2. TABLE OF CONTENTS
» Definition of HF
» Epidemiology and Causes
» Initial and Serial Evaluation
» Stage A (Patients at risk for HF) &
Stage B (Patients with Pre-HF)
» Stage C HF & Stage D (Advanced) HF
» Value Statements
» Additional Medical Therapies after GDMT
Optimization
» Device and Interventional Therapies for HFrEF
» Valvular Heart Disease
» Recommendations for Patients with Mildly Reduced
LVEF
» Recommendations for Patients
with Preserved LVEF
» Cardiac Amyloidosis
» Stage D (Advanced) HF
» Patients Hospitalized with acute
decompensated HF
» Comorbidities in patients with HF
» Special Populations
» Quality Metrics and Reporting
» Goals of Care
» Patient-Reported Outcomes and Evidence Gaps and
Future Research Directions
2
3. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Table 1.
Applying Class of
Recommendation
and Level of
Evidence to Clinical
Strategies,
Interventions,
Treatments, or
Diagnostic Testing in
Patient Care
CLASS (STRENGTH) OF RECOMMENDATION
CLASS 1 (STRONG) Benefit >>>
Risk
Suggested phrases for writing recommendations:
• Is recommended
• Is indicated/useful/effective/beneficial
• Should be performed/administered/other
• Comparative-Effectiveness Phrases†:
− Treatment/strategy A is recommended/indicated in preference to treatment B
− Treatment A should be chosen over treatment B
CLASS 2a (MODERATE) Benefit >>
Risk
Suggested phrases for writing recommendations:
• Is reasonable
• Can be useful/effective/beneficial
• Comparative-Effectiveness Phrases†:
− Treatment/strategy A is probably recommended/indicated in preference to treatment
B
− It is reasonable to choose treatment A over treatment B
CLASS 2b (Weak) Benefit ≥
Risk
Suggested phrases for writing recommendations:
• May/might be reasonable
• May/might be considered
• Usefulness/effectiveness is unknown/unclear/uncertain or not well-established
CLASS 3: No Benefit (MODERATE) Benefit =
Risk
Suggested phrases for writing recommendations:
• Is not recommended
• Is not indicated/useful/effective/beneficial
• Should not be performed/administered/other
CLASS 3: Harm (STRONG) Risk >
Benefit
Suggested phrases for writing recommendations:
• Potentially harmful
• Causes harm
• Associated with excess morbidity/mortality
• Should not be performed/administered/other
LEVEL (QUALITY) OF EVIDENCE‡
LEVEL A
• High-quality evidence‡ from more than 1 RCT
• Meta-analyses of high-quality RCTs
• One or more RCTs corroborated by high-quality registry studies
LEVEL B-R (Randomized)
• Moderate-quality evidence‡ from 1 or more RCTs
• Meta-analyses of moderate-quality RCTs
LEVEL B-NR (Nonrandomized)
• Moderate-quality evidence‡ from 1 or more well-designed, well-executed
nonrandomized studies, observational studies, or registry studies
• Meta-analyses of such studies
LEVEL C-LD (Limited Data)
• Randomized or nonrandomized observational or registry studies with limitations
of design or execution
• Meta-analyses of such studies
• Physiological or mechanistic studies in human subjects
LEVEL C-EO (Expert Opinion)
• Consensus of expert opinion based on clinical experience.
COR and LOE are determined independently (any COR may be paired with any LOE).
A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical
questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are
unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or
effective.
*The outcome or result of the intervention should be specified (an improved clinical outcome or increased
diagnostic accuracy or incremental prognostic information).
†For comparative-effectiveness recommendation (COR 1 and 2a; LOE A and B only), studies that
support the use of comparator verbs should involve direct comparisons of the treatments or strategies
being evaluated.
‡The method of assessing quality is evolving, including the application of standardized, widely-used, and
preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence
Review Committee.
COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence;
NR, nonrandomized; R, randomized; and RCT, randomized controlled trial.
3
4. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Stages of Heart Failure
Abbreviations: CVD indicates cardiovascular disease; GDMT, guideline-directed medical therapy; HF, heart failure; HTN, hypertension; and NYHA, New York Heart Association.
4
STAGE A:
At-Risk for Heart Failure
Patients at risk for HF but without
current or previous symptoms/signs of
HF and without structural/functional
heart disease or abnormal biomarkers.
Patients with HTN, CVD, diabetes,
obesity, exposure to cardiotoxic agents,
genetic variant for cardiomyopathy, or
family history of cardiomyopathy.
STAGE B:
Pre-Heart Failure
STAGE C:
Symptomatic Heart Failure
STAGE D:
Advanced Heart Failure
Patients without current or previous
symptoms/signs of HF but evidence of 1
of the following: structural heart disease,
increased filling pressures, or risk
factors and increased natriuretic peptide
levels or cardiac troponin (in the
absence of competing diagnosis)
Patients with current or previous
symptoms/signs of HF
Marked HF symptoms that interfere with
daily life and with recurrent
hospitalizations despite attempts to
optimize GDMT
Trajectory
of Stage C
HF
New Onset/De Novo HF
Resolution of Symptoms
Persistent HF
Worsening HF
5. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Diagnostic Algorithm for HF and LVEF
Based on HF Classification
* There is limited
evidence to guide
treatment for patients
who improve their
LVEF from mildly
reduced (41-49%) to
≥50%. It is unclear
whether to treat
these patients as
HFpEF or HFmrEF.
Abbreviations: BNP indicates B-type natriuretic peptide; ECG, electrocardiogram; 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; LV, left ventricle; LVEF, left ventricular ejection fraction; and NT-proBNP, N-terminal pro-B type natriuretic peptide.
5
Assessment
• Clinical history
• Physical exam
• ECG, labs
Natriuretic peptide
NT-proBNP > 125 pg/mL
BNP ≥ 35 pg/mL
Transthoracic Echocardiography
Additional testing, if necessary
HF Diagnosis Confirmed
• Determine cause and classify
• Evaluate for precipitating factors
• Initiate treatment
• Serial HF assessment
HFrEF
LVEF ≤ 40%
HFmrEF
LVEF 41%-49%
HFpEF
LVEF ≥ 50%
Initial Classification
HFrEF LVEF ≤ 40%
HFrEF LVEF ≤ 40%
HFimpEF LVEF>40%
Serial Assessment &
Reclassification
HFrEF LVEF ≤ 40%
HFmrEF LVEF 41%-49%
HFmrEF LVEF 41%-49%
HFpEF LVEF ≥ 50%
*LVEF ≥ 50%
6. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Epidemiology of Heart Failure in the United States
Increase in HF related deaths
from 2009 to 2014. Racial and ethnic disparities in death resulting
from HF persist.
Age-adjusted mortality rates for HF:
92/100,000 for non-Hispanic Black patients
87/100,000 for non-Hispanic White patients
53/100,000 for Hispanic patients
Disparities in racial and ethnic HF outcomes
warrant studies and health policy changes to
address health inequity.
Increase in HF hospitalizations
from 2013 to 2017.
Decline in overall HF incidence
from 2011 to 2014 with declining
incidence of HFrEF but increasing
incidence of HFpEF.
Abbreviations: HF indicates heart failure; HFpEF, heart failure with preserved ejection fraction; and HFrEF, heart failure with reduced ejection fraction.
6
8. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Initial Evaluation of Patients with Heart Failure
History and Physical exam
Class 1 Recommendations:
• Measure vitals signs and assess for evidence of congestion
• Evaluate for the presence of advanced HF
• In patients with cardiomyopathy use a 3-generation family
history to screen for inherited disease
• Use H&P to direct diagnostic strategies to uncover causes
which require disease specific management
• Identify cardiac & non-cardiac diseases, lifestyle & behavioral
factors, and SDOH which may cause or worsen HF
Laboratory and ECG testing
Class 1 Recommendations:
CBC, UA, serum electrolytes, serum creatinine, BUN, glucose,
lipid profile, LFTs, iron studies, and TSH
12-lead ECG to optimize management
For patients presenting with HF, the specific cause of HF should
be explored using additional laboratory testing for appropriate
management
Abbreviations: BUN indicates blood urea nitrogen; CBC indicates complete blood count; ECG, electrocardiogram; H&P, history and physical; HF, heart
failure; LFTs, liver function tests; SDOH, social determinates of health; and TSH, thyroid-stimulating hormone.
8
9. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Initial & Serial Evaluation: Use of Biomarkers
In patients with dyspnea
COR RECOMMENDATIONS
1
In patients presenting with dyspnea, measurement of BNP or
NT-proBNP is useful to support a diagnosis or exclusion of
HF.
In patients hospitalized for HF
COR RECOMMENDATIONS
1
In patients hospitalized for HF, measurements of BNP or NT-
proBNP levels at admission is recommended to establish
prognosis.
2a
In patients hospitalized for HF, a predischarge BNP or NT-
proBNP level can be useful to inform the trajectory of the
patient and establish a post-discharge prognosis.
In patients at risk for HF
COR RECOMMENDATIONS
2a
In patients at risk of developing HF, BNP or NT-proBNP-
based screening following team-based care, including a
CV specialist, can be useful to prevent the development of
LV dysfunction or new onset HF.
In patients with chronic HF
COR RECOMMENDATIONS
1
In patients with chronic HF, measurements of BNP or NT-
proBNP levels are recommended for risk stratification.
REMINDER
Potential noncardiac causes of
elevated natriuretic peptide
levels may include advancing
age, anemia, renal failure,
severe pneumonia, obstructive
sleep apnea, pulmonary
embolism, pulmonary arterial
hypertension, critical illness,
bacterial sepsis, and severe
burns.
Abbreviations: BNP indicates B-type natriuretic peptide; CV, cardiovascular; HF, heart failure; and NT-proBNP, N-terminal prohormone of B-type natriuretic peptide.
9
10. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Initial & Serial Evaluation:
Evaluation with Cardiac Imaging
Chest X-Ray
Class 1 Recommendation
In patients with suspected or
new-onset HF, or those
presenting with acute
decompensated HF, a chest x-
ray should be performed to
assess heart size and
pulmonary congestion and to
detect alternative cardiac,
pulmonary, and other diseases
that may cause or contribute to
the patient’s symptoms.
TTE
Class 1 Recommendation
In patients with suspected or
newly diagnosed HF, TTE
should be performed during
initial evaluation to assess
cardiac structure and function.
Cardiac CT, CMR &
SPECT/PET
Class 1 Recommendation
In patients for whom echo. is inadequate,
alternative imaging (e.g., CMR, cardiac
CT, radionuclide imaging) is
recommended for assessment of LVEF.
In patients with HF who have had a
significant clinical change, or who have
received GDMT and are being considered
for invasive procedures or device
therapy, repeat measurement of EF,
degree of structural remodeling, &
valvular function are useful to inform
therapeutic interventions.
Class 2a Recommendation
In patients with HF or cardiomyopathy,
CMR can be useful for diagnosis or
management.
Ischemia Evaluation
Class 2a Recommendation
In patients with HF, an
evaluation for possible ischemic
heart disease can be useful to
identify the cause and guide
management .
Class 2b Recommendation
In patients with HF and CAD
who are candidates for coronary
revascularization, noninvasive
stress imaging (stress echo.,
single-photon emission CT
[SPECT], CMR, or PET] may be
considered for detection of
myocardial ischemia to help
guide coronary
revascularization.
Class 3 No Benefit
In patients with HF in the
absence of:
1) clinical status change, 2)
treatment interventions that
might have had a significant
effect on cardiac function, or
3) candidacy for invasive
procedures or device therapy,
routine repeat assessment of
LV function is not indicated.
Abbreviations: CAD indicates coronary artery disease; CMR, cardiac magnetic resonance; CT, computed tomography; echo, echocardiography; EF, ejection fraction; GDMT, guideline-directed
medical therapy; LVEF, left ventricular ejection fraction; PET, position emission tomography; SPECT, single-photon emission CT; and TTE, transthoracic echocardiography.
10
11. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Initial & Serial Evaluation:
Invasive Evaluation of Patients with HF
Invasive Hemodynamics
COR RECOMMENDATIONS
2a
In select patients with HF with persistent or worsening
symptoms, signs, diagnostic parameters, and in
whom hemodynamics are uncertain, invasive
hemodynamic monitoring can be useful to guide
management.
3: No
Benefit
In patients with HF, routine use of invasive
hemodynamic monitoring is not recommended.
Endomyocardial Biopsy
COR RECOMMENDATIONS
2a
In patients with HF, endomyocardial biopsy may be
useful when a specific diagnosis is suspected that
would influence therapy.
3: Harm
For patients undergoing routine evaluation of HF,
endomyocardial biopsy should not be performed
because of risk of complications.
Guiding Principle: Invasive evaluations are most appropriate when they will guide management and influence therapy. Due to the
risk of complications, invasive procedures should not be used for the routine evaluation of HF.
Abbreviation: HF indicates heart failure.
11
12. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Initial & Serial Evaluation
Wearables & Remote Monitoring
In patients with NYHA class III HF with
a HF hospitalization within the
previous year, wireless monitoring of
the PA pressure by an implanted
hemodynamic monitor provides
uncertain value.
Value Statement: Uncertain Value (B-NR)
HF hospitalization in the past
year or elevated natriuretic
peptide levels
Adult patients with
NYHA III HF
Maximally tolerated stable
doses of GDMT with optimal
device therapy
The usefulness of wireless
monitoring of PA pressure by
an implanted hemodynamic
monitor
to reduce the risk of
subsequent HF
hospitalizations is uncertain.
(Class 2b)
Source: Pennmedicine.org
Exercise & Functional Capacity Testing
COR RECOMMENDATIONS
1
1. In patients with HF, assessment and
documentation of NYHA functional
classification are recommended to
determine eligibility for treatments
1
2. In selected ambulatory patients with HF,
CPET is recommended to determine
appropriateness of advanced
treatments (e.g., LVAD, heart
transplant)
2a
3. In ambulatory patients with HF,
performing a CPET or 6- minute walk
test is reasonable to assess functional
capacity
2a
4. In ambulatory patients with unexplained
dyspnea, CPET is reasonable to
evaluate the cause of dyspnea
Abbreviations: CPET indicates cardiopulmonary exercise testing; GDMT, guideline-directed medical therapy; HF, heart failure; LVAD, left
ventricular assist device; NYHA, New York Heart Association; and PA, pulmonary artery.
12
13. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
I-PRESERVE
Score
TOPCAT
Seattle Heart
Failure model
MAGGIC
Heart failure
survival score
CHARM Risk
score
ADHERE Classification and
Regression Tree (CART) Model
AHA Get with The Guidelines
score
EFFECT Risk score
ESCAPE Risk Model and
Discharge score
Initial & Serial Evaluation: Clinical Assessment
HF Risk Scoring
COR RECOMMENDATIONS
2a
In ambulatory or hospitalized patients
with HF, validated multivariable risk
scores can be useful to estimate
subsequent risk of mortality.
Selected Multivariable Risk Scores to Predict Outcome in HF
Acutely Decompensated HF Chronic HF
All patients HFpEF specific
CORONA Risk
score
GUIDE-IT
PARADIGM -HF
HFrEF
specific
HF- ACTION
Abbreviations: ADHERE indicates Acute Decompensated Heart Failure National Registry; AHA, American Heart Association; ARIC, Atherosclerosis Risk in Communities; CHARM, Candesartan in Heart failure-Assessment of
Reduction in Mortality and morbidity; CORONA, Controlled Rosuvastatin Multinational Trial in Heart Failure; EFFECT, Enhanced Feedback for Effective Cardiac Treatment; ESCAPE, Evaluation Study of Congestive Heart Failure
and Pulmonary Artery Catheterization Effectiveness; GUIDE-ID, Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HF-ACTION, Heart
Failure: A Controlled Trial Investigating Outcomes of Exercise Training MAGGIC Meta-analysis Global Group in Chronic Heart Failure; I-PRESERVE, Irbesartan in Heart Failure with Preserved Ejection Fraction Study; PCP-HF,
Pooled Cohort Equations to Prevent HF; and TOPCAT, Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial.
13
14. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Recommendations for Patients
at Risk of HF & Pre-HF
At Risk for HF (Stage A)
Primary Prevention
Pre-HF (Stage B)
Preventing the Syndrome
Patients with hypertension Optimal control of BP (1)
Patients with Type 2 diabetes and
CVD or high risk for CVD
SGLT2i (1)
Patients with CVD Optimal management of CVD (1)
Patients with exposure to cardiotoxic
agents
Multidisciplinary evaluation and
management (1)
First-degree relatives of patients with
genetic or inherited
cardiomyopathies
Genetic screening
and counselling (1)
Patients at risk for HF Natriuretic peptide screening (2a)
Patients at risk for HF
Validated multivariable risk score
(2a)
Patients with LVEF ≤ 40% ACEi (1)
Patient with recent MI and LVEF ≤ 40
% ARB if ACEi intolerant (1)
Patients with LVEF ≤ 40% Beta blocker (1)
Patient with LVEF ≤ 30 %; >1 y
survival; >40 d post MI ICD (1)
Patients with nonischemic
cardiomyopathy
Genetic counselling and testing (2a)
Continue Lifestyle modification and management strategies implemented in Stage A, through Stage B
Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BP, blood pressure; CVD, cardiovascular disease; HF, heart failure; ICD,
implantable cardioverter-defibrillator; LVEF, left ventricular ejection fraction; MI, myocardial infarction; and SGLT2i, sodium glucose cotransporter 2 inhibitor.
14
15. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Treatment of HFrEF Stages C and D
NOTE: *Participation in
investigational studies is
appropriate for stage C, NYHA
class II and III HF.
Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; CRT, cardiac resynchronization therapy; GDMT,
guideline-directed medical therapy; HF, heart failure; 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; SCD, sudden cardiac death; and SGLT2i, sodium-glucose cotransporter 2 inhibitor.
15
STEP 1
Established diagnosis of HFrEF
Address congestion
Initiate GDMT
STEP 2
Titrate to Target dosing as
tolerated, labs, health
status, and LVEF
STEP 3
Consider these patient scenarios
STEP 4
Implement additional GDMT and
device therapy, as indicated
STEP 5
Reassess symptoms, labs,
health status, and LVEF
STEP 6
Referral for HF specialty care for
additional therapy
Continue GDMT with serial reassessment and optimize dosing, adherence and patient education, address goals of care
HFrEF
LVEF ≤40% (Stage C)
ARNI in NYHA II-III;
ACEi or ARB in NYHA II-IV (1)
Beta blocker (1)
MRA (1)
SGLT2i (1)
Diuretics as needed (1)
LVEF ≤40%
Persistent HFrEF
(Stage C)
LVEF >40%
HFImpEF
(Stage C)
NYHA I-III; ambulatory
IV; LVEF ≤35%;
NSR and QRS ≥150 ms
with LBBB
NYHA I-III; LVEF ≤35%;
>1 y survival
NYHA III-IV, in African
American patients
Consider additional
therapies
CRT-D (1)
ICD (1)
Hydral-nitrates (1)
Symptoms improved
Refractory HF
(Stage D)
Investigational studies*
Palliative care (1)
(Can be initiated before
Stage D)
Cardiac transplant (1)
In Selected patients,
durable MCS (1)
16. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Value Statements for GDMT for HFrEF
Take Home Point:
An important aspect of HF care, Class 1 recommended medical
therapies for HFrEF have very high value (low cost).
16
In patients:
With previous or current
symptoms of chronic
HFrEF, in whom ARNi is
not feasible, tx with ACEi
or ARB provides high
economic value.
Value Statement:
High Value (A)
With chronic
symptomatic HFrEF,
tx with an ARNi
instead of an ACEi
provides high
economic value.
Value Statement:
High Value (A)
With HFrEF and
NYHA class II to IV
symptoms, MRA
therapy provides
high economic
value.
Value Statement:
High Value (A)
With HFrEF, with current
or previous symptoms,
beta-blocker therapy
provides high economic
value.
Value Statement:
High Value (A)
With symptomatic
chronic HFrEF, SGLT2i
therapy provides
intermediate
economic value.
Value Statement:
Intermediate Value (A)
Self-identified as African American with NYHA class III to IV HFrEF who are receiving optimal medical therapy with ACEi or ARB,
beta blockers, and MRA, the combination of hydralazine and isosorbide dinitrate provides high economic value.
Value Statement: High Value (B-NR)
Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HFrEF, heart failure with reduced ejection fraction; MRA, mineralocorticoid receptor
antagonist; SGLT2i, NR, non-randomized; sodium-glucose cotransporter 2 inhibitor; and tx, treatment.
17. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Value Statements for Device Therapy
A transvenous ICD provides high economic value in the primary prevention of SCD 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 & functional status.
Value Statement: High Value (A)
For patients who have LVEF <35%, sinus rhythm, LBBB with a QRS duration of >150 ms, and
NYHA class II, III, or ambulatory IV symptoms on GDMT, CRT implantation provides high
economic value.
Value Statement: High Value (B-NR)
17
Abbreviations: CRT indicates cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; ICD; implantable cardioverter-defibrillator; LBBB, left bundle branch block;
LVEF, left ventricular ejection fraction; ms; millisecond; NR, nonrandomized; NYHA, New York Heart Association; and SCD, sudden cardiac death.
18. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Additional Medical Therapies
after GDMT Optimization
Ivabradine
( 2a)
In patients with LVEF ≤
35% with NYHA II-III; NSR
with HR ≥ 70 bpm at rest
on maximally tolerated
Beta- Blockers.
Initial dose: 5 mg BID
Target dose: 7.5 mg BID
Vericiguat
(2b)
In patients with LVEF ≤
45%; recent HFH or IV
diuretics; elevated NP
levels.
Initial dose: 2.5 mg daily
Target dose: 10 mg daily
Digoxin
( 2b)
In patients with
symptomatic HF despite
GDMT or unable to tolerate
GDMT.
Initial dose: 0.125-0.25 mg
QID (follow monogram)
Target dose:
titrate to achieve
serum concentration
0.5- <0.9 ng/ml
PUFA
(2b)
In patients with HF and
NYHA II-IV
Dose: 1 gram daily of
n-3PUFA (850-880 mg of
EPA and DHA)
Potassium
binders
(2b)
Additional medical therapies after optimizing GDMT
Abbreviations: DHA indicates docosaexaenoic acid; EPA, eicosapentaenoic acid; GDMT, guideline-directed medical therapy; HF, heart failure; HFH, heart failure
hospitalization; HR, heart rate; IV, intravenous; LVEF, left ventricular ejection fraction; NP, natriuretic peptide; NSR, normal sinus rhythm; NYHA, New York Heart
Association; PUFA, polyunsaturated fatty acid; and RAASi, renin-angiotensin-aldosterone system inhibitors.
18
In HF patients with
hyperkalemia (≥ 5.5
mEq/L) while taking
RAASi.
Medications:
Patiromer; sodium
zirconium cyclosilicate
19. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Algorithm for CRT Indications in Patients
with Cardiomyopathy or HFrEF
Abbreviations: AF indicates atrial fibrillation; Amb, ambulatory; CM, cardiomyopathy; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; HB, heart
block; HF, Heart Failure; HFH, heart failure hospitalization; HFrEF, heart failure with reduced ejection fraction; LBBB, left bundle branch block; LVEF, left ventricular ejection
fraction; NSR, normal sinus rhythm; NYHA, New York Heart Association; and RV, right ventricle.
19
CRT recommendations
Patients with HF on GDMT >3mo and > 40 d if after MI, or with a special indication for pacing
Comorbidities limit
survival to <1 year
LVEF 36-50%
LBBB ≥150ms (1)
High degree or complete
heart block(2a)
Continue GDMT without
device
General health status
Evaluate LVEF
LVEF ≤35%
LVEF≤30%;
Ischemic CM;
LBBB≥150ms
(2b)
NYHA I NYHA II- Amb Class IV
Non LBBB≥150 ms (2a)
LBBB 120-149 ms(2a)
Non LBBB 120-149 ms (2b)
Special
Circumstances
AF
RV pacing frequent or
anticipated (2a)
NSR
RV pacing frequent or
anticipated (2a)
20. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Additional Device Therapies after GDMT
Optimization
Abbreviations: GDMT indicates guideline-directed medical therapy; HF, heart failure; HFH, heart failure hospitalization; HFrEF, heart failure with reduced ejection fraction; LVEF, left
ventricular ejection fraction; LVESD, left ventricular end systolic dimension; MR, mitral regurgitation; MV, mitral valve; NP, natriuretic peptide; NSR, normal sinus rhythm; NYHA,
New York Heart Association; and PASP, pulmonary artery systolic pressure.
20
In selected patients with HF
LVEF ≤35% and
suitable coronary anatomy
NYHA II-IV;
HFrEF;
severe secondary MR
NYHA II-IV;
Severe secondary MR;
Suitable anatomy;
LVEF 20-50%;
LVESD ≤70 mm;
PASP ≤70 mmHg
NYHA III;
History of HFH or
Elevated NP levels
Additional Device Therapies
after optimizing GDMT
Surgical
revascularization
(1)
Transcatheter edge-to-edge
MV repair
(2a)
Wireless PA pressure by
implanted hemodynamic
monitor
( 2b)
Optimization of GDMT before
Intervention for secondary
MR
(1)
21. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Treatment Approach in
Secondary Mitral Regurgitation
NOTE:
*Chordal-sparing MV replacement
may be reasonable to choose
over downsized annuloplasty
repair.
Abbreviations: AF indicates atrial fibrillation; CABG, coronary artery bypass graft; ERO, effective regurgitant orifice; GDMT, guideline-directed medical therapy;
HF, Heart Failure; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diameter; MR, mitral regurgitation; MV, mitral valve; PASP,
pulmonary artery systolic pressure; RF, regurgitant fraction; Rvol, regurgitant volume; and Rx, medication.
21
GDMT supervised by HF specialist (1)
Severe Stage D MR
(Rvol ≥60 ml, RF≥50%, ERO≥0.40 cm2)
Secondary Mitral Regurgitation
LVEF ≥50% LVEF <50%
MV surgery (2b)
Persistent symptoms on
optimal GDMT
Severe persistent
symptoms on optimal
GDMT and AF Rx
Transcatheter edge-to-edge MV repair (2a)
Mitral anatomy favorable:
LVEF 20-50%; LVESD≤70mm;
PASP≤70 mmHg?
Undergoing CABG
MV surgery* (2a)
NO
YES
Severe symptoms MV surgery (2b)
22. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Recommendations for Patients
with Mildly Reduced LVEF
Abbreviations: ARB indicates angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HF, heart failure; HFpEF, heart failure with preserved ejection
fraction; LV, left ventricle; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; and SGLT2i, sodium-glucose cotransporter-2 inhibitor.
22
Treatment for HFmrEF
Symptomatic HF with LVEF 41-49%
ACEi, ARB, ARNi
(2b)
SGLT2i
(2a)
Diuretics,
as needed
(1)
MRA
(2b)
Evidence-based
beta blockers
for HFrEF
(2b)
Patients With HFimpEF
COR RECOMMENDATIONS
1
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. (1)
23. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Recommendations for Patients
with Preserved LVEF
NOTE: *Greater benefit in patients with LVEF closer to 50%
Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HFimpEF, heart
failure with improved ejection fraction; HFmrEF, heart failure with mildly reduced ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular
ejection fraction; MRA, mineralocorticoid receptor antagonist; and SGLT2i, sodium- glucose cotransporter 2 inhibitor.
23
Treatment for HFpEF
Symptomatic HF with LVEF ≥50%
ARNi*
(2b)
SGLT2i
(2a)
Diuretics,
as needed
(1)
MRA*
(2b)
ARB*
(2b)
24. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Diagnosis and Treatment of
Transthyretin Cardiac Amyloidosis
Abbreviations: AF indicates atrial fibrillation; AL-CM, AL amyloid cardiomyopathy; ATTR-CM, transthyretin amyloid cardiomyopathy; ATTRV, variant transthyretin amyloidosis; ATTRwt, wild-
type transthyretin amyloidosis; CHA›DS2-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.
24
History, ECG, echocardiogram, cardiac MRI
suggestive of cardiac amyloidosis
Check for monoclonal
light chains (1)
Presence of
monoclonal
light chain?
Check Tc-99m-PYP
scan (1)
Hematology-oncology
consultation and consider heart
or other biopsy
NO
YES
Perform TTR gene sequencing (1)
Tc-99m-PYP
abnormal?
Cardiac
amyloidosis
unlikely
NO
YES
Treatment
ATTRwt-CM ATTRv-CM
• Referral to genetic
counselor
• Potential screening of
family members
• TTR silencer therapy
if neuropathy
Amyloid on
heart
biopsy?
Anticoagulation regardless of
CHA2DS2-VASc score (2a)
Tafamidis (1)
NYHA I-III
symptoms
Atrial fibrillation
Treatment by
hematologist-
oncologist
Individualized therapy HFrEF
Cardiac
amyloidosis
unlikely
No evidence
of amyloid
AL-CM ATTR-CM
Evidence
of amyloid
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.
Value Statement:
Low Value (B-NR)
25. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Recommendation for Specialty Referral to Advanced HF
COR RECOMMENDATIONS
1
1. 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 (e.g., LVAD, cardiac
transplantation, palliative care, and palliative inotropes).
Consider if “I-Need-Help” to aid with recognition of patients with advanced HF:
• Complete assessment is
not required before
referral
• After patients develop
end-organ dysfunction or
cardiogenic shock, they
may no longer quality for
advanced therapies
25
I Intravenous inotropes
N
New York Heart Association
class IIIB or IV, or persistently
elevated natriuretic peptides
E End-organ dysfunction
E EF ≤35%
D Defibrillator shocks
H Hospitalizations >1
E Edema despite
escalating diuretics
L Low systolic BP ≤90mmHg
P
Prognostic medication;
intolerance of GDMT
Abbreviations: BP indicates blood pressure; EF, ejection fraction; GDMT, guideline-directed medical therapy; and LVAD, left ventricular assist device.
26. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Non-pharmacological Management
in Advanced HF
Abbreviations: Cr indicates creatinine; HF, heart failure; IV, intravenous; Na+, sodium; and RCT, randomized clinical trial.
Meta-analysis1 of 6 RCTs
comparing liberal and
restricted fluid intake
No difference in mortality
or HF hospitalization
No difference in serum
Na+ or Cr
No difference in duration
of IV diuretics
COR RECOMMENDATIONS
2b
1. For patients with advanced HF and
hyponatremia, the benefit of fluid
restriction to reduce congestive
symptoms is uncertain
26
27. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Inotropic Support
Despite improving hemodynamic compromise, positive inotropic agents have not
shown improved survival in patients with HF in either the hospital or outpatient
setting.
COR RECOMMENDATIONS
2a
1. In patients with advanced (stage D) HF refractory to GDMT and device therapy who are eligible for and
awaiting MCS or cardiac transplantation, continuous intravenous inotropic support is reasonable as
“bridge therapy” (Class 2a)
2b
2. In select patients with stage D HF, despite optimal GDMT and device therapy who are ineligible for either
MCS or cardiac transplantation, continuous intravenous inotropic support may be considered as
palliative therapy for symptom control and improvement in functional status
3:
Harm
3. In patients with HF, long-term use of either continuous or intermittent intravenous inotropic agents, for
reasons other than palliative care or as a bridge to advanced therapies, is potentially harmful
Abbreviations: GDMT indicates guideline-directed medical therapy; HF, heart failure; and MCS, mechanical circulatory support.
27
28. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Durable Mechanical Support with
Left Ventricular Assist Device
SOURCE: https://www.mayoclinic.org/tests-procedures/ventricular-assist-
device/multimedia/left-ventricular-assist-device/img-20006714
INDICATIONS
• Frequent hospitalizations for HF
• NYHA class IIIB to IV symptoms
despite maximal GDMT
• Intolerance of GDMT
• Increasing diuretic requirement
• Symptomatic despite CRT
• Inotrope dependence
• Low peak VO2 (<14-16 ml/kg/m2)
• End-organ dysfunction
attributable to low cardiac output
CONTRAINDICATIONS
Absolute
• Irreversible hepatic, renal or
neurological disease
• Medical non-adherence
• Severe psychosocial
limitations
Relative
• Age >80 years for destination
therapy
• Obesity or malnutrition
• Musculoskeletal disease that
impairs rehabilitation
• Active systemic infection or
prolonged intubation
• Untreated malignancy
• Severe PVD
• Active substance abuse
• Impaired cognitive function
• Unmanaged psychiatric
disorder
• Lack of social support
Abbreviations: CRT indicates cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; LVAD, left ventricular assist device; NYHA, New
York Heart Association; PVD, peripheral vascular disease; and VO2, oxygen uptake.
28
29. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Mechanical Circulatory Support
Despite improving hemodynamic compromise, positive inotropic agents have not
shown improved survival in patients with HF in either the hospital or outpatient
setting.
COR RECOMMENDATIONS
1
1. In select patients with advanced HFrEF with NYHA class IV symptoms who
are deemed to be dependent on continuous intravenous inotropes or
temporary MCS, durable LVAD implantation is effective to improve
functional status, QOL and survival.
2a
2. In select patients who have NYHA class IV symptoms despite GDMT,
durable MCS can be beneficial to improve symptoms, functional class and
reduce mortality.
2a
3. In patients with advanced HFrEF and hemodynamic compromise and
shock, temporary MCS, including percutaneous and extracorporeal
ventricular assist devices, are reasonable as a ”bridge to recovery” or
“bridge to decision.”
In patients with advanced HFrEF who have
NYHA class IV symptoms despite GDMT,
durable MCS devices provide low to
intermediate economic value based on
current costs and outcomes
Value Statement: Uncertain Value (B-NR)
Abbreviations: GDMT indicates guideline-directed medical therapy; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; LVAD, left ventricular assist
device; MCS, mechanical circulatory support; NR, nonrandomized; NYHA, New York Heart Associations; and QOL, quality of life.
29
30. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Cardiac Transplantation
Median survival of adult transplant recipients is >12 years; versus <2 years for patients
with stage D HF without advanced therapies.
COR RECOMMENDATIONS
1
1. For selected patients with
advanced HF despite GDMT,
cardiac transplantation is
indicated to improve survival and
QOL (1)
In patients with stage D HF despite GDMT,
cardiac transplantation provides intermediate
economic value.
Value Statement: Intermediate Value (C-LD)
PATIENT SELECTION
• Minimizing waitlist mortality
while maximizing post-
transplant outcomes is a
priority
• CPET can refine candidate
prognosis and selection
• Appropriate patient selection
should include integration of
comorbidity burden, caretaker
status and goals of care
Abbreviations: CPET indicates cardiopulmonary exercise test; GDMT, guideline-directed medical therapy; HF, heart failure; LD, limited data; and QOL, quality of life.
30
31. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Assessment of Patients Hospitalized With Decompensated
HF
Evaluation
COR RECOMMENDATIONS
1 Address precipitating factors
1 Evaluate severity of congestion
1 Assess adequacy of perfusion
Goals for GDMT
COR RECOMMENDATIONS
1 Optimize volume status
1 Address reversible factors
1 Continue or initiate GDMT
COMMON FACTORS PRECIPITATING HF HOSPITALIZATION
• Acute coronary syndrome
• Uncontrolled hypertension
• Atrial fibrillation and arrhythmias
• Additional cardiac disease
• Acute infections
• Non-adherence to medications or diet
• Anemia
• Hypo-/Hyperthyroidism
• Medications that increase sodium retention
• Medications with negative inotrope
Abbreviation: GDMT indicates guideline-directed medical therapy.
31
32. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
GDMT During Hospitalization
Oral GDMT should be continued and optimized on
admission, as doing so is associated with lower post-
discharge death and readmission.
Admission:
Continue GDMT,
unless
contraindicated
(Class 1)
Inpatient:
Continue diuresis
despite mild
reduction in renal
function and BP
(Class 1)
Pre-Discharge:
Re-initiate and/or
optimize GDMT when
clinically stable
(Class 1)
Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; ARNi, angiotensin receptor-neprilysin inhibitor; AV, atrioventricular;
BP, blood pressure; GDMT, guideline-directed medical therapy; and VTE, venous thromboembolism.
32
Special considerations
• Consider discontinuation
of beta blockers in
patients with low cardiac
output, severe volume
overload, advanced AV
block or ACEi/ARNi with
angioedema
• VTE prophylaxis is
recommended in all
hospitalized patients
33. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Decongestion Strategy
Abbreviations: BUN indicates blood urea nitrogen; GDMT, guideline-directed medical therapy IV, intravenous; and MRA; mineralocorticoid.
33
MONITORING INITIAL
MANAGEMENT
TITRATE** DISCHARGE
• Fluid intake and
output
• Standardize daily
weight
• Clinical signs of
congestion
• Hypoperfusion
• Labs:
– Electrolytes
– BUN
– Creatinine
IV Loop Diuretic
(Class 1)
Provide diuretic
adjustment plan
(Class 1)
**Titration of diuretics and GDMT during hospitalization to resolve congestion, reduce symptoms and prevent readmission (Class 1)
IV nitroglycerin or nitroprusside may be added as an adjunct to diuretics for dyspnea in the absence of hypotension (Class 2b)
Double IV loop diuretic dose
(Class 2a)
Sequential nephron blockade
(e.g. thiazide)
(Class 2a)
Loop diuretic infusion
(Class 2a)
Additional of MRA
Low-dose dopamine
34. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Hospitalized Patients with Cardiogenic Shock
Shock: Clinical Criteria
I. SBP <90 mm Hg for > 30 minutes
a. Mean BP < 60 mm Hg for >30 minutes
b. Requirement of vasopressors to maintain
SBP ≥ 90 mm Hg or mean BP ≥60 mm Hg
II. Hypoperfusion:
a. Decreased mentation
b. Cold extremities, livedo reticularis
c. Urine output < 30 mL/h
d. Lactate >2 mmol/L
Shock: Hemodynamic Criteria
I. SBP <90 mmHg or mean BP <60 mmHg
II. Cardiac Index <2.2 L/min/m2
III. PCW >15 mm Hg
IV. Other hemodynamic considerations
a. Cardiac power output <0.6 W
b. Shock index >1
c. RV shock
• pulmonary artery pulse index <1
• CVP > 15 mm Hg
• CVP-PCW >0.6
COR RECOMMENDATIONS
1
1. Initiate ionotropic support
• To maintain systemic perfusion
• To preserve end-organ function
2a
2. Temporary MCS is reasonable when end-
organ function cannot be maintained by
pharmacologic means to support cardiac
function
2a
3. Management by a multidisciplinary team
experienced in shock is reasonable
2b
4. Consider placement of PA line to define
hemodynamic subsets and appropriate
management strategies
2b
5. Unable to maintain end-organ function
triage to centers with MCS capabilities
should be considered
Abbreviations: BP indicates blood pressure; CVP, central venous pressure; h, hour; L, liter; m2 , square meter; MCS, mechanical circulatory shock; min, minute; ml, milliliter; ; mmHg,
millimeter of mercury; mmol, a thousandth of a mole; PA, pulmonary artery; PCW, pulmonary capillary wedge, SBP, systolic blood pressure.; and W, watts.
34
35. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Transitions of Care
A transition of care plan should be
communicated prior to discharge (1)
This should include…
1 Early follow-up, ideally within 7 days (Class 2a)
2
Referrals to multidisciplinary HF management
programs (Class 1)
3
Participation in benchmarking programs to improve
GDMT and quality of care (Class 2a)
4
Addressing precipitating causes and high-risk factors
(e.g. co-morbidities and SDOH)
5 Adjusting diuretics
6 Coordination of safety laboratory checks
Abbreviations: GDMT indicates goal-directed medical therapies; HF, heart failure; and SDOH, social determinates of health.
35
36. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Additional Therapies in Patients
with HF and Comorbidities
In addition to optimized GDMT
Patients with HF and
hypertension
Optimal treatment according to
hypertension guidelines (1)
Patients with HF and
type 2 diabetes
SGLT2i for management of
hyperglycemia (1)
Select patients with HF and
LVEF < 35% and suitable
coronary anatomy
Surgical
revascularization (1)
Patients with HF attributable to
VHD or cancer therapy
Multidisciplinary
Management (1)
Select patients with
HF and AF
Anticoagulation (1)
Patients with HFrEF and
iron deficiency
IV iron replacement (2a)
Patients with AF and LVEF < 50% if
rhythm control strategy fails/not desired
and ventricular rates remain rapid despite
medical therapy
AV nodal ablation and
CRT implantation (2a)
Patients with HF and symptoms
attributable to AF
Atrial Fibrillation
ablation (2a)
Patients with HF with
obstructive sleep apnea
CPAP (2a)
In asymptomatic patients with
cancer therapy-related cardiomyopathy
(EF < 50%)
ARB, ACEi, and
beta blockers (2a)
Abbreviations: ACEi indicates 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 to 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.
36
37. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Recommendations for Managing Comorbidities
in Patients With HF
Management of anemia or
iron deficiency
COR RECOMMENDATIONS
2a
In patients with HFrEF and iron deficiency with or without
anemia, intravenous iron replacement is reasonable to
improve functional status and QOL
3:
Harm
In patients with HF and anemia, erythropoietin-stimulating
agents should not be used to improve morbidity and mortality
Management of
hypertension
COR RECOMMENDATIONS
1
In patients with HFrEF and hypertension, uptitration of GDMT
to the maximally tolerated target dose is recommended.
Management of sleep disorders
COR RECOMMENDATIONS
2a
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
2a
In patients with HF and obstructive sleep apnea, continuous positive airway pressure may
be reasonable to improve sleep quality and decrease daytime sleepiness
3:
Harm
In patients with NYHA class II to IV HFrEF and central sleep apnea, adaptive servo-
ventilation causes harm
Management of diabetes
COR RECOMMENDATIONS
1
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
Abbreviations: GDMT indicates guideline directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; NYHA, New
York Heart Association; QOL, quality of life; and SGLT2i, sodium-glucose cotransporter-2 inhibitor.
37
38. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Recommendations for Management of AF in HF
COR RECOMMENDATIONS
1
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.
1
For patients with chronic HF with permanent-persistent-
paroxysmal AF, DOAC is recommended over warfarin in
eligible patients.
COR RECOMMENDATIONS
2a
For patients with HF and symptoms caused by AF, AF ablation
is reasonable to improve symptoms and QOL.
2a
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, AV nodal ablation with implantation of
a CRT device is reasonable.
2a
For patients with chronic HF and permanent-persistent-
paroxysmal AF, chronic anticoagulant therapy is reasonable for
men and women without additional risk factors.
Abbreviations: AF indicates atrial fibrillation; AV, atrioventricular; 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; CRT, cardiac resynchronization therapy; DOAC, direct oral anticoagulant; LVEF, left ventricular ejection fraction; and QOL, quality of life.
38
39. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Recommendations for Disparities and
Vulnerable Populations
COR RECOMMENDATIONS
1
In vulnerable patient populations at risk for health disparities, HF risk
assessments and multidisciplinary management strategies should
target both known risks for CVD and social determinants of health, as
a means toward elimination of disparate HF outcomes.
COR RECOMMENDATIONS
1
Evidence of health disparities should be monitored and addressed at
the clinical practice and the health care system levels.
Abbreviations: CVD indicates cardiovascular disease; and HF, heart failure.
39
40. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Recommendations for Cardio-Oncology
COR RECOMMENDATIONS
1
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.
2a
In asymptomatic patients with cancer therapy–related cardiomyopathy (EF <50%), ARB, ACEi, and BBs are
reasonable to prevent progression to HF and improve cardiac function.
2a
In patients with CV 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.
2a
In patients with CV 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.
2b
In patients at risk of cancer therapy–related cardiomyopathy, initiation of beta blockers and ACEi-ARB for
the primary prevention of drug-induced cardiomyopathy is of uncertain benefit.
2b
In patients being considered for potentially cardiotoxic therapies, serial measurement of cardiac
troponin might be reasonable for further risk stratification.
Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BB, beta blocker; CV, cardiovascular; EF, ejection fraction; and HF, heart failure.
40
41. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Recommendations for HF and Pregnancy
In women with a history
of HF or cardiomyopathy,
including previous
peripartum
cardiomyopathy, patient-
centered counseling
regarding contraception
and the risks of
cardiovascular
deterioration during
pregnancy should be
provided (1)
In women with acute HF
caused by peripartum
cardiomyopathy and LVEF
<30%, anticoagulation
may be reasonable at
diagnosis, until 6 to 8
weeks postpartum,
although the efficacy
and safety are uncertain
(2b)
In women with HF or
cardiomyopathy who are
pregnant or currently
planning for pregnancy,
ACEi, ARB, ARNi, MRA,
SGLT2i, ivabradine, and
vericiguat should not be
administered because of
significant risks of
fetal harm (3 – Harm)
Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HF, heart failure; LV, left
ventricular; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; and SGLT2i, T2i, sodium-glucose cotransporter-2 inhibitor.
41
42. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Performance Measures
• Hospitals performing well on medication-related
performance measures have better HF mortality rates.
• Hospitals participating in registries have better processes
of care and outcomes.
• Performance measures can be implemented in both
inpatient and outpatient settings.
COR RECOMMENDATIONS
1
1. Performance measures based on professionally developed
CPGs should be used with the goal of improving quality of care
for patients with HF.
2a
2. Participation in QI programs, including patient registries that
provide benchmark feedback on nationally endorsed, CPG–
based quality and PM can be beneficial in improving the quality
of care for patients with HF.
Abbreviations: CPG indicates clinical practice guideline; HF, heart failure; QI, quality improvement; and PM, performance measure.
42
43. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Goals of Care
COR RECOMMENDATIONS
1
1. For all patients with HF, palliative and supportive care-including high quality communication, conveyance of
prognosis, clarifying goals of care, shared decision-making, symptom management, and caregiver support-should be
provided to improve QOL and relieve suffering.
1
2. For patients with HF being considered for, or treated with, life-extending therapies, the option for discontinuation
should be anticipated and discussed through the continuum of care, including at the time of initiation, and reassessed
with changing medical conditions and shifting goals of care.
2a
3. For patients with HF, execution of advance care directives can be useful to improve documentation of treatment
preference, delivery of patient-centered care, and dying in preferred place.
2a
4. For patients with HF– particularly stage D HF patients being evaluated for advanced therapies, patients requiring
inotropic support or temporary mechanical support, patients experiencing uncontrolled symptoms, major medical
decisions, or multimorbidity, frailty, and cognitive impairment – specialist palliative care consultation can be useful to
improve QOL and relieve suffering.
2a
5. In patients with advanced HF with expected survival <6 months, timely referral to hospice can be useful to improve
QOL.
Abbreviations: HF indicates heart failure; and QOL, quality of life.
43
44. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Patient Reported Outcomes
COR RECOMMENDATIONS
2a
In patients with HF, standardized assessment of patient reported health status using a validated questionnaire can be useful to provide
incremental information for patient functional status, symptoms burden and prognosis.
Abbreviations: HF indicates heart failure; NYHA, New York Heart Association; and QOL, quality of life.
44
NYHA-I NYHA-II NYHA-III NYHA-IV
Health status encapsulates symptoms, functional status,
and health-related QOL.
No limitation of
physical activity
Comfortable at rest,
but less than
ordinary activity
results in symptoms
Unable to carry on
any physical activity
with symptoms
Comfortable at rest,
but ordinary activity
results in symptoms
Standardized
patient-reported
health status
questionnaires are
independently
associated with
clinical outcomes.
Understanding
symptom burden and
prognosis may
improve quality of
treatment decisions
and QOL.
Routine assessment can
identify high-risk patients
needing closer
monitoring or referral.
Patient-reported health
status assessment
increases the patient’s
role, which can motivate
initiation and up titration
of medical therapy.
45. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Evidence Gaps and Future Research Directions
Common issues that should be addressed in future clinical research
Definitions
• Cardiomyopathies
• Myocardial injury
• Ejection fraction
ranges
Screening
• Cost effectiveness
• Predict higher
risk patients based
on comorbidities
Diagnostics & monitoring
• Treatment based
on etiology
• Using biomarkers
to optimize therapy
Nonmedical strategies
• Dietary intervention
• Efficacy and
safety of
cardiac rehab
Medical therapies
• See complete list in Table 33
of guideline document
Device Management and
Advanced Therapies
• Timely selection for invasive
therapies
• Interventional
approach to
tachyarrhythmias
• Safety and efficacy
of nerve stimulation/
ablation
Clinical outcomes
• Impact of therapy in patient-
reported outcomes
• Addressing patient goals
according to disease
trajectory
• Generalization of therapy
not represented in trials
Systems of Care and
SDOH
• Multidisciplinary care
models
• Eliminating disparities
• Palliative care
Comorbidities
• Atrial fibrillation and Valvular
heart disease
• Comorbidities and obesity
• Nutritional management
• Guideline therapy institution in
patients
with chronic
kidney disease
Future/Novel strategies
• Pharmacologic therapies
• Device therapy
• Invasive or non-invasive
hemodynamics
• Telehealth and
wearable
technologies
45
Abbreviations: SDOH indicates social determinates of health.
46. Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
Acknowledgments
Many thanks to our Guideline Ambassadors who were guided by Dr. Elliott Antman in
developing this translational learning product in support of the 2022 AHA/ACC/HFSA
Guideline for Heart Failure.
Neha Chandra, MD
Maxwell D. Eder, MD
Rishin Handa, MD
Gini Jeyashanmugaraja, MD
Jennifer Maning, MD
Sean Patrick Murphy, MD
Taylor Saley, MD
Rey Sanchez, MD
Mohamed Suliman, MD
The American Heart Association requests this electronic slide deck be cited as follows:
Chandra, N., Eder, M. D., Handa, R., Jeyashanmugaraja, G., Maning, J., Medhane, F., Murphy, S. P., Saley, T., Sanchez, R.,
Suliman, M., Bezanson, J. L., & Antman, E. M. (2022). AHA Clinical Update; Adapted from: 2022 AHA/ACC/HFSA Guideline for
Heart Failure. [PowerPoint slides]. Retrieved from https://professional.heart.org/en/science-news.
46
