The document provides guidelines for the management of heart failure. It discusses the epidemiology of heart failure, classifications based on ejection fraction, stages based on symptoms and disease progression, and treatment recommendations for each stage. Key points include increasing risk with age, treatments including controlling risk factors in early stages and use of diuretics, ACE inhibitors, ARBs, and beta blockers in later stages, and tailored treatment for those with heart failure and comorbidities like diabetes or hypertension.

1. ACC/AHA GUIDELINE FOR THE
MANAGEMENT OF HEART FAILURE
PRESENTED BY
NIDA Sehar Noman
MBA (Finance) & MS (pharmacology)
nidasehar19@yahoo.com

2. EPIDEMIOLOGY
• The lifetime risk of developing HF is 20% for
Americans 40 years of age
• HF incidence increases with age, rising from
approximately 20 per 1,000 individuals 65 to
69 years of age to >80 per 1,000 individuals
among those 85 years of age

3. HEART FAILURE
HF is a complex clinical syndrome that results from any
structural or functional impairment of ventricular filling or
ejection of blood.

4. CARDINAL MANIFESTATIONS
Dyspnea
Fatigue, which may limit exercise tolerance,
and fluid retention
Pulmonary
Splanchnic congestion
Peripheral edema

5. ACC/AHA HF CLASSIFICATIONS
CLASSIFICATION EF (%) DESCRIPTION
Heart failure with
reduced ejection
fraction (HFrEF)
<40 Also referred to as systolic HF.
Heart failure with
preserved ejection
fraction (HFpEF)
>50 Also referred to as diastolic HF.
a. HFpEF, borderline 41 to
49
These patients fall into a borderline or intermediate
group. Their characteristics, treatment patterns, and
outcomes appear similar to those of patients with
HFpEF.
b. HFpEF, improved >40 These patients with improvement or recovery in EF
may be clinically distinct from those with persistently
preserved or reduced EF.

6. COMPARISON OF ACCF/AHA STAGES OF HF AND
NYHA FUNCTIONAL CLASSIFICATIONS
ACCF/AHA Stages of HF NYHA Functional Classification
Stage A At high risk for HF
but without
structural heart
disease or
symptoms of HF
None
Stage B Structural heart
disease but without
signs or symptoms
of HF
I No limitation of physical
activity. Ordinary physical
activity does not cause
symptoms of HF.

7. Stage C Structural
heart disease
with prior or
current
symptoms of
HF
I No limitation of physical activity. Ordinary
physical activity does not cause symptoms
of HF.
II Slight limitation of physical activity.
Comfortable at rest, but ordinary physical
activity results in symptoms of HF.
III Marked limitation of physical activity.
Comfortable at rest, but less than ordinary
activity causes symptoms of HF.
IV Unable to carry on any physical activity
without symptoms of HF, or symptoms of
HF at rest.
Stage D Refractory HF
requiring
specialized
interventions
IV Unable to carry on any physical activity
without symptoms of HF, or symptoms of
HF at rest.

8. TREATMENT OF STAGES A TO D:
RECOMMENDATIONS
• Stage A:
Hypertension
lipid disorders
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.

9. Stage B:
 Angiotensin-converting enzyme (ACE) inhibitors should
be used to prevent symptomatic HF and reduce mortality
 Angiotensin-receptor blockers (arbs) are appropriate
unless contraindicated
 Evidence-based beta blockers should be used to reduce
mortality
 Statins should be used to prevent symptomatic HF and
cardiovascular events
 Beta blockers should be used in all patients with a
reduced EF to prevent symptomatic HF

10. Stage C
NONPHARMACOLOGICAL INTERVENTIONS:
Self-care
Exercise training (or regular physical activity)
Sodium restriction
Cardiac rehabilitation

11. CLASS I:
Diuretics
ACE inhibitors
ARBs
Use of 1 of the 3 beta blockers proven to reduce
mortality (e.g., bisoprolol, carvedilol, and sustained-
release metoprolol succinate)
Aldosterone receptor antagonists
chronic anticoagulant therapy

12. CLASS IIa
ARBs are reasonable to reduce morbidity and
mortality as alternatives to ACE inhibitors as
first-line therapy for patients with HFrEF
Digoxin
Chronic anticoagulation is reasonable for
patients with chronic HF who have
permanent/persistent/paroxysmal AF

13. CLASS IIb :
Addition of an ARB may be considered in
persistently symptomatic patients with HFrEF

14. CLASS III:
Routine combined use of an ACE inhibitor,
ARB, and aldosterone antagonist is potentially
harmful for patients
Inappropriate use of aldosterone receptor
antagonists is potentially harmful
 Anticoagulation is not recommended in
patients with chronic HFrEF without AF

15. Statins are not beneficial as adjunctive
therapy when prescribed solely
Nutritional supplements as treatment for HF
are not recommended
Calcium channel–blocking drugs are not
recommended as routine treatment

16. HEART FAILURE WITH DIABETES
EPIDEMIOLOGY
The prevalence of patients with both HF and DM in the general
population is estimated at 0.5% in men and 0.4% in women
The prevalence of both diseases is increasing worldwide with the
aging of the general population: 1.5 to 2% of individuals over the
age of 65 have both HF and DM

17. DIABETIC HEART FAILURE
Diabetic cardiomyopathy
Insulin-resistance and hyperglycemia
Metabolic alterations
Impaired calcium homeostasis
Renin angiotensin aldosterone system
activation
Diastolic dysfunction
Systolic dysfunction

18. TREATMENT OF HEART FAILURE IN PATIENTS
WITH DIABETES
RAAS INHIBITION:
Angiotensin II and aldosterone are the final effectors underlying the cardiorenal
continuum in DM
ACE INHIBITORS
ARBs
Beta-blockers
Diuretics
Metformin
Thiazolidinediones

19. HYPERTENSIVE HEART FAILURE
EPIDEMIOLOGY
Recent data from two population-based studies indicate that
hypertension is responsible for CHF in 4%–20% of patients. In a
Swedish study of 7500 patients followed up for 27 years,6 the
identified etiological factors for CHF were hypertension in
20.3%, and CAD either alone or in combination with
hypertension in 58.8%.

20. LEFT VENTRICULAR HYPERTROPHY
Left ventricular hypertrophy represents the
major biological adaptation to increased
pressure load and its limitations.
Thus, understanding ventricular remodeling
influences the entire issue of heart failure in
hypertension and its therapy

21. TREATMENT RECOMENDATION
 Angiotensin converting enzyme (ACE) inhibitor (dose
equivalent to 20 mg daily enalapril) is recommended
 Addition of a beta blocker is recommended even if blood
pressure is controlled
 If blood pressure remains 130/80 mm Hg then the addition of
a thiazide diuretic is recommended, followed by a
dihydropyridine calcium antagonist (eg, amlodipine or
felodipine)

22. If blood pressure remains more than 130/80
mm Hg, a dihydropyridine calcium antagonist
(eg, amlodipine or felodipine) may be
considered