Patients With Cardiac Structural Abnormalities or Remodeling Who Have Not Developed Heart Failure Symptoms (Stage B)

CLASS I
(1) All Class I recommendations for Stage A should apply to patients with cardiac structural abnormalities who have not developed HF.

(2) Beta blockers and ACEIs should be used in all patients with a recent or remote history of MI regardless of EF or presence of HF

(3) Beta blockers are indicated in all patients without a history of MI who have a reduced LVEF with no HF symptoms.

(4) Angiotensin converting enzyme inhibitors should be used in patients with a reduced EF and no symptoms of HF, even if they have not experienced MI.

(5) An ARB should be administered to post-MI patients without HF who are intolerant of ACEIs and have a low LVEF.

(6) Patients who have not developed HF symptoms should be treated according to contemporary guidelines after an acute MI.

(7) Coronary revascularization should be recommended in appropri- ate patients without symptoms of HF in accordance with contemporary guidelines (see ACC/AHA/ACP-ASIM Guidelines for the Management of Patients With Chronic Stable Angina).

(8) Valve replacement or repair should be recommended for patients with hemodynamically significant valvular stenosis or regurgitation and no symptoms of HF in accordance with contemporary guidelines.

CLASS IIa
(1) Angiotensin converting enzyme inhibitors or ARBs can be beneficial in patients with hypertension and LVH and no symptoms of HF.

(2) Angiotensin II receptor blockers can be beneficial in patients with low EF and no symptoms of HF who are intolerant of ACEIs.

(3) Placement of an ICD is reasonable in patients with ischemic cardiomyopathy who are at least 40 days post-MI, have an LVEF of 30% or less, are NYHA functional class I on chronic optimal medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year.

CLASS IIb
(1) Placement of an ICD might be considered in patients without HF who have nonischemic cardiomyopathy and an LVEF less than or equal to 30% who are in NYHA functional class I with chronic optimal medical therapy and have a reasonable expectation of survival with good functional status for more than 1 year.

CLASS III
(1) Digoxin should not be used in patients with low EF, sinus rhythm, and no history of HF symptoms, because in this population, the risk of harm is not balanced by any known benefit.

(2) Use of nutritional supplements to treat structural heart disease or to prevent the development of symptoms of HF is not recommended.

(3) Calcium channel blockers with negative inotropic effects may be harmful in asymptomatic patients with low LVEF and no symptoms of HF after MI.



JACC. 2009; 53; e1-e90