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American Heart AssociationCardiology2022advanced

Management of Heart Failure

Published by American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines · ACC/AHA Class of Recommendation and Level of Evidence

33Tables
15Figures

Summary

AI-generated

Heart failure remains a leading cause of morbidity and mortality globally. This 2022 guideline replaces the 2013 ACCF/AHA Guideline and the 2017 focused update to provide contemporary, evidence-based approaches to manage patients with heart failure, with the intent to improve quality of care and align with patients' interests.

heart failureHFrEFHFmrEFHFpEFSGLT2 inhibitorARNIMRAACC/AHA

Key Takeaways

  • 1
    Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) now includes 4 medication classes that include sodium-glucose cotransporter-2 inhibitors (SGLT2i).
  • 2
    SGLT2i have a Class of Recommendation 2a in HF with mildly reduced ejection fraction (HFmrEF).
  • 3
    New recommendations for HFpEF are made for SGLT2i, MRAs, and ARNi.
  • 4
    Improved LVEF is used to refer to those patients with previous HFrEF who now have an LVEF >40%. These patients should continue their HFrEF treatment.
  • 5
    Value statements were created for select recommendations where 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%.
  • 8
    Patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF.
  • 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.
  • 10
    Recommendations are provided for select patients with HF and iron deficiency, anemia, hypertension, sleep disorders, type 2 diabetes, atrial fibrillation, coronary artery disease, and malignancy.

What's New in This Version

Replaces the '2013 ACCF/AHA Guideline for the Management of Heart Failure' and the '2017 ACC/AHA/HFSA Focused Update'. It introduces the new terminology of 'HFimpEF' (HF with improved EF) and 'HFmrEF' (HF with mildly reduced EF). It includes SGLT2 inhibitors as a core part of GDMT for HFrEF and offers new recommendations for their use in HFmrEF and HFpEF. It formally incorporates value statements and modernizes the staging terminology ('At Risk for HF' and 'Pre-HF').

Key Recommendations

4.1. Clinical Assessment: History and Physical Examination

  • Rec_4.1_1

    In patients with HF, vital signs and evidence of clinical congestion should be assessed at each encounter to guide overall management, including adjustment of diuretics and other medications.

    1Evidence: B-NRDiagnostic/Monitoring

4.2. Use of Biomarkers for Prevention, Initial Diagnosis, and Risk Stratification

  • Rec_4.2_1

    In patients presenting with dyspnea, measurement of B-type natriuretic peptide (BNP) or N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) is useful to support a diagnosis or exclusion of HF.

    1Evidence: ADiagnostic

5.1. Patients at Risk for HF (Stage A: Primary Prevention)

  • Rec_5.1_2

    In patients with type 2 diabetes and either established CVD or at high cardiovascular risk, SGLT2i should be used to prevent hospitalizations for HF.

    1Evidence: APrevention/Pharmacological

7.3.1. Renin-Angiotensin System Inhibition With ACEi or ARB or ARNi

  • Rec_7.3.1_1

    In patients with HFrEF and NYHA class II to III symptoms, the use of ARNi is recommended to reduce morbidity and mortality.

    1Evidence: ATreatment/Pharmacological

7.3.2. Beta Blockers

  • Rec_7.3.2_1

    In patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations.

    1Evidence: ATreatment/Pharmacological

7.3.3. Mineralocorticoid Receptor Antagonists (MRAs)

  • Rec_7.3.3_1

    In patients with HFrEF and NYHA class II to IV symptoms, an MRA (spironolactone or eplerenone) is recommended to reduce morbidity and mortality, if eGFR is >30 mL/min/1.73 m2 and serum potassium is <5.0 mEq/L.

    1Evidence: ATreatment/Pharmacological

7.3.4. Sodium-Glucose Cotransporter 2 Inhibitors

  • Rec_7.3.4_1

    In patients with symptomatic chronic HFrEF, SGLT2i are recommended to reduce hospitalization for HF and cardiovascular mortality, irrespective of the presence of type 2 diabetes.

    1Evidence: ATreatment/Pharmacological

7.6.1. HF With Mildly Reduced Ejection Fraction

  • Rec_7.6.1_1

    In patients with HFmrEF, SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular mortality.

    2aEvidence: B-RTreatment/Pharmacological

7.6.2. HF With Improved Ejection Fraction

  • Rec_7.6.2_1

    In patients with HFimpEF after treatment, GDMT should be continued to prevent relapse of HF and LV dysfunction, even in patients who may become asymptomatic.

    1Evidence: B-RTreatment/Pharmacological

7.7.1. HF With Preserved Ejection Fraction

  • Rec_7.7.1_2

    In patients with HFpEF, SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular mortality.

    2aEvidence: B-RTreatment/Pharmacological

Scope & Objectives

Clinical Topic

Heart Failure

Objectives

To provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

Target Patient Population

Adult patients with or at risk of developing heart failure

Diagnostic Criteria

A complex clinical syndrome with symptoms and signs that result from any structural or functional impairment of ventricular filling or ejection of blood, further classified by LVEF (HFrEF ≤40%, HFmrEF 41%-49%, HFpEF ≥50%) and supported by objective measures like increased filling pressures or elevated natriuretic peptides.

Target Providers

CardiologistsHeart Failure SpecialistsInternistsInterventionalistsElectrophysiologistsSurgeonsPharmacistsAdvanced Nurse Practitioners

Patient Criteria & Setting

Therapeutic Area

Cardiovascular Disease

Guideline Scope

PreventionDiagnosisManagementTreatment

Care Settings

Ambulatory CareHospitalEmergency DepartmentIntensive Care Unit

Special Populations

WomenOlder adultsLower socioeconomic status populationsBlack populationsHispanic populationsAsian and Pacific Islander populationsNative American and Alaskan Native populationsPatients with cancerPregnant women

Evidence Grading

System: ACC/AHA Class of Recommendation and Level of Evidence

Evidence Levels

Level AHigh-quality evidence from more than 1 RCT, meta-analyses of high-quality RCTs, or 1 or more RCTs corroborated by high-quality registry studies.
Level B-RModerate-quality evidence from 1 or more RCTs or meta-analyses of moderate-quality RCTs (Randomized).
Level B-NRModerate-quality evidence from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies, or meta-analyses of such studies (Nonrandomized).
Level C-EOConsensus of expert opinion based on clinical experience (Expert Opinion).
Level C-LDRandomized or nonrandomized observational or registry studies with limitations of design or execution, meta-analyses of such studies, or physiological/mechanistic studies in human subjects (Limited Data).

Recommendation Strength

Class 1Strong recommendation; Benefit >>> Risk.
Class 2aModerate recommendation; Benefit >> Risk.
Class 2bWeak recommendation; Benefit ≥ Risk.
Class 3: HarmStrong recommendation against; Risk > Benefit.
Class 3: No BenefitModerate recommendation for no benefit; Benefit = Risk.

Safety & Contraindications

Contraindications

  • ARNi administered concomitantly with ACEi or within 36 hours of the last dose of an ACEi
  • ARNi or ACEi administered to patients with any history of angioedema
  • Thiazolidinediones in patients with LVEF <50%
  • Nondihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with LVEF <50%
  • Class IC antiarrhythmic medications and dronedarone in HFrEF
  • NSAIDs in HFrEF

Monitoring Guidance

Regular checks of serum potassium levels and renal function should be performed according to clinical status after initiating MRA therapy. Routine monitoring of cardiac function is reasonable for early identification of drug-induced cardiomyopathy in cancer patients.

Authors & Contributors

Paul A. HeidenreichBiykem BozkurtDavid AguilarLarry A. AllenJoni J. ByunMonica M. ColvinAnita DeswalMark H. DraznerShannon M. DunlayLinda R. EversJames C. FangSavitri E. FedsonGregg C. FonarowSalim S. HayekAdrian F. HernandezPrateeti KhazanieMichelle M. KittlesonChristopher S. LeeMark S. LinkCarmelo A. MilanoLorraine C. NnachetaAlexander T. SandhuLynne Warner StevensonOrly VardenyAmanda R. VestClyde W. Yancy

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinaryPatient involvementDrug interactions discussed

Learning Context

Difficulty

advanced

Learning Paths

Heart FailureCardiologyHFrEFHFpEFHFmrEFHFimpEFGDMTSGLT2 InhibitorsARNiClinical Practice Guidelines