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⁎ Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 of the full guideline for detailed information.
† ACC/AHA Representative ‡ ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison § ACC/AHA Task Force on Performance Measures Representative ‖ HFSA Representative ⁎ Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 of the full guideline for detailed information.
The 2022 American College of Cardiology/American Heart Association/Heart Failure Society of America (AHA/ACC/HFSA) Guideline for the Management of Heart Failure replaces the 2013 ACCF/AHA Guideline for the Management of Heart Failure and the 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose and manage patients with heart failure.
Methods
A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews and other evidence conducted in human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies published through September 2021 were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.
Results and Conclusions
Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients’ interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments that have high-quality published economic analyses.
Top 10 Take-Home Messages
1.
Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) now includes 4 medication classes, including sodium-glucose cotransporter-2 inhibitors (SGLT2i).
2.
SGLT2i have a Class of Recommendation 2a in HF with mildly reduced ejection fraction (HFmrEF). Weaker recommendations (Class of Recommendation 2b) are made for ARNi, ACEi, ARB, MRA, and beta-blocker in this population.
3.
New recommendations for HFpEF are made for SGLT2i (Class of Recommendation 2a), MRAs (Class of Recommendation 2b) and ARNi (Class of Recommendation 2b). Several prior recommendations have been renewed, including treatment of hypertension (Class of Recommendation 1), treatment of atrial fibrillation (Class of Recommendation 2a), use of ARB (Class of Recommendation 2b), and avoidance of routine use of nitrates or phosphodiesterase-5 inhibitors (Class of Recommendation 3: No Benefit).
4.
Improved left ventricular ejection fraction (LVEF) is used to refer to patients with previous HFrEF who now have LVEF > 40%. These patients should continue their treatment for HFrEF.
5.
Value statements were created for selected recommendations in which high-quality, cost-effectiveness studies of the intervention have been published.
6.
Amyloid heart disease has new recommendations for treatment, including screening for serum and urine monoclonal light chains, bone scintigraphy, genetic sequencing, tetramer stabilizer therapy, and anticoagulation.
7.
Evidence supporting increased filling pressures is important for the diagnosis of HF if the LVEF is > 40%. Evidence for increased filling pressures can be obtained from noninvasive (eg, natriuretic peptide, diastolic function on imaging) or invasive testing (eg, hemodynamic measurement).
8.
Patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF. An HF specialty team reviews HF management, assesses suitability for advanced HF therapies and uses palliative care including palliative inotropes where consistent with the patient's goals of care.
9.
Primary prevention is important for those at risk for HF (stage A) or pre-HF (stage B). Stages of HF were revised to emphasize the new terminologies of at risk for HF for stage A and pre-HF for stage B.
10.
Recommendations are provided for selected patients with HF and iron deficiency, anemia, hypertension, sleep disorders, type 2 diabetes, atrial fibrillation, coronary artery disease, and malignancy.
Purpose of the Executive Summary
The purpose of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (2022 HF guideline) is to provide an update and to consolidate the 2013 ACCF/AHA Guideline for the Management of Heart Failure
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.
2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.
into a new document. Related ACC/AHA guidelines include recommendations relevant to HF and, in such cases, the HF guideline refers to these documents. For example, the 2019 primary prevention of cardiovascular disease guideline
2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
provides recommendations for mitral valve (MV) clipping in mitral regurgitation (MR).
Areas of focus include:
•
Prevention of HF
•
Management strategies in stage C HF, including:
○
New treatment strategies in HF, including sodium-glucose cotransporter-2 inhibitors (SGLT2i) and angiotensin receptor-neprilysin inhibitors (ARNi);
○
Management of HF and atrial fibrillation (AF), including ablation of AF;
○
Management of HF and secondary MR, including MV transcatheter edge-to-edge repair;
○
Specific management strategies, including:
▪
Cardiac amyloidosis,
▪
Cardio-oncology,
▪
Implantable devices;
•
Left ventricular assist device (LVAD) use in stage D HF.
The intended primary target audience consists of clinicians who are involved in the care of patients with HF. The focus of the full clinical practice guideline
2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
is to provide the most up-to-date evidence to direct clinicians in making dicisions about the treatment of patients. This executive summary provides readers with the top 10 items they should know about the 2022 HF guideline
2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
and incorporates material from the full guideline along with each statement.
Document Review and Approval
The full clinical practice guideline was reviewed by: 2 official reviewers nominated by the AHA; 1 official reviewer nominated by the ACC; 2 official reviewers from the Heart Failure Society of America; 1 official Joint Committee on Clinical Practice Guidelines reviewer; and 32 individual content reviewers. Authors’ relationships with industry and other entities information is published in Appendix 1 of the full guideline.
2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
The Class of Recommendation (COR) indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The level of evidence (LOE) rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1).
Table 1Applying American College of Cardiology/American Heart Association Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*
Guideline-directed medical therapy (GDMT) for HF with reduced ejection fraction (HFrEF) now includes 4 medication classes that include SGLT2i. The 4 groups are: (1) renin-angiotensin system inhibition with angiotensin receptor-neprilysin inhibitors (ARNi), angiotensin-converting enzyme inhibitors (ACEi), or angiotensin (II) receptor blockers (ARB) alone; (2) beta-blockers; (3) mineralocorticoid receptor antagonists (MRAs); and (4) the new group, SGLT2i (Fig. 1).
Fig. 1Treatment of HFrEF stages C and D. Colors correspond to COR in Table 1. Treatment recommendations for patients with HFrEF are displayed. Step 1 medications may be started simultaneously at initial (low) doses recommended for HFrEF. Alternatively, these medications may be started sequentially, with the sequence guided by clinical or other factors, without the need to achieve target dosing before initiating the next medication. Medication dosages should be increased to target as tolerated. ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; COR, Class of Recommendation; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; HF, heart failure; HFimpEF, heart failure with improved ejection fraction; HFrEF, heart failure with reduced ejection fraction; hydral-nitrates, hydralazine and isosorbide dinitrate; ICD, implantable cardioverter-defibrillator; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; MCS, mechanical circulatory support; MRA, mineralocorticoid receptor antagonist; NSR, normal sinus rhythm; NYHA, New York Heart Association; and SGLT2i, sodium-glucose cotransporter 2 inhibitor. *Participation in investigational studies is appropriate for stage C, NYHA classes II and III HF.
Initiation of sacubitril/valsartan in haemodynamically stabilised heart failure patients in hospital or early after discharge: primary results of the randomised TRANSITION study.
Effect of sacubitril-valsartan vs enalapril on aortic stiffness in patients with heart failure and reduced ejection fraction: a randomized clinical trial.
In patients with previous or current symptoms of chronic HFrEF, the use of ACEi is beneficial to reduce morbidity and mortality when the use of ARNi is not feasible.
Consensus Trial Study Group Effects of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS).
Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. ATLAS Study Group.
Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: results of the Survival and Ventricular Enlargement Trial; The SAVE Investigators.
Acute Infarction Ramipril Efficacy (AIRE) Study Investigators Effect......Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure.
Trandolapril Cardiac Evaluation (TRACE) Study Group A clinical trial of the angiotensin-converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction.
Collaborative Group on ACE Inhibitor Trials Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure.
In patients with previous or current symptoms of chronic HFrEF who are intolerant to ACEi because of cough or angioedema and when the use of ARNi is not feasible, the use of ARB is recommended to reduce morbidity and mortality.
Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease (TRANSCEND) Investigators Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: a randomised controlled trial.
In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEi or ARB, replacement by an ARNi is recommended to further reduce morbidity and mortality.
Initiation of sacubitril/valsartan in haemodynamically stabilised heart failure patients in hospital or early after discharge: primary results of the randomised TRANSITION study.
Effect of sacubitril-valsartan vs enalapril on aortic stiffness in patients with heart failure and reduced ejection fraction: a randomized clinical trial.
(Referenced studies that support the recommendation are summarized in the Online Data Supplements)
Tabled
1
COR
LOE
Recommendation
1
A
In patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta-blockers proven to reduce mortality (eg, bisoprolol, carvedilol, sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations.
Effect of carvedilol on the morbidity of patients with severe chronic heart failure: results of the carvedilol prospective randomized cumulative survival (COPERNICUS) study.
(Referenced studies that support the recommendation are summarized in the Online Data Supplements.)
Tabled
1
COR
LOE
Recommendation
1
A
In patients with HFrEF and NYHA class II–IV symptoms, an MRA (spironolactone or eplerenone) is recommended to reduce morbidity and mortality, if estimated glomerular filtration rate is > 30 mL/min/1.73 m2 and serum potassium is < 5.0 mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely monitored thereafter to minimize risk of hyperkalemia and renal insufficiency.
(Referenced studies that support the recommendation are summarized in the Online Data Supplements.)
Tabled
1
COR
LOE
Recommendation
1
A
In patients with symptomatic chronic HFrEF, an SGLT2i is recommended to reduce hospitalization for HF and cardiovascular mortality, irrespective of the presence of type 2 diabetes.
Mildly reduced LVEF has new medication recommendations, including use of SGLT2i (Fig. 2). SGLT2i has a COR 2a in HF with mildly reduced EF (HFmrEF). Weaker recommendations (COR 2b) are made for ARNi, ACEi, ARB, MRA, and beta-blockers in this population.
Fig. 2Recommendations for patients with mildly reduced LVEF (41%–49%). Colors correspond to COR in Table 1. Medication recommendations for HFmrEF are displayed. ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HRmrEF, heart failure with mildly reduced ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; SGLT2i, sodium-glucose cotransporter 2 inhibitor.
In patients with current or previous symptomatic HFmrEF (LVEF, 41%–49%), use of evidence-based beta-blockers for HFrEF, ARNi, ACEi, or ARB, and MRAs may be considered to reduce the risk of HF hospitalization and cardiovascular mortality, particularly among patients with LVEF on the lower end of this spectrum.
Beta-blockers for heart failure with reduced, mid-range, and preserved ejection fraction: an individual patient-level analysis of double-blind randomized trials.
Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy (TRED-HF): an open-label, pilot, randomised trial.
Influence of ejection fraction on outcomes and efficacy of sacubitril/valsartan (lcz696) in heart failure with reduced ejection fraction: the Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial.
Preserved LVEF has new medication recommendations, including use of SGLT2i (Fig. 3). New recommendations for HF with preserved EF (HFpEF) are made for SGLT2i (COR 2a), MRAs (COR 2b), and ARNi (COR 2b). Several previous recommendations have been renewed, including treatment of hypertension (COR 1), treatment of AF (COR 2a), use of ARB (COR 2b), and avoidance of routine use of nitrates or phosphodiesterase-5 inhibitors (COR 3: no benefit).
Fig. 3Recommendations for patients with preserved LVEF (≥ 50%). Colors correspond to COR in Table 1. Medication recommendations for HFpEF are displayed. ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; SGLT2i, sodium-glucose cotransporter-2 inhibitor. *Greater benefit in patients with LVEF closer to 50%.
In selected patients with HFpEF, MRA may be considered to decrease hospitalizations, particularly in patients with LVEF on the lower end of this spectrum.
Influence of ejection fraction on outcomes and efficacy of sacubitril/valsartan (lcz696) in heart failure with reduced ejection fraction: the Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial.
Regional variation in patients and outcomes in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) trial.
In selected patients with HFpEF, ARNi may be considered to decrease hospitalizations, particularly in patients with LVEF on the lower end of this spectrum.
(Referenced studies that support the recommendations are summarized in the Online Data Supplements.)
Tabled
1
COR
LOE
Recommendations
1
C-LD
Patients with HFpEF and hypertension should have medication titrated to attain blood pressure targets in accordance with published clinical practice guidelines to prevent morbidity.
Effects of blood-pressure-lowering treatment in hypertension: 9. Discontinuations for adverse events attributed to different classes of antihypertensive drugs: meta-analyses of randomized trials.
In patients with HFpEF, management of AF can be useful to improve symptoms.
2b
B-R
In selected patients with HFpEF, the use of ARB may be considered to decrease hospitalizations, particularly in patients with LVEF on the lower end of this spectrum.
Heart failure with mid-range ejection fraction in CHARM: characteristics, outcomes and effect of candesartan across the entire ejection fraction spectrum.
Effect of phosphodiesterase-5 inhibition on exercise capacity and clinical status in heart failure with preserved ejection fraction: a randomized clinical trial.
The term improved LVEF is used to refer to those with previous HFrEF who now have LVEF > 40% (Fig. 4). These patients should continue their HFrEF treatments.
Fig. 4Classification and trajectories of HF based on LVEF. The classification for baseline and subsequent LVEF is shown. Patients with HFrEF who improve their LVEF to > 40% are considered to have HFimpEF and should continue HFrEF treatment. See Appendix 1 for suggested thresholds for laboratory findings. HF, heart failure; HFimpEF, heart failure with improved ejection fraction; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction. *There is limited evidence to guide therapy for patients who improve their LVEF from mildly reduced (41%–49%) to ≥ 50%. It is unclear whether to treat these patients as having HFpEF or HFmrEF.
(Referenced studies that support the recommendation are summarized in the Online Data Supplements.)
Tabled
1
COR
LOE
Recommendation
1
B-R
In patients with HFimpEF after treatment, GDMT should be continued to prevent relapse of HF and left ventricular dysfunction, even in patients who may become asymptomatic.
Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy (TRED-HF): an open-label, pilot, randomised trial.
ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines.
value statements were created for select recommendations where high-quality, cost-effectiveness studies of the intervention have been published. High value is defined as < $60,000/quality-adjusted life year gained (< 1 U.S. GDP/capita/QALY). Low value is defined as > $180,000/quality-adjusted life year gained (> 3 U.S. GDP/capita/QALY). High-value therapies include ARNi, ACEi, ARB, beta-blocker, MRA, implantable cardioverter-defibrillator, and cardiac resynchronization therapy. Intermediate-value therapies include SGLT2i and cardiac transplantation. The only therapy identified as low value was tafamidis for cardiac amyloidosis. The value of mechanical circulatory support and pulmonary pressure monitoring was considered uncertain.
Tabled
1
Value Statements
Level
Statements
High
In patients with previous or current symptoms of chronic HFrEF in whom ARNi is not feasible, treatment with an ACEi or ARB provides high economic value.
Costs and effects of enalapril therapy in patients with symptomatic heart failure: an economic analysis of the Studies of Left Ventricular Dysfunction (SOLVD) Treatment Trial.
Pharmacologic management of heart failure and left ventricular systolic dysfunction: effect in female, Black, and diabetic patients, and cost-effectiveness.
Cost-effectiveness of sacubitril-valsartan combination therapy compared with enalapril for the treatment of heart failure with reduced ejection fraction.
Cost-effectiveness of eplerenone compared with placebo in patients with myocardial infarction complicated by left ventricular dysfunction and heart failure.
Cost effectiveness of eplerenone in patients with heart failure after acute myocardial infarction who were taking both ACE inhibitors and beta-blockers: subanalysis of the EPHESUS.
For patients self-identified as African American with NYHA class III–IV HFrEF who are receiving optimal medical therapy with ACEi or ARB, beta-blocker and MRA, the combination of hydralazine and isosorbide dinitrate provides high economic value.
A transvenous implantable cardioverter-defibrillator provides high economic value in the primary prevention of sudden cardiac death, particularly when the patient's risk of death caused by ventricular arrythmia is deemed high and the risk of nonarrhythmic death (either cardiac or noncardiac) is deemed low, based on the patient's burden of comorbidities and functional status.
Lifetime cost-effectiveness of prophylactic implantation of a cardioverter defibrillator in patients with reduced left ventricular systolic function: results of Markov modelling in a European population.
Cost-effectiveness of defibrillator therapy or amiodarone in chronic stable heart failure: results from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT).
For patients who have LVEF ≤ 35%, sinus rhythm, left bundle branch block with a QRS duration of ≥ 150 ms, and NYHA class II, III or ambulatory IV symptoms on GDMT, cardiac resynchronization therapy implantation provides high economic value.
Cost-effectiveness of cardiac resynchronization therapy in the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) trial.
Economic value and cost-effectiveness of cardiac resynchronization therapy among patients with mild heart failure: projections from the REVERSE long-term follow-up.
At 2020 list prices, tafamidis provides low economic value (> $180,000 per QALY gained) in patients with HF with wild-type or variant transthyretin cardiac amyloidosis.
In patients with advanced HFrEF who have NYHA class IV symptoms despite GDMT, durable mechanical circulatory support devices provide low to intermediate economic value based on current costs and outcomes.
In patients with NYHA class III HF with an HF hospitalization within the previous year, wireless monitoring of the pulmonary artery pressure by an implanted hemodynamic monitor provides uncertain value.
Amyloid heart disease has new recommendations for treatment. Specific strategies for diagnosis and treatment of cardiac amyloidosis are recommended (Fig. 5). In patients with clinical suspicion for cardiac amyloidosis, screening for serum and urine monoclonal light chains with serum and urine immunofixation electrophoresis and serum-free light chains is recommended. If there is no evidence of serum or urine monoclonal light chains, bone scintigraphy is recommended to confirm the presence of transthyretin cardiac amyloidosis. If transthyretin cardiac amyloidosis is identified, genetic sequencing of the TTR gene is recommended to differentiate hereditary variant from wild-type transthyretin cardiac amyloidosis because confirmation of a hereditary variant would trigger genetic counseling and potential screening of family members. Transthyretin tetramer stabilizer therapy (tafamidis) is recommended in selected patients with wild-type or variant transthyretin cardiac amyloidosis. Anticoagulation is a reasonable treatment strategy to reduce the risk of stroke in patients with cardiac amyloidosis and AF.
Fig. 5Diagnostic and treatment of transthyretin cardiac amyloidosis algorithm. Colors correspond to COR in Table 1. AF, atrial fibrillation; AL-CM, amyloid cardiomyopathy; ATTR-CM, transthyretin amyloid cardiomyopathy; ATTRv, variant transthyretin amyloidosis; ATTRwt, wild-type transthyretin amyloidosis; CHA2DS2-VASc, congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category; ECG, electrocardiogram; H/CL, heart to contralateral chest; HFrEF, heart failure with reduced ejection fraction; IFE, immunofixation electrophoresis; MRI, magnetic resonance imaging; NYHA, New York Heart Association; PYP, pyrophosphate; Tc, technetium; and TTR, transthyretin.
Unveiling transthyretin cardiac amyloidosis and its predictors among elderly patients with severe aortic stenosis undergoing transcatheter aortic valve replacement.
In patients with high clinical suspicion for cardiac amyloidosis, without evidence of serum or urine monoclonal light chains, bone scintigraphy should be performed to confirm the presence of transthyretin cardiac amyloidosis.
In patients in whom a diagnosis of transthyretin cardiac amyloidosis is made, genetic testing with TTR gene sequencing is recommended to differentiate hereditary variant from wild-type transthyretin cardiac amyloidosis.
*Left ventricular wall thickness ≥ 14 mm in conjunction with fatigue, dyspnea or edema, especially in the context of discordance between wall thickness on echocardiogram and QRS voltage on ECG, and in the context of aortic stenosis, HFpEF, carpal tunnel syndrome, spinal stenosis, and autonomic or sensory polyneuropathy.
Recommendations for Treatment of Cardiac Amyloidosis
(Referenced studies that support the recommendations are summarized in the Online Data Supplements.)
Tabled
1
COR
LOE
Recommendations
1
B-R
In selected patients with wild-type or variant transthyretin cardiac amyloidosis and NYHA class I–III HF symptoms, transthyretin tetramer stabilizer therapy (tafamidis) is indicated to reduce cardiovascular morbidity and mortality.
In patients with cardiac amyloidosis and AF, anticoagulation is reasonable to reduce the risk of stroke, regardless of the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack [TIA], vascular disease, age 65–74 years, sex category) score.
Evidence supporting increased filling pressures is important for the diagnosis of HF if the LVEF is > 40% (Table 2). The signs and symptoms of HF are nonspecific and, thus, a diagnosis of HF requires supporting evidence. Increased cardiac filling pressure is a feature of HF, and this is assumed for patients with LVEF ≤ 40%. However, if the LVEF is 41%–49% (mildly reduced) or ≥ 50% (preserved), evidence of spontaneous or provokable increased LV filling pressures is needed to confirm a diagnosis of HF. Evidence of increased filling pressures can be obtained from noninvasive testing (eg, natriuretic peptide, diastolic function on imaging) or invasive testing (eg, hemodynamic measurement).
Table 2Classification of HF by LVEF
Type of HF According to LVEF
Criteria
HFrEF (HF with reduced EF)
LVEF ≤ 40%
HFimpEF (HF with improved EF)
Previous LVEF ≤ 40% and a follow-up measurement of LVEF > 40%
HFmrEF (HF with mildly reduced EF)
LVEF 41%–49% Evidence of spontaneous or provokable increased LV filling pressures (eg, elevated natriuretic peptide, noninvasive and invasive hemodynamic measurement)
HFpEF (HF with preserved EF)
LVEF ≥ 50% Evidence of spontaneous or provokable increased LV filling pressures (eg, elevated natriuretic peptide, noninvasive and invasive hemodynamic measurement)
Please see Appendix 1 for suggested thresholds for structural heart disease and evidence of increased filling pressures.
HF, heart failure; LV, left ventricular; LVEF, left ventricular ejection fraction.
Patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF. An HF specialty team, typically located in an advanced HF center, reviews HF management, assesses suitability for advanced HF therapies (eg, left ventricular assist devices, cardiac transplantation) and uses palliative care, including palliative inotropes where they are consistent with the patient's goals of care.
Recommendation for Specialty Referral for Advanced HF
Tabled
1
COR
LOE
Recommendation
1
C-LD
In patients with advanced HF, when consistent with the patient's goals of care, timely referral for HF specialty care is recommended to review HF management and assess suitability for advanced HF therapies (eg, left ventricular assist device, cardiac transplantation, palliative care, and palliative inotropes).
2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; developed in collaboration with the International Society for Heart and Lung Transplantation.
2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.
Specialist clinics for reducing emergency admissions in patients with heart failure: a systematic review and meta-analysis of randomised controlled trials.
Primary prevention is important for those at risk for HF (stage A) or pre-HF (stage B). Stages of HF were revised to emphasize the new terminologies of at-risk for HF for stage A and pre-HF for stage B (Fig. 6) (Table 3). In the full guideline, primary prevention included all health care strategies that prevent the development of symptomatic HF (stage C). Healthy lifestyle habits, such as maintaining regular physical activity, maintaining normal weight, and consuming a healthful diet, are recommended. Blood pressure should be controlled in accordance with published clinical practice guidelines. SGLT2i are recommended in patients with type 2 diabetes and either established cardiovascular disease or at high risk for cardiovascular disease. Natriuretic peptide biomarker–based screening followed by team-based care, including a cardiovascular specialist, can be useful to prevent the development of left ventricular dysfunction (systolic or diastolic) or new-onset HF (pre-HF, stage B). Validated multivariable risk scores can also be useful to estimate subsequent risk of incident HF. In asymptomatic patients with LVEF ≤ 40% (pre-HF, stage B), ACEi, ARB, evidence-based beta-blockers, statins, and implantable cardioverter-defibrillators are recommended in certain patients.
Fig. 6ACC/AHA Stages of HF. The ACC/AHA stages of HF are shown. ACC indicates American College of Cardiology; AHA, American Heart Association; CVD, cardiovascular disease; GDMT, guideline-directed medical therapy; and HF, heart failure.
At risk for HF but without symptoms, structural heart disease, or cardiac biomarkers of stretch or injury (eg, patients with hypertension, atherosclerotic CVD, diabetes, metabolic syndrome and obesity, exposure to cardiotoxic agents, genetic variant for cardiomyopathy, or positive family history of cardiomyopathy).
Stage B: Pre-HF
No symptoms or signs of HF and evidence of 1 of the following:
For thresholds of cardiac structural, functional changes, elevated filling pressures, and biomarker elevations, refer to Appendix 1. CKD, chronic kidney disease; CVD, cardiovascular disease; GDMT, guideline-directed medical therapy; HF, heart failure.
or Persistently elevated cardiac troponin in the absence of competing diagnoses, resulting in such biomarker elevations such as acute coronary syndrome, CKD, pulmonary embolus, or myopericarditis
Stage C: Symptomatic HF
Structural heart disease with current or previous symptoms of HF.
Stage D: Advanced HF
Marked HF symptoms that interfere with daily life and with recurrent hospitalizations despite attempts to optimize GDMT.
For thresholds of cardiac structural, functional changes, elevated filling pressures, and biomarker elevations, refer to Appendix 1. CKD, chronic kidney disease; CVD, cardiovascular disease; GDMT, guideline-directed medical therapy; HF, heart failure.
the Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension.
In patients with type 2 diabetes and either established cardiovascular disease or at high cardiovascular risk, SGLT2i should be used to prevent hospitalizations for HF.
In the general population, healthful lifestyle habits, such as regular physical activity, maintaining normal weight, healthful dietary patterns, and avoiding smoking, are helpful to reduce future risk of HF.
For patients at risk of developing HF, natriuretic peptide biomarker–based screening followed by team-based care, including a cardiovascular specialist optimizing GDMT, can be useful to prevent the development of LV dysfunction (systolic or diastolic) or new-onset HF.
PONTIAC (NT-proBNP selected prevention of cardiac events in a population of diabetic patients without a history of cardiac disease): a prospective randomized controlled trial.
Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: results of the Survival and Ventricular Enlargement Trial; The SAVE Investigators.
Trandolapril Cardiac Evaluation (TRACE) Study Group A clinical trial of the angiotensin-converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction.
SOLVD Investigators Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions.
In patients with recent or remote histories of myocardial infarction or acute coronary syndrome, statins should be used to prevent symptomatic HF and adverse cardiovascular events.
Heart Protection Study Collaborative Group N-terminal pro-B-type natriuretic peptide, vascular disease risk, and cholesterol reduction among 20,536 patients in the MRC/BHF heart protection study.
Comparative effect of atorvastatin (80 mg) versus simvastatin (20 to 40 mg) in preventing hospitalizations for heart failure in patients with previous myocardial infarction.
In patients with recent myocardial infarction and LVEF ≤ 40% who are intolerant to ACEi, ARB should be used to prevent symptomatic HF and reduce mortality.
In patients with recent or remote histories of myocardial infarction or acute coronary syndrome and LVEF ≤ 40%, evidence-based beta-blockers should be used to reduce mortality.
Beta-adrenergic blocking agent use and mortality in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a post hoc analysis of the studies of left ventricular dysfunction.
Additive beneficial effects of beta-blockers to angiotensin-converting enzyme inhibitors in the Survival and Ventricular Enlargement (SAVE) Study. SAVE Investigators.
In patients who are at least 40 days post-myocardial infarction with LVEF ≤ 30% and NYHA class I symptoms while receiving GDMT and have reasonable expectation of meaningful survival for > 1 year, an implantable cardioverter-defibrillator is recommended for primary prevention of sudden cardiac death to reduce total mortality.
Beta-adrenergic blocking agent use and mortality in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a post hoc analysis of the studies of left ventricular dysfunction.
Additive beneficial effects of beta-blockers to angiotensin-converting enzyme inhibitors in the Survival and Ventricular Enlargement (SAVE) Study. SAVE Investigators.
A randomized, placebo-controlled trial assessing the effects of rosiglitazone on echocardiographic function and cardiac status in type 2 diabetic patients with New York Heart Association functional class I or II heart failure.
Specific-treatment recommendations are provided for patients with HF and certain comorbidities (Fig. 7). Recommendations are provided for selected patients with HF and iron deficiency, anemia, hypertension, sleep disorders, type 2 diabetes, AF, coronary artery disease, and malignancy.
Fig. 7Recommendations for Treatment of Patients With HF and Selected Comorbidities. Colors correspond to COR in Table 1. Recommendations for treatment of patients with HF and select comorbidities are displayed. *Patients with chronic HF with permanent-persistent-paroxysmal AF and a CHA2DS2-VASc score of ≥ 2 (for men) and ≥ 3 (for women). ACEi, angiotensin-converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin receptor blocker; AV, atrioventricular; CHA2DS2-VASc, congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65–74 years, sex category; CPAP, continuous positive airway pressure; CRT, cardiac resynchronization therapy; EF, ejection fraction; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; SGLT2i, sodium-glucose cotransporter 2 inhibitor; and VHD, valvular heart disease.
Recommendations for the Management of Comorbidities in Patients With HF
(Referenced studies that support the recommendations are summarized in the Online Data Supplements.)
Tabled
1
COR
LOE
Recommendations
Management of Anemia or Iron Deficiency
2a
B-R
In patients with HFrEF and iron deficiency with or without anemia, intravenous iron replacement is reasonable to improve functional status and quality of life.
Beneficial effects of long-term intravenous iron therapy with ferric carboxymaltose in patients with symptomatic heart failure and iron deficiencydagger.
2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
In patients with HF and obstructive sleep apnea, continuous positive airway pressure may be reasonable to improve sleep quality and decrease daytime sleepiness.
In patients with HF and suspicion of sleep-disordered breathing, a formal sleep assessment is reasonable to confirm the diagnosis and differentiate between obstructive and central sleep apnea.
Suppression of central sleep apnea by continuous positive airway pressure and transplant-free survival in heart failure: a post hoc analysis of the Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure Trial (CANPAP).
In patients with HF and type 2 diabetes, the use of SGLT2i is recommended for the management of hyperglycemia and to reduce HF-related morbidity and mortality.
(Referenced studies that support the recommendations are summarized in the Online Data Supplements.)
Tabled
1
COR
LOE
Recommendations
1
A
Patients with chronic HF with permanent-persistent-paroxysmal AF and a CHA2DS2-VASc score of ≥ 2 (for men) and ≥ 3 (for women) should receive chronic anticoagulant therapy.
For patients with chronic HF with permanent-persistent-paroxysmal AF, a direct-acting oral anticoagulant is recommended over warfarin in eligible patients.
Left ventricular systolic dysfunction, heart failure, and the risk of stroke and systemic embolism in patients with atrial fibrillation: insights from the ARISTOTLE trial.
Ablation versus amiodarone for treatment of persistent atrial fibrillation in patients with congestive heart failure and an implanted device: results from the AATAC multicenter randomized trial.
Rhythm control for patients with atrial fibrillation complicated with heart failure in the contemporary era of catheter ablation: a stratified pooled analysis of randomized data.
For patients with AF and LVEF ≤ 50%, if a rhythm-control strategy fails or is not desired, and ventricular rates remain rapid despite medical therapy, atrioventricular nodal ablation with implantation of a cardiac resynchronization therapy device is reasonable.
Assessment of atrioventricular junction ablation and VVIR pacemaker versus pharmacological treatment in patients with heart failure and chronic atrial fibrillation: a randomized, controlled study.
A randomized controlled trial of atrioventricular junction ablation and cardiac resynchronization therapy in patients with permanent atrial fibrillation and narrow QRS.
For patients with chronic HF and permanent-persistent-paroxysmal AF, chronic anticoagulant therapy is reasonable for men and women without additional risk factors.
Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC).
Assessment of the CHA2DS2-VASc score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation.
Recommendation for Revascularization for Coronary Artery Disease
(Referenced studies that support the recommendation are summarized in the Online Data Supplements.)
Tabled
1
COR
LOE
Recommendation
1
B-R
In selected patients with HF, reduced EF (EF ≤ 35%) and suitable coronary anatomy, surgical revascularization plus GDMT is beneficial to improve symptoms, cardiovascular hospitalizations, and long-term all-cause mortality.
Ten-year outcomes after coronary artery bypass grafting according to age in patients with heart failure and left ventricular systolic dysfunction: an analysis of the extended follow-up of the STICH Trial (Surgical Treatment for Ischemic Heart Failure).
(Referenced studies that support the recommendations are summarized in the Online Data Supplements.)
Tabled
1
COR
LOE
Recommendations
1
B-NR
In patients who develop cancer therapy–related cardiomyopathy or HF, a multidisciplinary discussion involving the patient about the risk-benefit ratio of cancer therapy interruption, discontinuation or continuation is recommended to improve management.
In asymptomatic patients with cancer therapy–related cardiomyopathy (EF < 50%), ARB, ACEi and beta-blocker are reasonable to prevent progression to HF and improve cardiac function.
In patients with cardiovascular risk factors or known cardiac disease being considered for potentially cardiotoxic anticancer therapies, pretherapy evaluation of cardiac function is reasonable to establish baseline cardiac function and guide the choice of cancer therapy.
Cardiotoxicity and cardiac monitoring during adjuvant trastuzumab in daily Dutch practice: a study of the Southeast Netherlands Breast Cancer Consortium.
Utility of routine left ventricular ejection fraction measurement before anthracycline-based chemotherapy in patients with diffuse large B-cell lymphoma.
The clinical utility of baseline cardiac assessments prior to adjuvant anthracycline chemotherapy in breast cancer: a systematic review and meta-analysis.
In patients with cardiovascular risk factors or known cardiac disease receiving potentially cardiotoxic anticancer therapies, monitoring of cardiac function is reasonable for the early identification of drug-induced cardiomyopathy.
In patients at risk of cancer therapy–related cardiomyopathy, initiation of beta-blocker and ACEi/ARB for the primary prevention of drug-induced cardiomyopathy is of uncertain benefit.
Enalapril and carvedilol for preventing chemotherapy-induced left ventricular systolic dysfunction in patients with malignant hemopathies: the OVERCOME trial (preventiOn of left Ventricular dysfunction with Enalapril and caRvedilol in patients submitted to intensive ChemOtherapy for the treatment of Malignant hEmopathies).
Prevention of cardiac dysfunction during adjuvant breast cancer therapy (PRADA): a 2 x 2 factorial, randomized, placebo-controlled, double-blind clinical trial of candesartan and metoprolol.
Multidisciplinary approach to novel therapies in cardio-oncology research (MANTICORE 101-Breast): a randomized trial for the prevention of trastuzumab-associated cardiotoxicity.
Anthracycline-induced cardiotoxicity: a multicenter randomised trial comparing two strategies for guiding prevention with enalapril: the International CardioOncology Society-one trial.
Prevention of trastuzumab and anthracycline-induced cardiotoxicity using angiotensin-converting enzyme inhibitors or beta-blockers in older adults with breast cancer.
In patients being considered for potentially cardiotoxic therapies, serial measurement of cardiac troponin might be reasonable for further risk stratification.
Role of troponins I and T and N-terminal prohormone of brain natriuretic peptide in monitoring cardiac safety of patients with early-stage human epidermal growth factor receptor 2-positive breast cancer receiving trastuzumab: a herceptin adjuvant study cardiac marker substudy.
Cutoffs provided for natriuretic peptide levels may have lower specificity, especially in older patients or in patients with AF or CKD. Usually, higher cutoff values are recommended for the diagnosis of HF in these patients. Natriuretic peptide cutoffs selected for population screening for pre-HF (stage B HF) may be < 99% reference limits and need to be defined according to the population at risk. AF, atrial fibrillation; BNP, brain natriuretic peptide; CKD, chronic kidney disease; GLS, global longitudinal strain; HF, heart failure; LAVI, left atrial volume index; LVMI, left ventricular mass index; NT-proBNP, natriuretic peptide tests; PA, pulmonary artery; RWT, relative wall thickness; and TR, tricuspid regurgitation.
Cutoffs provided for natriuretic peptide levels may have lower specificity, especially in older patients or in patients with AF or CKD. Usually, higher cutoff values are recommended for the diagnosis of HF in these patients. Natriuretic peptide cutoffs selected for population screening for pre-HF (stage B HF) may be < 99% reference limits and need to be defined according to the population at risk. AF, atrial fibrillation; BNP, brain natriuretic peptide; CKD, chronic kidney disease; GLS, global longitudinal strain; HF, heart failure; LAVI, left atrial volume index; LVMI, left ventricular mass index; NT-proBNP, natriuretic peptide tests; PA, pulmonary artery; RWT, relative wall thickness; and TR, tricuspid regurgitation.
Cutoffs provided for natriuretic peptide levels may have lower specificity, especially in older patients or in patients with AF or CKD. Usually, higher cutoff values are recommended for the diagnosis of HF in these patients. Natriuretic peptide cutoffs selected for population screening for pre-HF (stage B HF) may be < 99% reference limits and need to be defined according to the population at risk.AF, atrial fibrillation; BNP, brain natriuretic peptide; CKD, chronic kidney disease; GLS, global longitudinal strain; HF, heart failure; LAVI, left atrial volume index; LVMI, left ventricular mass index; NT-proBNP, natriuretic peptide tests; PA, pulmonary artery; RWT, relative wall thickness; and TR, tricuspid regurgitation.
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.
2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.
2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
Initiation of sacubitril/valsartan in haemodynamically stabilised heart failure patients in hospital or early after discharge: primary results of the randomised TRANSITION study.
Effect of sacubitril-valsartan vs enalapril on aortic stiffness in patients with heart failure and reduced ejection fraction: a randomized clinical trial.
Effects of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS).
Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. ATLAS Study Group.
Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: results of the Survival and Ventricular Enlargement Trial; The SAVE Investigators.
Trandolapril Cardiac Evaluation (TRACE) Study Group
A clinical trial of the angiotensin-converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction.
Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease (TRANSCEND) Investigators
Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: a randomised controlled trial.
Effect of carvedilol on the morbidity of patients with severe chronic heart failure: results of the carvedilol prospective randomized cumulative survival (COPERNICUS) study.
Beta-blockers for heart failure with reduced, mid-range, and preserved ejection fraction: an individual patient-level analysis of double-blind randomized trials.
Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy (TRED-HF): an open-label, pilot, randomised trial.
Influence of ejection fraction on outcomes and efficacy of sacubitril/valsartan (lcz696) in heart failure with reduced ejection fraction: the Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial.
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For thresholds of cardiac structural, functional changes, elevated filling pressures, and biomarker elevations, refer to Appendix 1. CKD, chronic kidney disease; CVD, cardiovascular disease; GDMT, guideline-directed medical therapy; HF, heart failure.
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