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A Clinician's Guide to the 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure

  • MICHELLE M. KITTLESON
    Correspondence
    Reprint requests: Michelle M. Kittleson, MD, PhD, Department of Cardiology, Smidt Heart Institute, 8670 Wilshire Blvd, 2nd Floor, Los Angeles, CA 90211.
    Affiliations
    Department of Cardiology, Smidt Heart Institute, Los Angeles, California
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      The American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) 2022 Guideline for the Management of Heart Failure provides patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure (HF).

      Placeholder. 2022 AHA/ACC/HFSA guideline for the management of heart failure. 2022.

      A culmination of almost 2 years of effort by the 26 members of the writing committee, the document includes 159 pages of text (including 40 pages of references), 14 sections, 33 tables, 15 figures, and 192 recommendations—daunting to any clinician interested in optimizing the care of patients with HF. What is the best way to navigate a new guideline? Spoiler alert: It is not to read through the entire document, start to finish.

      Navigating a New Guideline

      When cracking the figurative spine on any new guideline document (and the 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure in particular), first read the Top 10 Take-Home Messages, based on what the guideline architects consider the most exciting practice-changing areas. Second: Scan the Table of Contents to understand the breadth and depth of the document. Third: Scrutinize the tables and figures for readily digestible diagnostic and therapeutic algorithms. These 3 steps transform a new guideline document from intimidating to familiar and accessible.
      The more familiar the guideline document becomes, the more likely you will be to turn to it when confronting a clinical dilemma. Use the search function to identify the content relevant to your question, then narrow your focus from the applicable table and/or figure to the pertinent recommendation to the detailed supportive text. If lingering questions remain, seek out the hidden pearls, the Evidence Tables in the Online Data Supplement. The evidence underlying every guideline recommendation is painstakingly summarized therein, an invaluable resource when a deeper dive is warranted.

      Important Themes from the 2022 Guideline

      When one performs this exercise with the 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure, several themes emerge that distinguish this document from the 2013 Guideline
      • Yancy CW
      • Jessup M
      • Bozkurt B
      • et al.
      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.
      and the 2016
      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.
      and 2017
      • Yancy CW
      • Jessup M
      • Bozkurt B
      • et al.
      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.
      Focused Updates:
      • 1.
        the classification of HF across the spectrum of ejection fraction (EF) is revamped to include HF with reduced EF (HFrEF), HF with mildly reduced EF (HFmrEF), HF with improved EF (HFimpEF), and HF with preserved EF (HFpEF);
      • 2.
        the benefit of sodium-glucose cotransporter-2 inhibitors (SGLT2i) is emphasized;
      • 3.
        diagnostic and treatment strategies for cardiac amyloidosis are discussed; and
      • 4.
        the impact of disparities in vulnerable populations is highlighted.

      Clinically Relevant Distinctions: HFmrEF, HFpEF, and HFimpEF

      For a classification system to be useful, it should be clinically meaningful and influence management. In the 2013 Guideline, patients with HF and EF 41%–49% were labeled HFpEF, borderline,
      • Yancy CW
      • Jessup M
      • Bozkurt B
      • et al.
      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.
      a term with limited utility for diagnosis and management. In keeping with the new Universal Definition of HF,
      • Bozkurt B
      • Coats AJS
      • Tsutsui H
      • et al.
      Universal Definition and Classification of Heart Failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure.
      the 2022 Guideline recognizes that patients with HF symptoms and EF 41%–49% are often in a dynamic trajectory to improvement from HFrEF or deterioration from HFpEF and, thus, a distinct category from HFpEF, HFmrEF, is appropriate.
      • Bozkurt B
      • Coats AJS
      • Tsutsui H
      • et al.
      Universal Definition and Classification of Heart Failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure.
      The second new classification in the new document, HFimpEF, is also clinically meaningful. A patient who presents with EF 25% that improves to EF 50%–55% with guideline-directed medical therapy (GDMT) is not the same as a patient with HF symptoms whose EF is 50%–55% on presentation. The 2022 Guideline underscores this distinction with a discrete category: HFimpEF. This distinction is important: based on a landmark trial in patients with HFimpEF,
      • Halliday BP
      • Wassall R
      • Lota AS
      • et al.
      Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy (TRED-HF): an open-label, pilot, randomised trial.
      there is now a Class I indication that 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.
      Figure 3 and Table 4 effectively illustrate the importance of EF trajectory in guiding classification of patients with HF across the spectrum of EF; Figures 11 and 12 demonstrate how these classifications influence management.

      Celebrating SGLT2i as an Essential Component of GDMT

      In 2013, SGLT2i warranted barely a blip on a cardiologist's radar, although the scene had been set in 2008 when the U.S. Food and Drug Administration required that any approved therapy for type 2 diabetes demonstrate cardiovascular safety.
      73 FR 77724 - Guidance for Industry on Diabetes Mellitus-Evaluating Cardiovascular Risk in New Antidiabetic Therapies to Treat Type 2 Diabetes; Availability. Office of the Federal Register.
      Thus, multiple medications in the new class of SGLT2i were run through the gauntlet of cardiovascular outcome trials and it was an unexpected boon when, between 2015 and 2020, multiple SGLT2i were deemed not only safe, but also effective in reducing atherosclerotic events and—even more unexpectedly—HF.
      • Zinman B
      • Wanner C
      • Lachin JM
      • et al.
      Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes.
      • Neal B
      • Perkovic V
      • Mahaffey KW
      • et al.
      Canagliflozin and cardiovascular and renal events in type 2 diabetes.
      • Wiviott SD
      • Raz I
      • Bonaca MP
      • et al.
      Dapagliflozin and cardiovascular outcomes in type 2 diabetes.
      • Cannon CP
      • Pratley R
      • Dagogo-Jack S
      • et al.
      Cardiovascular outcomes with ertugliflozin in type 2 diabetes.
      The world was primed for 2019, when dapagliflozin decreased cardiovascular death and HF hospitalization in patients with HFrEF without diabetes.
      • McMurray JJV
      • Solomon SD
      • Inzucchi SE
      • et al.
      Dapagliflozin in patients with heart failure and reduced ejection fraction.
      Good news soon followed from empagliflozin in HFrEF in 2020
      • Packer M
      • Anker SD
      • Butler J
      • et al.
      Cardiovascular and renal outcomes with empagliflozin in heart failure.
      and in HFpEF in 2021.
      • Anker SD
      • Butler J
      • Filippatos G
      • et al.
      Empagliflozin in heart failure with a preserved ejection fraction.
      The 2022 Guideline celebrates the enormous impact of SGLT2i in HF, providing a Class I indication in HFrEF and a Class 2a indication in HFmrEF and HFpEF. The 2022 Guideline also emphasizes the importance of comprehensive GDMT as the mainstay of pharmacological therapy for HFrEF with an angiotensin receptor-neprilysin inhibitor, beta blocker, mineralocorticoid antagonist, and SGLT2i; Figure 6 and Table 14 empower clinicians to overcome therapeutic inertia and titrate these essential agents to target doses to optimize outcomes.

      Advances in Cardiac Amyloidosis

      In the 2013 Guideline, cardiac amyloidosis merited 1 paragraph, a sign of how little was known about diagnosis and treatment.
      • Yancy CW
      • Jessup M
      • Bozkurt B
      • et al.
      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.
      Amazingly, in just a few years, there have been multiple areas of advancement in transthyretin cardiac amyloidosis: 1) imaging techniques allow accurate noninvasive diagnosis;
      • Gillmore JD
      • Maurer MS
      • Falk RH
      • et al.
      Nonbiopsy diagnosis of cardiac transthyretin amyloidosis.
      2) observational studies indicate that cardiac amyloidosis may be underrecognized in patients with HF;
      • Castano A
      • Narotsky DL
      • Hamid N
      • et al.
      Unveiling transthyretin cardiac amyloidosis and its predictors among elderly patients with severe aortic stenosis undergoing transcatheter aortic valve replacement.
      ,
      • Gonzalez-Lopez E
      • Gallego-Delgado M
      • Guzzo-Merello G
      • et al.
      Wild-type transthyretin amyloidosis as a cause of heart failure with preserved ejection fraction.
      and 3) there is an U.S. Food and Drug Administration–approved therapy, tafamidis.
      • Maurer MS
      • Schwartz JH
      • Gundapaneni B
      • et al.
      Tafamidis treatment for patients with transthyretin amyloid cardiomyopathy.
      Reflecting these advances in diagnosis and management, the 2022 Guideline devotes an entire section to this topic.
      Figure 13 summarizes diagnostic and management strategies. What are the most important high-yield subtleties? First, diagnosis of cardiac amyloidosis requires a high index of suspicion, particularly with presence of LV thickening along with fatigue, dyspnea, or edema, especially in the context of carpal tunnel syndrome, lumbar spinal stenosis, and autonomic or sensory polyneuropathy. Second, a technetium pyrophosphate (99mTc-PYP) scan cannot be interpreted without the results of a monoclonal light chain screen (serum and urine immunofixation electrophoresis and serum free light chains): a positive 99mTc-PYP scan is diagnostic of transthyretin cardiac amyloidosis only in the absence of a light-chain abnormality. Third, tafamidis receives a Class I indication in patients with transthyretin cardiac amyloidosis and New York Heart Association functional class I to III HF symptoms to decrease cardiovascular morbidity and mortality. Tafamidis prevents, but does not reverse, amyloid deposition and has greater benefit when administered early in the disease course, reinforcing the importance of a high index of suspicion for early diagnosis.

      Disparities in Vulnerable Populations

      In the 2013 Guideline, “disparities” merited 2 mentions in the text. In the 9 years since that guideline was published, our understanding of the impact of social determinants of health on disease trajectories has grown, as has our awareness that optimal patient care is about more than pathophysiology, diagnosis, and treatment strategies. Table 11 offers an invaluable practical guide to the potential barriers to effective HF self-care and example interventions. Table 27 emphasizes the risks of specific vulnerable populations so that management can be appropriately tailored and optimized.
      A remarkable inclusion in the 2022 Guideline are the value statements provided for treatments with high-quality published economic analyses. Interventions range from uncertain value (wireless monitoring of pulmonary artery pressure and durable mechanical circulatory support) to low value (tafamidis) to intermediate value (SGLT2i and heart transplantation), although the majority of HF interventions are high value (angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, beta blocker, mineralocorticoid antagonist, hydralazine and isosorbide dinitrate, defibrillators, and cardiac resynchronization therapy). How the cost vs benefit of these interventions will evolve over time and how we should balance value with efficacy should be the focus of future investigation.

      From Clinical Practice Guidelines to Optimal Patient Care

      An oft-quoted statistic is that it takes an estimated average of 17 years for only 14% of new scientific discoveries to enter day-to-day clinical practice
      • Balas EA
      • Boren SA.
      Managing clinical knowledge for health care improvement.
      and there is sobering evidence of inadequate implementation of life-saving GDMT in patients with HF.
      • Greene SJ
      • Butler J
      • Albert NM
      • et al.
      Medical therapy for heart failure with reduced ejection fraction: the CHAMP-HF Registry.
      In an effort to create guidelines that are trusted, timely, and accessible resources to optimize patient care, the development process and presentation of clinical practice guidelines has undergone considerable revision over the past few decades;
      • Jacobs AK
      • Anderson JL
      • Halperin JL.
      The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey.
      ,
      • Levine GN
      • O'Gara PT
      • Beckman JA
      • et al.
      Recent innovations, modifications, and evolution of ACC/AHA clinical practice guidelines: an update for our constituencies: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
      the 2022 ACC/AHA/HFSA Guideline on Heart Failure Management has benefited greatly from this process.
      As you review the Top 10 Take Home Messages, Table of Contents, tables, and figures, ask yourself how the contents can help you to take better care of your patients. With patients with an EF of 41%–49%, ask: are they getting better, or worse, and how can management be tailored accordingly? With patients with HFrEF not on optimal GDMT at target doses, ask: why not? With congested patients with HFmrEF of HFpEF, ask: could this be cardiac amyloidosis? And with every patient, ask: what are their barriers to effective self-care and how can they be addressed? Great science alone will not save lives—for that, we need effective implementation. A reliable, timely, and accessible clinical practice guideline is the start, along with the dedication of every clinician to ask the right questions and implement its contents, one patient at a time.

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