Many definitions of heart failure have been used, reflecting the existing understanding of the pathophysiological condition at that time. Heart failure is a complex syndrome in which abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion. Because most evidence-based recommendations are based on clinical trials where significant left ventricular systolic dysfunction is present, the term ‘heart failure’ is used in this document to refer to predominant left ventricular systolic dysfunction unless otherwise stated. Diastolic heart failure (or heart failure with preserved systolic function [PSF]), right heart failure, left or right ventricular failure, biventricular heart failure, congestive heart failure (CHF), acute or chronic heart failure, cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy, ischemic cardiomyopathy and nonischemic cardiomyopathy are examples of other terms often used in clinical practice and research to describe specific presentations and underlying pathologies.
Heart failure is common, especially in older patients, and its incidence is predicted to increase (1
). It reduces quality of life, exercise tolerance and survival. Depending on the severity of symptoms, heart dysfunction, age and other factors, heart failure can be associated with an annual mortality of 5% to 50%. A better understanding of the underlying pathophysiological mechanisms, combined with many new treatments developed over the past 20 years, has greatly improved the prognosis; many patients can now hope for long periods of stable, improved symptoms and improved heart function. Nonetheless, an inexorable course can also occur, and many new approaches to treatment continue to be developed.
This consensus conference was convened by the Canadian Cardiovascular Society (CCS) to review new evidence and update previous consensus conferences (2
) to provide a set of evidence-informed recommendations that would provide clinicians, and other health care professionals involved in the management of heart failure patients, with clear directions and options to optimize care of individual patients. Furthermore, a concurrent plan for knowledge translation was developed. Through increased use of these evidence-based proven therapies and other recommendations based on the consensus of heart failure experts where adequate clinical trial evidence was not available, the purpose is to improve health outcomes and quality of life across the broad spectrum of heart failure patients in Canada and to measure that impact. Specific patient subgroups are identified in individual recommendations when appropriate. The present document does not repeat the reviews of data presented in the previous consensus conferences, but aims to highlight new data while updating previous recommendations where appropriate. Readers are referred to the previous publications for additional background information and rationale. New or expanded sections cover diagnosis and investigation, acute heart failure (AHF), multidisciplinary care and heart failure clinics, polypharmacy, device therapy, surgical approaches, heart failure in the elderly and issues related to end-of-life care. Following a review of the literature and a critical appraisal of the evidence, recommendations were arrived at by informed consensus through face-to-face meetings, conference calls, e-mail correspondence, and final review by all members of both the primary and the secondary panel. The primary panelists were principally responsible for the document, but the secondary panelists reviewed the recommendations and provided feedback, and some were involved in section working groups.
The class of recommendation and the grade of evidence were determined as follows:
Class I: Evidence or general agreement that a given procedure or treatment is beneficial, useful and effective.
Class II: Conflicting evidence or a divergence of opinion about the usefulness or efficacy of the procedure or treatment.
Class IIa: Weight of evidence is in favour of usefulness or efficacy.
Class IIb: Usefulness or efficacy is less well established by evidence or opinion.
Class III: Evidence or general agreement that the procedure or treatment is not useful or effective and in some cases may be harmful.
Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses.
Level of Evidence B: Data derived from a single randomized clinical trial or nonrandomized studies.
Level of Evidence C: Consensus of opinion of experts and/or small studies.