the context of a health care provider's
clinical judgment in the care of a particular patient. For that reason, the
guidelines may be viewed as an educational tool analogous to textbooks and
journals, but in a more user-friendly tone.
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GUIDELINE AVAILABILITY
Electronic
copies available from the Office of Quality and
Performance web site
Print
copies available
from:
The Office of Quality and Performance (10Q)
Veterans Health Administration,
Department of Veterans Affairs
810 Vermont, NW
Washington, DC 20420
COPYRIGHT STATEMENT: No copyright
restrictions apply.
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