1. 1

2. Content
Classification of Recommendation and Level of
Evidence
HF definition and classifications
Diagnosis and evaluation of HF
2

3. Content
Treatment recommendations: stages A to D
Treatment recommendations: Hospitalized patients
Important Comorbidities in HF
Conclusion
3

4. ACCF/AHA task force
The American College of Cardiology Foundation
(ACCF) and the American Heart Association (AHA)
have jointly produced guidelines in the area of
cardiovascular disease since 1980. The ACCF/AHA
Task Force on Practice Guidelines (Task Force),
charged with developing, updating, and revising
practice guidelines for cardiovascular diseases and
procedures, directs and oversees this effort.
The previous guidline was in 2009
4

5. Classification of Recommendation
and Level of Evidence5

6. Definition &
classifications
HF is defined as:
complex clinical syndrome that results from
any structural or functional impairment of
ventricular filling or ejection of blood.
6

7. Definition &
classifications
HF classifications:
7
NYHA Exercise capacity &
symptoms
ACC Development and
progression of disease
HFrEF
HFpEF
Depend on EF

8. Definition &
classificationsNYHA Vs. ACCF/AHA stages
8

9. Definition &
classifications
9
Border line Improved
HFrE
F
≤40%
HFpEF
41-
49% <40%

10. Diagnosis & evaluation of HF
• Hx & physical examination
• Risk scoring
Clinical evaluation
• ECG
• CBC
Diagnostic tests
Biomarkers
10
Done by:
• Electrolytes
• Lipid profile
• Kidney
functions
• Natriuretic peptides
• Biomarkers of myocardial injury
• Biomarkers of myocardial fibrosis

11. Diagnosis & evaluation of HF
• Hx & physical examination
• Risk scoring
Non invasive
cardiac imaging
Invasive
evaluation
11
Done by:
• Pulmonary artery catheter
• Invasive hemodynamic monitoring
• Coronary angiography

12. Treatment recommendations:
Stage A
12
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Hypertension and lipid disorders should be controlled in
accordance with contemporary guidelines to lower the
risk of HF
I A
Other conditions that may lead to or contribute to HF,
such as obesity, diabetes mellitus, tobacco use, and
known cardiotoxic agents, should be controlled or
avoided.
I C

13. Treatment recommendations:
Stage B
13
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
In patients with a history of MI and reduced EF, ACE
inhibitors or ARBs should be used to prevent HF
I A
In patients with MI and reduced EF, evidence-based beta
blockers should be used to prevent HF
I B
In patients with MI, statins should be used to prevent HF I A

14. Treatment recommendations:
Stage B
14
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Blood pressure should be controlled to prevent
symptomatic HF
I A
ACE inhibitors should be used in all patients with a
reduced EF to prevent HF
I A
Beta blockers should be used in all patients with a
reduced EF to prevent HF
I C

15. Treatment recommendations:
Stage B
15
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
An ICD is reasonable in patients with asymptomatic
ischemic cardiomyopathy who are at least 40 d post-MI,
have an LVEF ≤30%, and on GDMT
IIa B
Nondihydropyridine calcium channel blockers may be
harmful in patients with low LVEF
III:
Harm
C

16. Treatment recommendations:
Stage C HFrEF
16
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Diuretics are recommended in patients with HFrEF with
fluid retention
I C
ACE inhibitors are recommended for all patients with
HFrEF
I A
ARBs are recommended in patients with HFrEF who are
ACE inhibitor intolerant
I A
ARBs are reasonable as alternatives to ACE inhibitors as
first-line therapy in HFrEF
I A

17. Treatment recommendations:
Stage C HFrEF
17
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Routine combined use of an ACE inhibitor, ARB, and
aldosterone antagonist is potentially harmful
III:
Harm
C
Use of 1 of the 3 beta blockers proven to reduce
mortality is recommended for all stable patients
I A

18. Treatment recommendations:
Stage C HFrEF
18
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Aldosterone receptor antagonists are recommended in
patients with NYHA class II–IV
who have LVEF ≤ 35%
I A
Aldosterone receptor antagonists are recommended in
patients following an acute MI
who have LVEF >40% with symptoms of HF or DM
I B
Inappropriate use of aldosterone receptor antagonists
may be harmful
III:
Harm
B

19. Treatment recommendations:
Stage C HFrEF
19
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
The combination of hydralazine and isosorbide-dinitrate
is recommended for African Americans with NYHA class
III–IV HFrEF on GDMT
I A
A combination of hydralazine and isosorbide-dinitrate
can be useful in patients with HFrEF who cannot be
given ACE inhibitors or ARBs
IIa B
Digoxin can be beneficial in patients with HFrEF IIa B

20. Treatment recommendations:
Stage C HFrEF
20
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Patients with chronic HF with
permanent/persistent/paroxysmal AF and an additional
risk factor for cardio-embolic stroke should receive
chronic anticoagulant therapy
I A
The selection of an anticoagulant agent should be
individualized
I C

21. Treatment recommendations:
Stage C HFrEF
21
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Chronic anticoagulation is reasonable for patients with
chronic HF who have permanent/
persistent/paroxysmal AF but are without an additional
risk factor for cardioembolic stroke
IIa B
Anticoagulation is not recommended in patients with
chronic HFrEF without AF,a prior thromboembolic event,
or a cardioembolic source
III:
No
benefit
B

22. Treatment recommendations:
Stage C HFrEF
22
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Statins are not beneficial as adjunctive therapy when
prescribed solely for HF
III:
No
benefit
A
Omega-3 PUFA supplementation is reasonable to use as
adjunctive therapy in HFrEF or HFpEF patients
IIa B
Long-term use of an infusion of a positive inotropic drug
is not recommended and may be harmful except as
palliation
III:
Harm
C

23. Treatment recommendations:
Stage C HFrEF
23
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Calcium channel–blocking drugs are not recommended
as routine treatment in HFrEF
III:
No
benefit
A

24. Treatment recommendations:
Stage C
24

25. Treatment recommendations:
Stage C
25

26. Treatment recommendations:
Stage C
26

27. Treatment recommendations:
Stage C
27

28. Treatment recommendations:
Stage C
28

29. Treatment recommendations:
Stage C HFpEF
29
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Systolic and diastolic blood pressure should be
controlled according to published clinical practice
guidelines
I B
Diuretics should be used for relief of symptoms due to
volume overload
I C
Coronary revascularization for patients with CAD in
whom angina or demonstrable myocardial ischemia is
present despite GDMT
IIa C

30. Treatment recommendations:
Stage C HFpEF
30
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Management of AF according to published clinical
practice guidelines for HFpEF to improve symptomatic
HF
IIa C
Use of beta-blocking agents, ACE inhibitors, and ARBs
for hypertension in HFpEF
IIa C
ARBs might be considered to decrease hospitalizations
in HFpEF
IIb B

31. Treatment recommendations:
Stage D
31
Recommendations CO
R
LO
E
Cardiogenic shock pending definitive therapy or
resolution
l C
BTT or MCS in stage D refractory to GDMT lla B
Short-term support for threatened end-organ dysfunction
in hospitalized patients with stage D and severe HFrEF
llb B
BTT indicates bridge to transplant; COR, Class of Recommendation; GDMT, guideline-directed medical therapy; HFrEF, heart
failure with reduced ejection fraction; and LOE, Level of Evidence

32. Treatment recommendations:
Stage D
32
Recommendations CO
R
LO
E
Long-term support with continuous infusion palliative
therapy in select stage D HF
llb B
Routine intravenous use, either continuous or
intermittent, is potentially harmful in stage D HF
III:
Harm
B
Short-term intravenous use in hospitalized patients
without evidence of shock or threatened end-organ
performance is potentially harmful
III:
Harm
B
COR indicates Class of Recommendation; HF, heart failure; and LOE, Level of Evidence

33. Treatment recommendations:
Stage D
33

34. Treatment recommendations:
Hospitalized patients
34
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; and LOE, Level
HF patients hospitalized with fluid overload should be
treated with intravenous diuretics
I B
HF patients receiving loop diuretic therapy should
receive an initial parenteral dose ≥ to their chronic oral
daily dose; then dose should be serially adjusted
I B
HFrEF patients requiring HF hospitalization on GDMT
should continue GDMT except in cases of hemodynamic
instability or where contraindicated
I B

35. Treatment recommendations:
Hospitalized patients
35
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Initiation of beta-blocker therapy at a low dose is
recommended after optimization of volume status and
discontinuation of intravenous agents
I B
Thrombosis/thromboembolism prophylaxis is
recommended for patients hospitalized with HF
I B

36. Treatment recommendations:
Hospitalized patients
36
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Serum electrolytes, urea nitrogen, and creatinine should
be measured during titration of
HF medications, including diuretics
I C
When diuresis is inadequate, it is reasonable to:
A. give higher doses of intravenous loop diuretics; or
B. add a second diuretic (e.g., thiazide)
lla B

37. Treatment recommendations:
Hospitalized patients
37
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Low-dose dopamine infusion may be considered with
loop diuretics to improve
llb B
When diuresis is inadequate, it is reasonable to:
A. give higher doses of intravenous loop diuretics; or
B. add a second diuretic (e.g., thiazide)
lla B

38. Treatment recommendations:
Hospitalized patients
38
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Ultrafiltration may be considered for patients with
obvious volume overload
llb B
Ultrafiltration may be considered for patients with
refractory congestion
Ilb C

39. Treatment recommendations:
Hospitalized patients
39
Recommendations CO
R
LO
E
COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure
with reduced ejection fraction; and LOE, Level of Evidence
Intravenous nitroglycerin, nitroprusside, or nesiritide may
be considered an adjuvant to diuretic therapy for stable
patients with HF
IIb A
In patients hospitalized with volume overload and severe
hyponatremia, vasopressin antagonists may be
considered
IIb B

40. Important comorbidities
with HF
42

41. Conclusion
HF is a disabling disease unless proper control
measures have been taken
HF diagnosis and treatment guidelines targets the
prevention of disease progression and enhancing
quality of life
ACE inhibitors or ARBs, diuretics, inotropes & β
Blockers are the main treatment agents of choice for
HF
43

42. 44