2022 Heart Failure Guideline Slide Set.pptx

2022 AHA/ACC/HFSA Guideline for the
Management of Heart Failure
Endorsed by the Heart Failure Society of America

Citation
This slide set is adapted from the 2022 AHA/ACC/HFSA Guidelinefor the
Managementof Heart Failure.Published onlineahead of print April 1, 2022,
availableat: Circulation.
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 AndJournal of the
American Collegeof Cardiology published onlineahead of print April 1, 2022. J
Am Coll Cardiol. https://www.jacc.org/doi/10.1016/j.jacc.2021.12.012

2022 Writing Committee Members*
Paul A. Heidenreich, MD, MS, FACC,FAHA, FHFSA, Chair†
Biykem Bozkurt,MD, PhD,FACC, FAHA, FHFSA, Vice Chair†
David Aguilar, MD, MSc, FAHA†
Larry A. Allen, MD, MHS, FACC, FAHA,
FHFSA†
Adrian F. Hernandez, MD, MHS‡
Prateeti Khazanie, MD, MPH, FHFSA†
Michelle M. Kittleson, MD, PhD†
Christopher S. Lee, PhD, RN, FAHA, FHFSA†
Mark S. Link, MD†
Joni J. Byun†
Monica M. Colvin, MD, MS, FAHA†
Anita Deswal, MD, MPH, FACC, FAHA,
FHFSA‡
Shannon M. Dunlay, MD, MS, FAHA,
FHFSA†
Linda R. Evers, JD†
Carmelo A. Milano, MD†
Lorraine C. Nnacheta, DrPH, MPH†
Alexander T. Sandhu, MD, MS†
Lynne Warner Stevenson, MD, FACC, FAHA,
FHFSA†
James C. Fang, MD, FACC, FAHA, FHFSA† Orly Vardeny, PharmD, MS, FAHA, FHFSA║
Savitri E. Fedson, MD, MA†
Gregg C. Fonarow, MD, FACC, FAHA,
FHFSA§
Amanda R. Vest, MBBS, MPH, FHFSA║
Clyde W. Yancy, MD, MSc, MACC, FAHA,
FHFSA†
Salim S. Hayek, MD, FACC†
*Writing committeemembers are required to recuse themselves from voting on sections to which their specificrelationships withindustrymay apply;see Appendix 1
for detailed information. † ACC/AHARepresentative. ‡ ACC/AHAJointCommittee on Clinical PracticeGuidelines Liaison.§Task Force PerformanceMeasures. ║
HFSA
Representative. #Former JointCommittee member; current member during the writing effort.

Top 10 Take-HomeMessages
2022 Guidelinefor the Management of Heart Failure

Top 10 Take Home Messages
1. Guideline-directed medical therapy (GDMT) for heart failure
(HF) with reduced ejection fraction (HFrEF) now includes 4
medication classes which include sodium-glucose
cotransporter-2 inhibitors (SGLT2i).
5

2. SGLT2 inhibitors have a 2a recommendation in heart failure
with mildly reduced ejection fraction (HFmrEF). Weaker
recommendations (2b) are made for ARNi, ACEi, ARB, MRA and
beta blockers in this population.
6

3. New recommendations for HFpEF are made for SGLT2
inhibitors (2a) , MRAs (2b) and ARNi (2b). Several prior
recommendations have been renewed including treatment of
hypertension (1), treatment of atrial fibrillation (2a), use of ARBs
(2b) avoidance of routine use of nitrates or phosphodiesterase-5
inhibitors (3-no Benefit).
7

4. Improved LVEF is used to refer to those patients with a
previous HFrEF who now have an LVEF > 40%. These patients
should continue their HFrEF treatment.
8

5. Value statements were created for select recommendations
where high-quality cost-effectiveness studies of the intervention
have been published.
9

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.
10

7. Evidence supporting increased filling pressures is important
for the diagnosis of HF if the LVEF is >40%. Evidence for increased
filling pressures can be obtained from non-invasive (e.g.,
natriuretic peptide, diastolic function on imaging) or invasive
testing (e.g., hemodynamic measurement).
11

8. Patients with advanced HF who wish to prolong survival
should be referred to a team specializing in HF. A heart failure
specialty team reviews HF management, assesses suitability for
advanced HF therapies and uses palliative care including
palliative inotropes where consistent with the patient’s goals of
care.
12

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 of “at risk” for HF for Stage A and Pre-HF
for Stage B.
13

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.
14

CLASS(STRENGTH)OFRECOMMENDATION LEVEL(QUALITY)OFEVIDENCE‡
LEVELA
CLASS1(STRONG)
Risk
Benefit>>>
• High-quality evidence‡ from more than 1 RCT
• Meta-analyses of high-quality RCTs
• Oneormore RCTs corroborated by high-quality registry studies
Suggested phrases for writingrecommendations:
• Isrecommended
• Isindicated/useful/effective/beneficial
• Should be performed/administered/other
• Comparative-Effectiveness Phrases†:
Table 2. Applying
American College of
Cardiology/American
Heart Association
Class of
LEVELB-R (Randomized)
Moderate-quality evidence‡ from 1 ormore RCTs
Meta-analyses of moderate-quality RCTs
− Treatment/strategy A is recommended/indicated in preference to •
•
treatment B
Treatment A should bechosen overtreatment B
−
LEVELB-NR (Nonrandomized)
CLASS2a(MODERATE)
Risk
Benefit>> • Moderate-quality evidence‡ from 1 ormore well-designed, well-executed
nonrandomized studies, observational studies, orregistry studies
• Meta-analyses of such studies
• Isreasonable
• Can beuseful/effective/beneficial
• Comparative-Effectiveness Phrases†:
LEVELC-LD (LimitedData)
−
−
Treatment/strategy A is probably recommended/indicated in
Recommendation
and Level of Evidence
to Clinical Strategies,
Interventions,
• Randomized or nonrandomized observational orregistry studies with
limitations ofdesign or execution
• Meta-analyses of such studies
• Physiological ormechanistic studies in human subjects
preference to treatment B
It is reasonable to choose treatment A overtreatment B
CLASS2b(Weak)
Risk
Benefit ≥
LEVELC-EO (ExpertOpinion)
• May/might bereasonable
• Consensus ofexpert opinion based on clinical experience.
• May/might beconsidered
•COR and LOE are determined independently (any COR may be paired with any LOE).
• Usefulness/effectiveness is unknown/unclear/uncertain ornot well-
established •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.
Treatments, or CLASS3:NoBenefit(MODERATE)
Risk
Benefit=
Diagnostic Testingin
Patient Care
•*The outcome or result of the intervention should be specified (an improved clinical
outcome or increased diagnostic accuracy or incremental prognostic information).
• Isnot recommended
• Isnot indicated/useful/effective/beneficial
• Should not beperformed/administered/other
•†For comparative-effectiveness recommendation (COR1 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.
(Updated May 2019)*
•‡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.
CLASS3:Harm(STRONG)
Benefit
Risk>
•COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level
of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled trial.
• Potentially harmful
• Causes harm
• Associated with excess morbidity/mortality
• Should not beperformed/administered/other
15

Table 3. Stages of HF
Stages Definition and Criteria
At risk for HF but without symptoms, structuralheart
disease, or cardiac biomarkers of stretch or injury (e.g.,
patients with hypertension, atherosclerotic CVD, diabetes,
metabolic syndrome and obesity, exposure to cardiotoxic
agents, genetic variant for cardiomyopathy,or positive
family history of cardiomyopathy).
StageA:At Risk for HF
17

Table 3. Stages of HF (con’t.)
Stage B: Pre-HF No symptoms or signs of HF and evidence of 1 of the following:
Structuralheart disease*
 Reduced left or right ventricular systolic function
o Reduced ejection fraction, reduced strain
 Ventricular hypertrophy
 Chamber enlargement
 Wall motion abnormalities
 Valvular heart disease
Evidence for increased filling pressures*
 By invasive hemodynamic measurements
 By noninvasive imaging suggesting elevated filling pressures (e.g.,
Doppler echocardiography)
Patients with riskfactors and
 Increased levels of BNPs* or
 Persistently elevated cardiactroponin
in the absence of competing diagnoses resulting in such biomarker
elevations such as acute coronary syndrome, CKD, pulmonary
embolus, or myopericarditis
18

Table 3. Stages of HF (con’t.)
Structural heart disease with current or previous symptoms of HF.
Stage C: Symptomatic HF
Stage D:Advanced HF
Marked HF symptoms that interfere with daily life and with
recurrent hospitalizations despite attempts to optimize GDMT.
BNP indicates B-typenatriureticpeptide;CKD,chronickidney
disease;GDMT,guideline-directedmedical therapy;HF,
heart failure; LV,left ventricular; and RV,rightventricular.
19

Figure 1.
ACC/AHA
Stages of
HF
The ACC/AHA
stages of HF are
shown.
ACC indicates
American College of
Cardiology; AHA,
American Heart
Association; CVD,
cardiovascular
disease; GDMT,
guideline-directed
medical therapy;
and HF, heart
failure.
20

Figure 2. Trajectory of Class C HF
The trajectory of stage C
HF is displayed. Patients
whose symptoms and
signs of HF are resolved
are still stage C and
should be treated
accordingly. If all HF
symptoms, signs, and
structural abnormalities
resolve, the patient is
considered to have HF in
remission.
*Full resolution of
structural and functional
cardiac abnormalities is
uncommon.
HF indicates heart
failure; and LV, left
ventricular.
21

Table 4. Classification of HF by LVEF
Type of HFAccording to LVEF Criteria
 LVEF ≤40%
HFrEF (HF with reduced EF)
HFimpEF (HF with improved
 Previous LVEF ≤40% and a follow-up measurement of LVEF >40%
EF)
 LVEF 41%–49%
HFmrEF (HF with mildly  Evidence of spontaneous or provokable increased LV filling pressures (e.g.,
elevated natriuretic peptide, noninvasive and invasive hemodynamic
measurement)
reduced EF)
 LVEF ≥50%
HFpEF (HF with preserved EF)  Evidence of spontaneous or provokable increased LV filling pressures (e.g.,
elevated natriuretic peptide, noninvasive and invasive hemodynamic
measurement)
HF indicates heart failure; LV, left ventricular; and LVEF, left ventricular ejection fraction.
22

Figure 3. Classification and Trajectories of HF Based on LVEF
23

Figure 4.
Diagnostic
Algorithm for HF
and EF-Based
Classification
The algorithm for a diagnosis of
HF and EF-based classification is
shown.
BNP indicates B-type natriuretic
peptide; ECG,
electrocardiogram; EF, ejection
fraction; HF, heart failure;
HFmrEF, heart failure with mildly
reduced ejection fraction;
HFpEF, heart failure with
preserved ejection fraction;
HFrEF, heart failure with reduced
ejection fraction; LVEF, left
ventricular ejection fraction; LV,
left ventricular; NP, natriuretic
peptides; and NT-proBNP, N-
terminal pro-B type natriuretic
peptide.
24

Initial and Serial Evaluation
25

Clinical Assessment: History and Physical Examination
RecommendationsforClinicalAssessment: History and PhysicalExamination
Referenced studies that support the recommendations are summarized in the Online Data Supplements.
COR
1
LOE Recommendations
1. In patients with HF, vital signs and evidence of clinical congestion should be
assessed at each encounter to guide overall management,including adjustmentof
diuretics and othermedications.
B-NR
2. In patients with symptomatic HF, clinical factorsindicating the presence of
advancedHFshould be sought via the history and physical examination.
1 B-NR
26

Clinical Assessment: History and Physical
Examination (con’t.)
3. In patients with cardiomyopathy, a 3-generation family history should be obtainedor
1
1
B-NR
B-NR
updated when assessing the cause of the cardiomyopathyto identify possible
inherited disease.
4. In patients presenting with HF, a thorough history and physical examination should
direct diagnostic strategies to uncover specific causes that maywarrantdisease-
specific management.
5. In patients presenting with HF, a thorough history and physical examination should
be obtained and performed to identifycardiac and noncardiac disorders, lifestyle
and behavioralfactors, and social determinants of health that might cause or
accelerate the development orprogression of HF.
1 C-EO
27

Table 5. Other Potential Nonischemic Causes of HF
Cause Reference
(23-25)
(26)
Chemotherapy and other cardiotoxic medications
Rheumatologic or autoimmune
Endocrine or metabolic (thyroid, acromegaly, pheochromocytoma, diabetes, obesity)
Familial cardiomyopathy or inherited and genetic heart disease
Heart rhythm–related (e.g., tachycardia-mediated, PVCs, RV pacing)
Hypertension
(27-31)
(32)
(33)
(34)
Infiltrative cardiac disease (e.g., amyloid, sarcoid, hemochromatosis)
Myocarditis (infectious, toxin or medication, immunological, hypersensitivity)
Peripartum cardiomyopathy
(21, 35, 36)
(37, 38)
(39)
HF indicates heart
failure; PVC, premature Stress cardiomyopathy (Takotsubo)
(40, 41)
(42-44)
ventricular contraction;
Substance abuse (e.g., alcohol, cocaine, methamphetamine)
and RV, right ventricular.
28

Initial Laboratory and
Electrocardiographic Testing
RecommendationsforInitial Laboratory and Electrocardiographic Testing
COR
1
LOE Recommendations
1. Forpatientspresenting with HF, the specific cause of HFshould be explored using
B-NR
additionallaboratory testing for appropriate management.
2. Forpatientswho are diagnosedwith HF, laboratory evaluation should include
complete blood count, urinalysis, serum electrolytes, blood urea nitrogen,serum
creatinine, glucose, lipid profile, liver function tests, iron studies, and thyroid-
1
1
C-EO
C-EO
stimulating hormone to optimize management.
3. Forall patients presenting with HF, a 12-lead ECG should be performed at the initial
encounterto optimize management.
29

Use of Biomarkers for Prevention, Initial
Diagnosis, and Risk Stratification
4.2. RecommendationsforUse of Biomarkers for Prevention, Initial Diagnosis, and Risk Stratification
COR
1
LOE
A
Recommendations
1. In patients presenting with dyspnea, measurement of B-type natriuretic peptide
(BNP) orN-terminalprohormone of B-type natriuretic peptide (NT-proBNP) is
usefulto support a diagnosis or exclusion of HF.
2. In patients with chronic HF,measurements of BNPor NT-proBNPlevels are
recommended for risk stratification.
1 A
30

Use of Biomarkers for Prevention, Initial
Diagnosis, and Risk Stratification (con’t.)
3. In patients hospitalized for HF, measurement of BNPorNT-proBNPlevels at
1 A
admission is recommended to establish prognosis.
4. In patients at risk of developing HF, BNPorNT-proBNP–based screening followed by
team-based care, including a cardiovascularspecialist, can be usefulto prevent the
B-R
2a
developmentof LV dysfunction ornew-onset HF.
5. In patients hospitalized for HF, a predischarge BNPorNT-proBNPlevel can be useful
2a B-NR
to inform the trajectory of the patientand establish a postdischarge prognosis
31

Table 6. Selected Potential Causes of Elevated
Natriuretic Peptide Levels
Cardiac
HF, including RV HF syndromes
ACS
Heart muscle disease, including LVH
VHD
Pericardial disease
AF
Myocarditis
Cardiac surgery
Cardioversion
Toxic-metabolic myocardial insults,
including cancer chemotherapy
32

Table 6. Selected Potential Causes of Elevated
Natriuretic Peptide Levels (50-53) (con’t.)
Noncardiac
Advancing age
Anemia
Renal failure
Pulmonary: Obstructive sleep apnea, severe
pneumonia
Pulmonary embolism, pulmonary arterial
hypertension
Critical illness
Bacterial sepsis
Severe burns
ACS indicates acute coronary
syndromes; AF, atrial fibrillation; HF,
heart failure; LVH, leftventricular
hypertrophy; RV, right ventricular; and
VHD, valvular heart disease.
33

Genetic Evaluation and Testing
Recommendationsfor Genetic Evaluation and Testing
Recommendations
COR
1
LOE
1. In first-degree relatives of selected patients with genetic orinherited cardiomyopathies,
genetic screening and counseling are recommended to detect cardiac disease and prompt
B-NR
consideration of treatments to decrease HFprogression and sudden death.
2. In select patients with nonischemic cardiomyopathy,referralfor genetic counseling and
2a B-NR testing is reasonable to identify conditions that could guide treatment for patients and family
members.
34

Table 7. Examples of Factors Implicating Possible
Genetic Cardiomyopathy
Phenotypic Category Patient orFamily Member Phenotypic Finding* Ask SpecificallyAbout Family Members*
With
Cardiac morphology Marked L
V hypertrophy Any mention of cardiomyopathy, enlarged
L
V noncompaction or weak heart, HF.
Right ventricular thinningor fatty replacement on
imaging or biopsy
Document even if attributed to other causes,
such as alcohol or peripartum
cardiomyopathy
Findings on 12-lead ECG Abnormal high or low voltage or conduction, and
repolarization, altered RV forces
Long QT or Brugada syndrome
35

Table 7. Examples of Factors Implicating Possible
Genetic Cardiomyopathy(con’t.)
ICD
Dysrhythmias Frequent NSVT or very frequent PVCs Recurrent syncope
Sudden death attributed to “massive
heart attack” without known CAD
Sustained ventricular tachycardia or fibrillation
Unexplained fatal event such as
drowning or single-vehicle crash
Early onsetAF “Lone” AF before age 65 years
Early onset conduction disease Pacemaker before age 65 years
Any known skeletal muscle disease,
including mention of Duchenne and
Becker’s, Emory-Dreifuss limb-girdle
dystrophy
Extracardiac features • Skeletal myopathy
• Neuropathy
• Cutaneous stigmata
• Other possible manifestations of systemic
syndromes
AF indicates atrial
fibrillation; CAD,
coronary artery
disease; LV, left
ventricular; NSVT,
nonsustained
ventricular
tachycardia; PVC,
premature
ventricular
Systemic syndromes:
 Dysmorphic features
 Mental retardation
 Congenital deafness
 Neurofibromatosis
 Renal failure with neuropathy
contraction; and
RV, right
ventricular.
36

Evaluation With Cardiac Imaging
RecommendationsforEvaluationWith Cardiac Imaging
COR LOE Recommendations
1. In patients with suspectedornew-onset HF,orthose presenting with acute
decompensatedHF, a chest x-ray should be performed to assess heart size and
pulmonarycongestion and to detect alternative cardiac,pulmonary, andother
diseases that may cause orcontribute to the patient’s symptoms.
1 C-LD
2. In patients with suspectedornewly diagnosed HF, transthoracic
echocardiography (TTE) should be performed during initial evaluation to
assess cardiac structure and function.
1 C-LD
37

Evaluation With Cardiac Imaging (con’t.)
3. In patients with HFwho have had a significant clinical change, orwho have received
GDMT andare being consideredfor invasive proceduresor device therapy, repeat
C-LD
1
measurement of EF, degree of structuralremodeling, and valvular function are useful
to inform therapeutic interventions.
4. In patients for whomechocardiography is inadequate, alternative imaging (e.g.,
cardiac magnetic resonance [CMR], cardiac computedtomography [CT], radionuclide
imaging) is recommended forassessment of LVEF.
1 C-LD
B-NR
5. In patients with HForcardiomyopathy,CMR can be usefulfordiagnosis or
management.
2a
38

Evaluation With Cardiac Imaging (con’t.)
6. In patients with HF, an evaluation for possible ischemic heart disease can be usefulto identify
B-NR
2a
2b
the cause and guide management.
7. In patients with HFand CAD who are candidates for coronary revascularization, noninvasive
stress imaging (stress echocardiography, single-photonemission CT [SPECT], CMR, or
positron emission tomography [PET]) maybe considered for detection of myocardialischemia
B-NR
C-EO
to help guide coronary revascularization.
8. In patients with HFin the absence of: 1) clinical status change,2) treatment interventionsthat
might have had a significant effect on cardiac function, or3) candidacyforinvasive
procedures ordevice therapy, routine repeat assessment of LVfunction is not indicated.
3: No Benefit
39

Invasive Evaluation
RecommendationsforInvasive Evaluation
1. In patients with HF, endomyocardialbiopsy may be usefulwhen a specific
diagnosis is suspected that would influence therapy.
2a B-NR
40

Invasive Evaluation (con’t.)
2. In selected patients with HFwith persistent orworsening symptoms,
signs, diagnostic parameters, and in whom hemodynamics are
uncertain, invasive hemodynamic monitoring can be usefulto guide
2a C-EO
management.
3. In patients with HF, routine use of invasive hemodynamic monitoring is
3: No
B-R
not recommended.
Benefit
4. Forpatientsundergoing routine evaluation of HF, endomyocardial
biopsy should not be performed because of the risk of complications.
3: Harm C-LD
41

Wearables and Remote Monitoring (Including
Telemonitoringand Device Monitoring)
Recommendation forWearables and Remote Monitoring (Including Telemonitoring andDevice Monitoring)
Referenced studies that support the recommendation are summarized in the Online Data Supplements.
COR
2b
LOE
B-R
Recommendation
1. In selected adult patientswith NYHAclass III HFand history of a HFhospitalization in the past
year orelevated natriuretic peptide levels, on maximally tolerated stable dosesof GDMTwith
optimaldevice therapy,the usefulness of wireless monitoring of PApressure byan implanted
hemodynamic monitorto reduce the risk of subsequent HFhospitalizations is uncertain.
2. In patients with NYHAclass III HFwith a HFhospitalization within the previous year, wireless
Value Statement:
monitoring of the PApressure byan implanted hemodynamic monitorprovidesuncertain value .
Uncertain Value (B-NR)
42

Exercise and Functional Capacity Testing
Recommendationsfor Exercise and FunctionalCapacityTesting
COR
1
LOE Recommendations
1. In patients with HF, assessment and documentation of NYHAfunctionalclassification are
C-LD
recommended to determine eligibility fortreatments.
2. In selected ambulatory patients with HF, cardiopulmonaryexercise testing (CPET)is
1 C-LD recommended to determine appropriateness of advanced treatments (e.g., LV
AD, heart
transplant).
3. In ambulatorypatients with HF, performing a CPETor6- minute walk test is reasonable to
2a
2a
C-LD
C-LD
assess functionalcapacity.
4. In ambulatory patients with unexplained dyspnea,CPET is reasonable to evaluate the cause
of dyspnea.
43

Initial and Serial Evaluation: Clinical
Assessment: HF RiskScoring
Recommendation for Initial and Serial Evaluation: ClinicalAssessment: HFRisk Scoring
COR
2a
LOE Recommendation
1. In ambulatory orhospitalized patients with HF, validated multivariable risk
scores can be usefulto estimate subsequentrisk of mortality.
B-NR
44

Table 8. Selected Multivariable Risk Scores to
Predict Outcome in HF
Risk Score
Chronic HF
All Patients With Chronic HF
Seattle Heart Failure Model
Year Published
2006
https://depts.washington.edu/shfm/?width=1440&h
eight=900
Heart Failure Survival Score 1997
2013
MAGGIC
http://www.heartfailurerisk.org/
CHARM Risk Score
CORONARisk Score
Specific to Chronic HFrEF
2006
2009
PARADIGM-HF
HF-ACTION
GUIDE-IT
2020
2012
2019
45

Table 8. Selected Multivariable Risk Scores to
Predict Outcome in HF (con’t.)
Specific to Chronic HFpEF
I-PRESERVE Score
TOPCAT
(9) 2011
2020
ADHERE indicates Acute
(10)
Decompensated Heart Failure
National Registry; AHA, indicates
American Heart Association; ARIC,
AtherosclerosisRisk in Communities;
Acutely Decompensated HF
ADHERE Classification and (11) 2005
CHARM, Candesartan in Heart failure- Regression Tree (CART) Model
Assessment of Reduction in Mortality
and morbidity; CORONA, Controlled
Rosuvastatin Multinational Trial in
Heart Failure; EFFECT, Enhanced
AHA Get With The Guidelines (12) 2010, 2021
Feedback for Effective Cardiac
Treatment; ESCAPE, Evaluation Study Score https://www.mdcalc.com/gwtg-
heart-failure-risk-score (17)
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-
EFFECT Risk Score (13) 2003, 2016
2010
ACTION, Heart Failure: A Controlled
Trial Investigating Outcomesof
ExerciseTraining 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; TOPCAT,
Treatment of Preserved Cardiac
Function Heart Failure with an
http://www.ccort.ca/Research/CHF
RiskModel.aspx (18)
ESCAPE Risk Model and
Discharge Score
(14)
Aldosterone Antagonist trial.
46

Stage A (Patients at Risk for HF)
47

Patients at Risk for HF (Stage A: Primary
Prevention)
Recommendationsfor Patients at Risk forHF(StageA: Primary Prevention)
COR
1
LOE
A
Recommendations
1. In patients with hypertension,blood pressure should be controlled in accordance with
GDMT for hypertension to prevent symptomatic HF.
2. In patients with type 2 diabetesand eitherestablished CVD orat high cardiovascular
risk, SGLT2ishould be used to prevent hospitalizations forHF.
1 A
48

Patients at Risk for HF (Stage A: Primary
Prevention) (con’t.)
3. In the generalpopulation, healthy lifestyle habits such as regularphysicalactivity,
1 B-NR maintaining normalweight, healthydietary patterns,and avoiding smoking are
helpfulto reduce future risk of HF.
4. Forpatientsat risk of developing HF, natriuretic peptide biomarker–based
screening followed byteam-based care, including a cardiovascular specialist
optimizing GDMT, can be usefulto prevent the development of LVdysfunction
2a
2a
B-R
(systolic or diastolic) ornew-onsetHF.
5. In the generalpopulation, validated multivariable risk scores can be usefulto
B-NR
estimate subsequentrisk of incident HF.
49

Figure 5.
Recommendations
(Class 1 and 2a) for
Patients at Risk of
HF (Stage A) and
Those With Pre-HF
(Stage B)
Colors correspond to COR in Table 2.
Class 1 and Class 2a recommendations for
patients at risk for HF (stage A) and those with
pre-HF (stage B) are shown. Management
strategies implemented in patients at risk for
HF (stage A) should be continued though
stage B.
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.
50

Table 9. Selected Multivariable Risk Scores to Predict
Development of Incident HF
Risk Score Year Published
1999
Framingham Heart Failure Risk Score
Health ABC Heart Failure Score
ARIC Risk Score
2008
2012
2019
PCP-HF
HF indicates heart failure; and PCP-HF, Pooled Cohort Equations to Prevent HF.
51

Stage B (Patients With Pre-HF)
52

Management of Stage B: Preventing the
Syndrome of Clinical HF in Patients With Pre-HF
Recommendationsfor Managementof Stage B: Preventing the Syndrome of Clinical HFin PatientsWith Pre-HF
COR
1
LOE Recommendations
1. In patie nts with LVEF ≤40%,ACEi should be used to prevent sympto ma tic HF and reduce
A
mortality.
2. In patients with a recent or remote history of MI orACS, statins should be used to prevent
1
1
A
symptomatic HFand adverse cardiovascularevents.
3. In patients with a recent orremote history of MI oracute coronary syndrome (ACS) andLVEF
B-R
≤40%, e vide nce-based beta blockers should be used to reduce mo rt
alit y.
53

Management of StageB: Preventing the
Syndrome of Clinical HF in Patients With
Pre-HF (con’t.)
4. In patients with a recent or remote history of MI orACS, statins should be used to prevent
1
1
B-R
symptomatic HFand adverse cardiovascularevents.
5. In patients who are at least 40 days post-MI with LVEF ≤30% and NYHA class I symptoms w
hile
B-R receiving GDMTand have reasonable expectation of meaningfulsurvival for >1 year, an ICD is
recommended for primaryprevention of sudden cardiac death(SCD) to reduce totalmortality.
6. In patie nts with LVEF ≤40%, beta blockers should be used to prevent symptomatic HF.
1 C-LD
B-R
7. In patients with LVEF <50%, thiazolidinediones should not be used because they increase the risk
of
3: Harm
HF, including hospitalizations.
8. In patients with LVEF <50%, nondihydropyridine calcium channelblockers with negative inotropic
3: Harm C-LD
effects maybe harmful.
54

Table 10. Other ACC/AHA Clinical Practice Guidelines
Addressing Patients With Stage B HF
Consideration Reference
Patients with an acute MI who have not developed HF symptoms 2013 ACCF/AHA Guideline for the Management of ST-
treated in accordance with GDMT Elevation Myocardial Infarction
2014 AHA/ACC Guideline for the Management of Patients With
Non–ST-Elevation Acute Coronary Syndromes
Coronary revascularization for patients without symptoms of HF 2015 ACC/AHA/SCAI Focused Update on Primary
in accordance with GDMT Percutaneous Coronary Intervention for Patients With ST-
Elevation Myocardial Infarction: An Update of the 2011
ACCF/AHA/SCAI Guideline for Percutaneous Coronary
Intervention and the 2013ACCF/AHA Guideline for the
Management of ST-Elevation Myocardial Infarction (This
guideline has been replaced by Lawton, 2021.)
2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the
Guideline for the Diagnosis and Management of Patients With
Stable Ischemic Heart Disease
2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft
Surgery (This guideline has been replaced by Lawton, 2021.)
55

Table 10. Other ACC/AHA Clinical Practice Guidelines
Addressing Patients With Stage B HF (con’t.)
V
alve replacement or repair for patients with 2020 ACC/AHA Guideline for the Management of
hemodynamically significant valvular stenosis or Patients With Valvular Heart Disease
regurgitation and no symptoms of HF in accordance
AATS indicates American
Association for Thoracic
Surgery; ACC, American
College of Cardiology;
ACCF, American College
of Cardiology
with GDMT
Foundation; AHA,
American Heart
Association; GDMT,
guideline-directed
medical therapy; HF,
heart failure; MI,
myocardial infarction;
PCNA, Preventive
Patients with congenital heart disease that may increase 2018 AHA/ACC Guideline for the Management of
Cardiovascular Nurses
Association; SCAI,
Society for
the risk for the development of HF Adults With Congenital Heart Disease
Cardiovascular
Angiography and
Interventions; and STS,
The Society of Thoracic
Surgeons.
56

Nonpharmacological Interventions: Self-
Care Support in HF
Recommendationsfor NonpharmacologicalInterventions: Self-Care Support in HF
COR LOE
A
Recommendations
1. Patientswith HFshould receive care from multidisciplinary teams to
facilitate the implementation of GDMT, address potentialbarriers to
self-care, reduce the risk of subsequent rehospitalization for HF, and
improve survival.
1
58

Nonpharmacological Interventions: Self-
Care Support in HF (con’t.)
2. Patients with HFshould receive specific education and supportto facilitate
1 B-R
HFself-care in a multidisciplinary manner.
3. In patients with HF, vaccinating against respiratoryillnesses is reasonable to
2a B-NR
reduce mortality.
4. In adults with HF, screening for depression, socialisolation, frailty, and low
health literacy as risk factors for poorself-care is reasonable to improve
2a B-NR
management.
59

Table 11. Potential Barriers to Effective HF Self-Care
and Example Interventions
Potential Barrier
MedicalBarriers
Cognitive impairment
Example Screening Tools Example Interventions
Mini-Cog Home health aide
Mini-Mental State Examination (MMSE)
Montreal CognitiveAssessment (MoCA)
Home meal deliveries
Adult day care
Geriatric psychiatry referral
Memory care support groups
Psychotherapy
Depression Hamilton Depression RatingScale (HAM-D)
Beck Depression Inventory-II (BDI-II)
Patient Health Questionnaire-9 (PHQ-9)
Selective serotonin reuptake inhibitors
Nurse-led support
60

and Example Interventions (con’t.)
Substance use disorders Tobacco,Alcohol, Prescription medication, and Referral to social work services and
other Substance use (TAPS) community support partners
Referral for addiction psychiatry consultation
Cardiac rehabilitation
Frailty Fried frailty phenotype
Registered dietitian nutritionist evaluation for
malnutrition
Social Barriers
Financial burden of HF treatments COmprehensive Score for financial Toxicity– PharmD referral to review prescription
FunctionalAssessment of Chronic Illness
Therapy (COST-FACIT)
assistance eligibilities
61

Food insecurity Hunger Vital Sign, 2 items
U.S. Household Food Security Survey
Module, 6 items
Determine eligibility for the Supplemental
NutritionAssistance Program (SNAP)
Connect patients with community partners
such as food pantries/food banks
Home meal deliveries
Registered dietitian nutritionistevaluation for
potential malnutrition
Homelessness or housing insecurity Homelessness Screening Clinical Reminder
(HSCR)
Referral to local housing services
Connect patients with community housing
partners
62

Intimate partner violence or elder
abuse
Humiliation, Afraid, Rape, Kick (HARK)
questionnaire
Referral to social work services and
community support partners
Partner Violence Screen (PVS)
WomanAbuse ScreeningTool (WAST)
Limited English proficiency or other Routinely inquire in which language the patient Access to interpreter services covering a wide
language barriers is most comfortable conversing range of languages, ideally in person or,
alternatively, via video platform
Printed educational materials in a range of
appropriate languages
63

Low health literacy ShortAssessment of Health Literacy (SAHL) Agency for Healthcare Research and Quality
Rapid Estimate ofAdult Literacy in Medicine– (AHRQ) Health Literacy Universal
Short Form (REALM-SF) Precautions Toolkit
Brief Health Literacy Screen (BHLS), 3 items Written education tools provided at sixth
grade reading level or below
Graphic educational documents
Social isolation or low social support Patient-Reported Outcomes Measurement
Information System (PROMIS) Social Isolation Support group referral
Short Form
Determine eligibility for home care services
64

Transport limitations No validated tools currently available. Referral to social work services
Determine eligibility for insurance or state-
based transportation,or reduced-cost public
transportation
Maximize opportunities for telehealth visits
and remote monitoring
HF indicates heart failure.
65

Dietary Sodium Restriction
Recommendation for Dietary Sodium Restriction
Recommendation
COR
2a
LOE
1. For patientswith stage C HF, avoiding excessive sodium intake is reasonable
to reduce congestive symptoms.
C-LD
66

Management of StageC HF: Activity, Exercise
Prescription,and Cardiac Rehabilitation
RecommendationsforManagement of Stage C HF:Activity, Exercise Prescription, and Cardiac
Rehabilitation
COR
1
LOE
A
Recommendations
1. For patientswith HFwho are able to participate, exercise training (or regular
physical activity) is recommended to improve functionalstatus, exercise
performance, and QOL.
2. In patients with HF, a cardiac rehabilitation program can be usefulto improve
2a B-NR functionalcapacity, exercise tolerance, and health-related QOL.
67

Diuretics and Decongestion Strategies in
Patients With HF
Recommendationsfor Diuretics and Decongestion Strategies in PatientsWith HF
COR
1
LOE Recommendations
1. In patients with HFwho have fluid retention,diuretics are recommendedto relieve
B-NR
congestion, improve symptoms, and prevent worsening HF.
2. For patientswith HFand congestive symptoms, addition of a thiazide (e.g., metolazone)
to treatment with a loop diuretic should be reserved for patients who do not respond to
moderate- orhigh-dose loop diuretics to minimize electrolyte abnormalities.
1 B-NR
68

Table 12. Commonly Used Oral Diuretics in
Treatment of Congestion for Chronic HF
Drug Initial Daily Maximum Duration of
Action
Dose Total Daily
Dose
Loop diuretics
Bumetanide 0.5–1.0 mg 10 mg 4–6 h
once or twice
Furosemide 20–40 mg 600 mg 6–8 h
once or twice
Torsemide 10–20 mg 200 mg 12–16 h
once
69

Table 12. Commonly Used Oral Diuretics in
Treatment of Congestion for Chronic HF (con’t.)
Thiazide diuretics
Chlorthiazide 250–500 mg 1000 mg
100 mg
6–12 h
24–72 h
6–12 h
once or twice
Chlorthalidone 12.5–25 mg
once
Hydrochloro- 25 mg once or 200 mg
thiazide twice
Indapamide
Metolazone
2.5 mg once
2.5 mg once
5 mg 36 h
20 mg 12–24 h
HF indicates heart failure.
70

Renin-Angiotensin System Inhibition With ACEi
or ARB or ARNi
Recommendationsfor Renin-Angiotensin System Inhibition WithACEi orARB orARNi
COR
1
LOE
A
Recommendations
1. In patients with HFrEFand NYHAclass II to III symptoms, the use ofARNiis
recommended to reduce morbidity and mortality.
2. In patients with previous orcurrent symptomsof chronic HFrEF, the use of
ACEi is beneficial to reduce morbidity and mortality when the use ofARNiis
not feasible.
1 A
71

or ARB or ARNi (con’t.)
3. In patients with previous orcurrent symptomsof chronic HFrEFwho are intolerant
toACEi because of coughor angioedemaand when the use ofARNi is not feasible,
1 A
the use ofARB is recommended to reduce morbidity and mortality.
4. In patients with previous orcurrent symptomsof chronic HFrEF, in whomARNiis
not feasible, treatment with anACEi orARB provides high economic value.
Value Statement: High
Value (A)
5. In patients with chronic symptomatic HFrEFNYHAclass II or III who tolerate an
ACEi orARB, replacement byanARNi is recommended to furtherreduce
morbidity and mortality.
1 B-R
72

or ARB or ARNi (con’t.)
6. In patients with chronic symptomatic HFrEF, treatment with anARNi instead of
Value (A)
anACEi provides high economic value.
7. ARNi should not be administered concomitantly withACEi orwithin 36 hours of
the last dose of anACEi.
3: Harm B-R
8. ARNi should not be administered to patients with any history of angioedema.
3: Harm
3: Harm
C-LD
C-LD
9. ACEi should not be administered to patients with any history of angioedema.
73

Beta Blockers
Recommendation for Beta Blockers
COR
1
LOE Recommendation
1. In patients with HFrEF,with current orprevious symptoms,use of 1 of the 3 beta
blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, sustained-release
metoprololsuccinate) is recommended to reduce mortalityand hospitalizations.
A
2. In patients with HFrEF,with current orprevious symptoms,beta-blocker therapy
provides high economic value.
Value Statement:
High Value (A)
74

MineralocorticoidReceptor Antagonists (MRAs)
RecommendationsforMineralocorticoid ReceptorAntagonists (MRAs)
1. In patients with HFrEFand NYHAclass II-IVsymptoms, an
MRA(spironolactone oreplerenone) is recommended to reduce morbidity and
1 A mortality, if eGFR is >30 mL/min/1.73 m2 and serum potassium is <5.0 mEq/L. Careful
monitoring of potassium, renalfunction, and diuretic dosing should be performed at initiation
and closely monitored thereafter to minimize risk of hyperkalemia and renalinsufficiency.
2. In patients with HFrEFand NYHAclass II-IVsymptoms, MRAtherapy provides high
Value (A) economic value.
3. In patients taking MRAwhose serum potassium cannot be maintainedat <5.5 mEq/L, MRA
3: Harm B-NR
should be discontinued to avoid life-threatening hyperkalemia.
75

Sodium-Glucose Cotransporter2 Inhibitors
Recommendation forSGLT2i
COR LOE Recommendation
1. In patients with symptomatic chronic HFrEF, SGLT2iare recommended to
reduce hospitalization for HFand cardiovascular mortality, irrespective of the
presence of type 2 diabetes.
1 A
2. In patients with symptomatic chronic HFrEF, SGLT2itherapy provides
intermediate economic value.
Value Statement:
Intermediate Value
(A)
76

Hydralazine and Isosorbide Dinitrate
Recommendationsfor Hydralazine and Isosorbide Dinitrate
1. Forpatientsself-identified asAfricanAmerican with NYHAclass III-IVHFrEF
who are receiving optimal medical therapy,the combination of hydralazine and
isosorbide dinitrate is recommended to improve symptoms and reduce morbidity
and mortality.
1 A
77

Hydralazine and Isosorbide Dinitrate
(con’t.)
2. For patientsself-identified asAfricanAmerican with NYHAclass III-IVHFrEFwho are
Value Statement:
High Value (B-NR)
receiving optimal medical therapy withACEi orARB, beta blockers,and MRA, the
combination of hydralazine and isosorbide dinitrate provides high economic value.
3. In patients with current orprevious symptomatic HFrEFwho cannot be given first-line
agents, such asARNi,ACEi, orARB, because of drug intolerance orrenalinsufficiency, a
combination of hydralazine and isosorbide dinitrate might be considered to reduce
morbidity and mortality.
2b C-LD
78

Figure 6.
Treatment of
HFrEF Stages
C and D
Treatment recommendations for
patients with HFrEF are displayed.
Step 1 medications may be started
simultaneously at initial (low)
doses recommended for HFrEF.
Alternatively, these medications
may be started sequentially, with
sequence guided by clinical or
other factors, without need to
achieve target dosing before
initiating next medication.
Medication doses should be
increased to target as tolerated.
79

Other Drug Treatment
Recommendationsfor OtherDrug Treatment
COR
2b
LOE
B-R
Recommendations
1. In patients with HFclass II to IV symptoms, omega-3 polyunsaturatedfatty
acid (PUFA) supplementation maybe reasonable to use as adjunctive therapy
to reduce mortality and cardiovascularhospitalizations.
80

Other Drug Treatment (con’t.)
2. In patie nts with HF who e xpe rie nce hype rkale mia (serum potassium level ≥5.5
mEq/L)
w hile taking a re nin-angiotensin-aldosterone system inhibito r ( RAASi), the e
ffectiveness
of potassium binde rs (patiromer, sodium zirc onium cyclosilicate) to improve outcomes
by fac ilitating c ontinuation of RAASi therapy is unc e rtain.
2b B-R
B-R
3. In patients with chronic HFrEFwithouta specific indication (e.g., venous
thromboembolism [VTE],AF, a previous thromboembolic event, ora cardioembolic
source), anticoagulation is not recommended.
3: No
Benefit
81

Drugs of Unproven Value or That May
Worsen HF
Recommendationsfor Drugs of Unproven Value orDrugs ThatMay Worsen HF
COR
3: No
LOE
A
Recommendations
1. In patients with HFrEF,dihydropyridine calcium channel-blocking drugs are not
recommended treatment for HF.
Benefit
3: No 2. In patients with HFrEF,vitamins, nutritional supplements, and hormonaltherapy are
not recommended otherthan to correct specific deficiencies.
3. In patients with HFrEF,nondihydropyridine calcium channel-blocking drugs are not
recommended.
B-R
A
Benefit
3: Harm
82

Drugs of Unproven Value or That May
Worsen HF (con’t.)
4. In patients with HFrEF,class IC antiarrhythmic medicationsand dronedaronemay
3: Harm
3: Harm
A
increase the risk of mortality.
5. In patients with HFrEF,thiazolidinediones increase the risk of worsening HF
A
symptoms and hospitalizations.
6. In patients with type 2 diabetesand high cardiovascular risk, the dipeptidyl
peptidase-4(DPP-4)inhibitors saxagliptin and alogliptin increase the risk of HF
hospitalization and should be avoided in patients with HF.
3: Harm
3: Harm
B-R
7. In patients with HFrEF,NSAIDs worsenHFsymptomsand should be avoided or
withdrawn whenever possible.
B-NR
83

Table 13. Selected Prescription MedicationsThat May
Cause or Exacerbate HF
Drug orTherapeutic Class AssociatedWith HF Magnitude of HF
Induction or
Levelof Evidence for PossibleMechanism(s)
HFInduction or
Onset
Causes Direct
MyocardialToxicity
Exacerbates
Underlying
Myocardial
Dysfunction
Precipitation Precipitation
COX, nonselective inhibitors X
X
Major B
B
Prostaglandin inhibition Immediate
(NSAIDs) leading to sodium and
water retention,
COX, selective inhibitors Major
(COX-2 inhibitors) increased systemic
vascular resistance, and
blunted responseto
diuretics
Thiazolidinediones X Major A Possible calcium
channelblockade
Intermediate
84

Table 13. Selected Prescription MedicationsThat May Cause
or Exacerbate HF (con’t.)
Saxagliptin
Alogliptin
X
X
X
X
Major
Major
Major
Major
A
A
A
B
Unknown Intermediateto delayed
Flecainide Negative inotrope, Immediateto intermediate
Disopyramide proarrhythmic effects
Proarrhythmic Immediateto intermediate
Sotalol X Major A
properties, beta
blockade
Dronedarone
Alpha-1 blockers
Doxazosin
X
X
Major A
B
Negative inotrope
Moderate Beta-1-receptor
stimulation with
increases in renin
Intermediateto delayed
COX indicates
cyclo-
oxygenase;
and HF, heart
failure.
and aldosterone
Diltiazem
Verapamil
Nifedipine
X
X
X
Major B
B
C
Negative inotrope Immediateto intermediate
Immediate to intermediate
Major
Moderate Negative inotrope
85

GDMT Dosing: Sequencing and Uptitration
RecommendationsforGDMT Dosing:Sequencing and Uptitration
1. In patients with HFrEF,titration of guideline-directedmedication dosing to
achieve target doses showedto be efficaciousin RCTs is recommended, to reduce
cardiovascular mortality and HFhospitalizations, unless not well tolerated.
1 A
2. In patients with HFrEF,titration and optimization of guideline-directed
medications as frequentlyas every 1 to 2 weeks depending on the patient’s
symptoms, vital signs, and laboratory findings can be usefulto optimize
management.
2a C-EO
86

Table 14. Drugs Commonly Used for HFrEF (Stage C HF)
Mean DosesAchieved in References
Drug Initial Daily Dose(s) Target Doses(s)
Clinical Trials
ACEi
Captopril
Enalapril
Fosinopril
Lisinopril
6.25 mg 3 times daily
2.5 mg twice daily
5–10 mg once daily
2.5–5 mg once daily
2 mg once daily
50 mg 3 times daily
10–20 mg twice daily
40 mg once daily
20 mg twice daily
10 mg once daily
4 mg once daily
122.7 mg total daily (19)
(3)
…
16.6 mg total daily
NA
32.5–35.0 mg total daily (17)
…
Perindopril
Quinapril
Ramipril
NA
NA
NA
NA
5 mg twice daily …
1.25–2.5 mg once daily
1 mg once daily
…
Trandolapril …
87

(con’t.)
ARB
Candesartan
Losartan
Valsartan
ARNi
4–8 mg once daily
32 mg once daily
160 mg twice daily
24 mg total daily
129 mg total daily
254 mg total daily
(20)
(18)
(21)
49 mg sacubitril and 51 mg
valsartan twice daily
(22)
97 mg sacubitril and 103 182 mg sacubitril and 193
mg valsartan twice daily mg valsartan total daily
Sacubitril-valsartan (therapy may be initiated at
24 mg sacubitril and 26 mg
valsartan twice daily)
88

(con’t.)
Beta blockers
Bisoprolol 1.25 mg once daily
3.125 mg twice daily
10 mg once daily
10 mg once daily
25–50 mg twice daily
80 mg once daily
8.6 mg total daily
37 mg total daily
NA
(1)
(23)
…
Carvedilol
Carvedilol CR
Metoprolol succinate (11)
extended release 12.5–25 mg once daily 200 mg once daily 159 mg total daily
(metoprolol CR/XL)
Mineralocorticoid receptor antagonists
Spironolactone
Eplerenone
12.5–25 mg once daily
25 mg once daily
25–50 mg once daily 26 mg total daily (6)
50 mg once daily 42.6 mg total daily (13)
89

(con’t.)
SGLT2i
Dapagliflozin
Empagliflozin
10 mg once daily
10 mg once daily
10 mg once daily
10 mg once daily
9.8 mg total daily (8)
NR (9)
Isosorbide dinitrate and hydralazine
20 mg isosorbide dinitrate 40 mg isosorbide dinitrate 90 mg isosorbide dinitrate (10)
(24)
Fixed dose combination and 37.5 mg hydralazine 3 and 75 mg hydralazine 3 and ~175 mg hydralazine
times daily times daily total daily
Isosorbide dinitrate and
hydralazine
20–30 mg isosorbide 120 mg isosorbide dinitrate
dinitrate and 25–50 mg total daily in divided doses
NA
hydralazine 3–4 times daily and 300 mg hydralazine
total daily in divided doses
90

(con’t.)
If Channelinhibitor
Ivabradine
Soluble guanylate cyclase stimulator
5 mg twice daily 7.5 mg twice daily 12.8 total daily (25-27)
Vericiguat 2.5 mg once daily 10 mg once daily 9.2 mg total daily (28)
Individualized variable (29, 30)
0.125–0.25 mg daily
(modified according to
monogram)
dose to achieve serum
digoxin concentration 0.5–
<0.9 ng/mL
Digoxin NA
ACE indicatesangiotensin-converting enzyme;
ARB, angiotensin receptor blocker; CR, controlled
release; CR/XL, controlledrelease/extended
release; HF, heart failure; HFrEF, heart failure with
reduced ejection fraction; NA, not applicable; NR,
not reported; and SGLT2i, sodium glucose
cotransporter 2 inhibitor.
91

Table 15. Benefits of Evidence-Based Therapies for
Patients With HFrEF
Evidence-BasedTherapy RelativeRisk Reduction inAll-
Cause Mortalityin Pivotal
NNT to PreventAll-Cause
MortalityOverTime*
NNT forAll-Cause Mortality
(Standardized to 12 mo)
NNT forAll- Cause
Mortality(Standardized to
RCTs, % 36 mo)
ACEi orARB 17
16
34
30
17
43
36
23
22 over 42 mo
36 over 27 mo
28 over 12 mo
9 over 24 mo
43 over 18 mo
25 over 10 mo
12 over 24 mo
14 over 60 mo
77
80
28
18
63
21
24
70
26
27
9
ARNi†
Beta blocker
Mineralocorticoid receptorantagonist 6
SGLT2i 22
7
Hydralazine or nitrate‡
CRT
ICD
8
23
ACEi indicates angiotensin-converting enzyme inhibitor; ARB,
angiotensin receptor blocker; ARNi, angiotensin receptor neprilysin
inhibitor; CRT, cardiac resynchronization therapy; ICD, implantable
cardioverter-defibrillator; SGLT2i, sodium-glucose cotransporter-2
inhibitor; and NNT, number needed to treat.
*Median duration follow-up in the respective clinical trial.
†Benefit of ARNi therapy incremental to that achieved with ACEi therapy. For the other
medications shown, the benefits are based on comparisons to placebo control.
‡Benefit of hydralazine-nitrate therapy was limited to African American patients in
this trial.
92

Management of StageC HF: Ivabradine
Recommendation forthe Management of Stage C HF: Ivabradine
COR LOE
B-R
Recommendation
1. Forpatientswith symptomatic (NYHAclass II to III) stable chronic HFrEF
( LVEF ≤35%) who are re ceiving GDMT, including a beta blocker at
maximum tolerated dose, and who are in sinus rhythm with a heart rate of
≥70 bpm at rest, iva bra dine can be be nefic ial to reduce HF
hospitalizations
and c ardiovascular death.
2a
93

Pharmacological Treatment for Stage C
HFrEF (Digoxin)
Recommendation for the PharmacologicalTreatment for Stage C HFrEF(Digoxin)
COR
2b
LOE
B-R
Recommendation
1. In patients with symptomatic HFrEFdespite GDMT(or who are unable to tolerate
GDMT), digoxin might be considered to decrease hospitalizations for HF.
94

Pharmacological Treatment for Stage C HFrEF:
Soluble Guanylyl Cyclase Stimulators
Recommendation for PharmacologicalTreatmentforStage C HFrEF: Soluble Guanylyl Cyclase
Stimulators
COR
2b
LOE
B-R
Recommendation
1. In selected high-risk patients with HFrEFand recent worsening of HFalready
on GDMT, an oral soluble guanylate cyclase stimulator (vericiguat) maybe
considered to reduce HFhospitalization and cardiovasculardeath.
95

Figure 7.
Additional
Medical
Therapies for
Patients With
HFrEF
Colors correspond to COR in Table 2
Recommendations for additional medical
therapies that may be considered for patients
with HF are shown.
GDMT indicates guideline-directed medical
therapy; HF, heart failure; HFH, heart failure
hospitalization; HFrEF, heart failure with reduced
ejection fraction; IV, intravenous; LVEF, left
ventricular ejection fraction; LVESD, left
ventricular end systolic dimension; MV, mitral
valve; MR, mitral regurgitation; NP, natriuretic
peptide; NSR, normal sinus rhythm; and NYHA,
New York Heart Association; RAASi,renin-
angiotensin-aldosterone system inhibitors.
96

ICDs and CRTs
Recommendationsfor ICDs and CRTs
COR
1
LOE Recommendations
1. In patients with nonischemic DCM or ischemic heart disease at least 40 days post-MI
with
LVEF ≤35% and NYHA class II or III symptoms on c hronic GDMT, who have
reasonable
A
expectation of meaningfulsurvival for >1 year, ICD therapy is recommended for primary
prevention of SCD to reduce totalmortality.
2. Atransvenous ICD provideshigh economic value in the primary prevention of SCD
Value Statement: HighValue
(A)
particularly when the patient’s risk of death caused byventricular arrythmia is deemed high
and the risk of nonarrhythmic death (either cardiac ornoncardiac) is deemed low based on
the patient’s burdenof comorbidities and functionalstatus.
97

ICDs and CRTs (con’t.)
3. In patients at least 40 days post-MI with LVEF ≤30% and NYHA class I symptoms w hile
1
1
B-R
B-R
receiving GDMT, whohave reasonable expectation of meaningfulsurvival for >1 year, ICD
therapy is recommendedfor primaryprevention of SCD to reduce totalmortality.
4. For patients who have LVEF ≤35%, sinus rhythm, left bundle branch block (LBBB) with a
QRS duration ≥150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT,
CRTis indicated to reduce totalmortality, reduce hospitalizations, and improve symptoms
and QOL.
5. For patients who have LVEF ≤35%, sinus rhythm, LBBB with a QRS duration of ≥150 ms,
Value Statement: HighValue
(B-NR)
and NYHAclass II, III, or ambulatory IVsymptoms on GDMT, CRTimplantation provides
high economic value.
98

6. For patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with a QRS
duration ≥150ms, and NYHA class II, III, or ambulatory class IV symptoms on GDMT,
CRT can be useful to reduce total mortality, reduce hospitalizations, and improve symptoms
2a
2a
2a
B-R
B-R
and QOL.
7. In patients with high-degree or complete heart block and LVEF of 36% to 50%, CRT is
reasonable to reduce totalmortality, reduce hospitalizations, and improve symptoms and
QOL.
8. In patie nts with AF and LVEF ≤35% on GDMT, CRT can be useful to reduce total
mortality, improve symptoms and QOL, and increase LVEF, if: a) the patient requires
ventricularpacing orotherwise meets CRTcriteria and b) atrioventricularnodalablation or
pharmacologicalrate controlwill allow near 100% ventricular pacing with CRT.
B-NR
99

9. For patients on GDMT who have LVEF ≤35% and are undergoing pla c ement of a
new
or re plac e ment device implantation with anticipated requirement for signific ant
(>40%)
ve ntric ular pacing, CRT can be useful to reduce total mortality, reduce hospitalizations,
and improve symptoms and QOL.
2a B-NR
10. For patients who have LVEF ≤35%, sinus rhythm, LBBB with a QRS duration of
120 to
149 ms, and NYHA class II, III, or ambulatory IV symptoms on GDM T, CRT can be
useful to reduce total mortality, reduce hospitalizations, and improve symptoms and
2a
2a
B-NR
B-NR
QOL.
11. In patients with genetic arrhythmogenic cardiomyopathywith high-risk features of
sudden death, with EF ≤45%, implantation of ICD is re asonable to de c rease
sudden
death.
100

12. For patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with QRS
duration of 120 to 149 ms, and NYHA class III or ambulatory class IV on GDM T, CRT
may be considered to reduce total mortality, reduce hospitalizations, and improve
symptoms and QOL.
2b B-NR
13. For patients who have LVEF ≤30%, isc he mic c ause of HF, sinus rhythm, LBBB
with a
QRS duration ≥150 ms, and NYHA class I symptoms on GDM T, CRT may be
considered to reduce hospitalizations and improve symptoms and QOL.
2b B-NR
B-R
14. In patients with QRS duration <120 ms, CRTis not recommended.
3: No Benefit
101

15. For patientswith NYHAclass I orII symptoms and non-LBBB patternwith
3: No
B-NR
C-LD
QRS duration <150 ms, CRTis not recommended (16-21, 28-33).
Benefit
16. For patientswhose comorbidities or frailty limit survival with good
functionalcapacity to <1 year, ICD and cardiac resynchronization therapy
with defibrillation (CRT-D)are not indicated(1-9, 16-21).
3: No
Benefit
102

Figure 8.
Algorithm for CRT
Indications in
Patients With
Cardiomyopathy
or HFrEF
Recommendations for cardiac
resynchronization therapy (CRT) are
displayed.
AF indicates atrial fibrillation; Amb,
ambulatory; CM, cardiomyopathy; GDMT,
guideline-directed medical therapy; HB,
heart block; HF, heart failure; HFrEF, heart
failure with reduced ejection fraction; LBBB,
left bundle branch block; LV, left
ventricular; LVEF, left ventricular ejection
fraction; NSR, normal sinus rhythm; NYHA,
New York Heart Association; and RV, right
ventricular.
103

Revascularization for CAD
Recommendation for Revascularization for CAD
1. In selected patie nts with HF, reduced EF (EF ≤35%), and suitable
coronary anatomy, surgical revascularization plus GDMT is beneficial
to improve symptoms, c ardiovascular hospitalizations, and long-te rm
all-c ause mo rta lity.
1 B-R
104

Figure 9.
Additional Device
Therapies
Recommendations for additional
nonpharmaceutical interventions that may
be considered for patients with HF are
shown.
GDMT indicates guideline-directed medical
therapy; HF, heart failure; HFH, heart failure
hospitalization; HFrEF, heart failure with
reduced ejection fraction; IV, intravenous;
LVEF, left ventricular ejection fraction;
LVESD, left ventricular end systolic
dimension; MV, mitral valve; MR, mitral
regurgitation; NP, natriuretic peptide; NSR,
normal sinus rhythm; NYHA, New York Heart
Association; and PASP, pulmonary artery
systolic pressure.
105

Valvular Heart Disease
RecommendationsforValvular Heart Disease
COR
1
LOE Recommendations
1. In patients with HF, VHD should be managed in a multidisciplinary manner in
accordance with clinical practice guidelines forVHD to prevent worsening of HF
and adverse clinical outcomes.
B-R
2. In patients with chronic severe secondary MR and HFrEF,optimization of GDMT
is recommended before any intervention for secondary MR related to LV
dysfunction.
1 C-LD
106

Figure 10.
Treatment
Approach in
Secondary Mitral
Regurgitation
Colors correspond to Table 2
107

HF With Mildly Reduced Ejection Fraction
RecommendationsforHFWith Mildly Reduced Ejection Fraction
COR
2a
LOE
B-R
Recommendations
1. In patients with HFmrEF,SGLT2ican be beneficialin decreasing HF
hospitalizations and cardiovascularmortality.
2. Among patients with current orprevious symptomatic HFmrEF(LVEF 41%–
49%), use of evidence-based beta blockers for HFrEF,ARNi,ACEi orARB, and
MRAs may be considered to reduce the risk of HFhospitalization and
cardiovascular mortality, particularly among patients with LVEF on the lowerend
of this spectrum.
2b B-NR
108

Figure 11.
Recommendations
for Patients With
Mildly Reduced
LVEF (41%–49%)
Medication recommendations for HFmrEF are
displayed.
ACEi indicates angiotensin-converting
enzyme inhibitor; ARB, angiotensin receptor
blocker; ARNi, angiotensin receptor-
neprilysin inhibitor; HRmrEF, 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.
109

HF With Improved Ejection Fraction
Recommendation forHFWith Improved Ejection Fraction
COR LOE
B-R
Recommendation
1. In HFimpEFafter treatment, GDMTshould be continuedto prevent relapseof HF
and LV dysfunction,even in patients who maybecome asymptomatic.
1
110

HF With Preserved Ejection Fraction
Recommendationsfor HFWith Preserved Ejection Fraction*
1. Patients with HFpEFand hypertension should have medication titratedto
attain blood pressure targets in accordance with published clinical practice
guidelines to prevent morbidity.
1 C-LD
2. In patients with HFpEF, SGLT2ican be beneficialin decreasing HF
hospitalizations and cardiovascularmortality.
2a
2a
B-R
3. In patients with HFpEF, management ofAFcan be usefulto improve
symptoms.
C-EO
111

HF With Preserved Ejection Fraction (con’t.)
4. In selected patients with HFpEF, MRAs maybe considered to decrease
2b
2b
2b
B-R
B-R
hospitalizations, particularly among patients with LVEFon the lowerend of this
spectrum.
5. In selected patients with HFpEF, the use ofARB maybe consideredto decrease
hospitalizations, particularly among patientswith LVEF on the lowerend of this
spectrum.
6. In selected patients with HFpEF,ARNimay be considered to decrease
B-R
B-R
hospitalizations, particularly among patients with LVEFon the lowerend of this
spectrum.
7. In patients with HFpEF, routine use of nitrates orphosphodiesterase-5 inhibitors to
3: No-
increase activity orQOLis ineffective.
Benefit
112

Figure 12.
Recommendations
for Patients W ith
Preserved LVEF
( ≥50%)
Medication recommendations for HFpEF are
displayed.
*Greater benefit in patients with LVEF closer
to 50%.
ARB indicates angiotensin receptor blocker;
ARNi, angiotensin receptor-neprilysin
inhibitor; HF, heart failure; HFpEF, heart
failure with preserved ejection fraction; LVEF,
left ventricular ejection fraction; MRA,
mineralocorticoid receptor antagonist; and
SGLT2i, sodium-glucose cotransporter 2
inhibitor.
113

Diagnosis of Cardiac Amyloidosis
RecommendationsforDiagnosis of CardiacAmyloidosis
COR
1
LOE Recommendations
1. Patients forwhom there is a clinical suspicion for cardiac amyloidosis* should have
B-NR screening for serumand urine monoclonallight chains with serum and urine *LV wall thickness
≥14 mm in
conjunction with
fatigue, dyspnea,
or edema,
immunofixation electrophoresis and serum free light chains.
especially in the
context of
discordance
2. In patients with high clinical suspicion for cardiac amyloidosis, without evidence of
between wall
thickness on
1
1
B-NR
B-NR
serum orurine monoclonallight chains, bone scintigraphyshould be performedto
echocardiogram
and QRS voltage
on ECG, and in
the context of
aortic stenosis,
HFpEF, carpal
tunnel syndrome,
spinal stenosis,
and autonomic or
sensory
confirm the presence of transthyretin cardiac amyloidosis.
3. In patients for whoma diagnosis of transthyretin cardiac amyloidosis is made, genetic
testing withTTR gene sequencing is recommended to differentiatehereditary variant
from wild-type transthyretin cardiac amyloidosis. polyneuropathy.
114

Treatment of Cardiac Amyloidosis
RecommendationsforTreatmentof CardiacAmyloidosis
COR
1
LOE Recommendations
1. In select patients with wild-type orvariant transthyretin cardiac amyloidosis and NYHAclass I
B-R to III HFsymptoms, transthyretin tetramer stabilizer therapy (tafamidis) is indicated to reduce
cardiovascular morbidity and mortality.
Value Statement: Low 2. At 2020 list prices, tafamidis provides low economic value (>$180,000 per QALYgained)
in
Value (B-NR) patients with HFwith wild-type orvariant transthyretin cardiac amyloidosis.
3. In patients with cardiac amyloidosis andAF, anticoagulation is reasonable to reduce the risk of
stroke re gardle ss of the CHA DS -VASc (congestive heart failure , hypertension, age ≥75
years,
2 2
2a C-LD
diabetes mellitus, stroke ortransient ischemic attack[TIA], vasculardisease, age 65 to 74 years,
sex category) score .
115

Figure 13. Diagnostic
and Treatment of
Transthyretin
Cardiac Amyloidosis
Algorithm
AF indicates atrial fibrillation; AL-CM, AL
amyloid cardiomyopathy; ATTR-CM,
transthyretin amyloid cardiomyopathy; ATTRv,
variant transthyretin amyloidosis; ATTRwt, wild-
type transthyretin amyloidosis; 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; 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.
116

Specialty Referral for Advanced HF
Recommendation forSpecialty Referral forAdvanced HF
1. In patients with advancedHF, whenconsistentwith the patient’sgoals of
care, timely referralforHFspecialty care is recommended to review HF
management and assesssuitability for advancedHFtherapies (e.g., LV
AD,
cardiac transplantation,palliative care, and palliative inotropes).
1 C-LD
118

Table 16. ESC Definition of Advanced HF
All of these criteria must be present despite optimal guideline-
directed treatment:
1. Severe and persistent symptoms of HF (NYHA class III
[advanced] or IV)
2. Severe cardiac dysfunction defined by ≥1
of these:
 LVEF ≤30%
 Isolated RV failure
 Nonoperable severe valve abnormalities
 Nonoperable severe congenital heart disease
 EF ≥40%, elevated natriuretic peptide levels
and evidence of significant diastolic
dysfunction
119

Table 16. ESC Definition of Advanced HF (con’t.)
3. Hospitalizations or unplanned visits in the past 12 mo for episodes of:
 Congestion requiring high-dose intravenous diuretics or diuretic
combinations
 Low outputrequiring inotropes or vasoactive medications
 Malignant arrhythmias
4. Severe impairment of exercise capacity with inability to exercise or low 6-minute walk test
distance (<300 m) or peak VO2 (<12–14 mL/kg/min) estimated to be of cardiac origin
EF indicates ejection
fraction; ESC, European
Society of Cardiology; HF,
heart failure; LVEF, left
ventricular ejection
fraction; NYHA, New York
Heart Association; RV, right
ventricular; and VO2,
oxygen
Criteria 1 and 4 can be met in patients with cardiac dysfunction (as described in criterion 2) but who
also have substantial limitations as a result of other conditions(e.g., severe pulmonary disease,
noncardiac cirrhosis, renal disease). The therapeutic options for these patients may be more limited.
consumption/oxygen
uptake.
Adapted from Crespo-Leiro
et al.
120

Table 17. INTERMACS Profiles
P rofile∗ P rofile De sc
ription
Features
1 Critical cardiogenic shock Life-threatening hypotension and rapidly escalating inotropic/pressor support, with
critical organ hypoperfusion often confirmed by worsening acidosis and lactate
levels.
2 Progressive decline “Dependent” on inotropic support but nonetheless showssigns of continuing
deterioration in nutrition, renal function, fluid retention, or other major status
indicator. Can also applyto a patient with refractory volume overload, perhaps with
evidence of impaired perfusion, in whom inotropic infusions cannot be maintained
because of tachyarrhythmias, clinical ischemia, or other intolerance.
121

Table 17. INTERMACS Profiles (con’t.)
ription
Features
3 Stable but inotrope
dependent
Clinically stable on mild-moderate doses of intravenous inotropes (or has a temporary
circulatory support device) after repeated documentation of failure to wean without symptomatic
hypotension, worsening symptoms, or progressive organ dysfunction (usually renal).
4 Resting symptoms on oral Patient who is at home on oral therapy but frequently has symptoms of congestion at rest or with
therapy at home activities of daily living (dressing or bathing). He or she may have orthopnea, shortness of
breath during dressing or bathing, gastrointestinal symptoms (abdominal discomfort, nausea,
poor appetite), disabling ascites, or severe lower extremity edema.
5 Exertion intolerant Patient who is comfortable at rest but unable to engage in any activity, living predominantly
within the house or housebound.
122

ription
Features
6 Exertion limited Patient who is comfortable at rest without evidence of fluid overload but who is able to do some
mild activity.Activities of daily living are comfortable, and minoractivities outside the home
such as visiting friends or going to a restaurant can be performed, but fatigue results within a
few minutes or with any meaningful physical exertion.
7 Advanced NYHAclass III Patient who is clinically stable with a reasonable level of comfortable activity, despite a history
of previous decompensation that is not recent. This patient is usuallyable to walk more than a
block.Any decompensation requiring intravenousdiuretics or hospitalization within the
previous month should make this person a Patient Profile 6 or lower.
123

ICD indicates implantable cardioverter-defibrillator;
INTERMACS, Interagency Registry for Mechanically Assisted
Circulatory Support; and NYHA, New York Heart Association.
124

Table 18. Clinical Indicators of Advanced HF
Repeated hospitalizations or emergency department visits for HF in the past 12 mo.
Need for intravenous inotropic therapy.
Persistent NYHA functional class III to IV symptoms despite therapy.
Severely reduced exercise capacity (peak VO2,<14 mL/kg/min or <50% predicted, 6-minute walk test distance
<300 m, or inability to walk 1 block on level ground because of dyspnea or fatigue).
Intolerance to RAAS inhibitors because of hypotension or worsening renal function.
Intolerance to beta blockers as a result of worsening HF or hypotension.
Recent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose >160
mg/d or use of supplemental metolazone therapy.
125

Table 18. Clinical Indicators of Advanced HF
(con’t.)
Refractory clinical congestion.
Progressive deterioration in renal or hepatic function.
Worsening right HF or secondary pulmonary hypertension.
Frequent SBP ≤90 mm Hg.
HF indicates heart
failure; ICD, implantable
cardioverter-
defibrillator; MAGGIC,
Meta-analysis Global
Group in Chronic Heart
Failure; NYHA, New York
Heart Association; RAAS,
renin-angiotensin-
aldosterone system; SBP,
systolic blood pressure;
SHFM, Seattle Heart
Failure model; and VO2,
oxygen
Cardiac cachexia.
Persistent hyponatremia (serum sodium, <134 mEq/L).
Refractory or recurrent ventricular arrhythmias;frequent ICD shocks.
Increased predicted 1-year mortality (e.g., >20%) according to HF survival models (e.g., MAGGIC, SHFM).
consumption/oxygen
uptake.
126

Table 19. Indications and Contraindications
to Durable Mechanical Support
Indications (combination of these):
 
 
 
 
 
 
 
 
Frequent hospitalizations for HF
NYHA class IIIb to IV functional limitations despite maximal therapy
Intolerance of neurohormonal antagonists
Increasing diuretic requirement
Symptomatic despite CRT
Inotrope dependence
Low peak VO2 (<14–16)
End-organ dysfunction attributable to low cardiac output
127

Table 19. Indications and Contraindications
to Durable Mechanical Support (con’t.)
Contraindications:
Absolute
 
 
 
 
 
Irreversible hepatic disease
Irreversible renal disease
Irreversible neurological disease
Medical nonadherence
Severe psychosocial limitations
128

Relative
 
 
 
 
 
 
 
 
 
 
Age >80 y for destination therapy
Table 19. Obesity or malnutrition
Indications and
Contraindications
to Durable
Musculoskeletal disease that impairs rehabilitation
Active systemic infection or prolonged intubation
Untreated malignancy
Mechanical
Support (con’t.)
Severe PVD
Active substance abuse
Impaired cognitive function
Unmanaged psychiatric disorder
Lack of social support
CRT indicates cardiac
resynchronization therapy;
HF, heart failure; NYHA, New
York Heart Association; VO2,
oxygen consumption; and
PVD, peripheral vascular
disease.
129

Nonpharmacological Management:
Advanced HF
Recommendation for NonpharmacologicalManagement:AdvancedHF
1. Forpatientswith advancedHFand hyponatremia, the benefit of fluid
restriction to reduce congestive symptoms is uncertain.
2b C-LD
130

Inotropic Support
Recommendationsfor Inotropic Support
1. In patients with advanced(stage D) HFrefractory to GDMT and device
2a B-NR therapy who are eligible for and awaiting MCS orcardiac transplantation,
continuous intravenousinotropic support is reasonable as “bridge therapy”.
2. In select patients with stage D HF, despite optimalGDMT and device
therapy who are ineligible for eitherMCS or cardiac transplantation,
continuous intravenousinotropic support maybe considered as palliative
2b B-NR
B-R
therapy for symptomcontroland improvement in functionalstatus.
3. In patients with HF, long-termuse of eithercontinuous orintermittent
3: Harm intravenous inotropic agents, for reasons otherthan palliative care oras a
bridge to advanced therapies, is potentially harmful.
131

Table 20. Intravenous Inotropic Agents Used
in the Management of HF
InotropicAgent Dose (mcg/kg)
Bolus Infusion
Drug Kinetics Effects Adverse Effects Special
CO HR SVR PVR
and Considerations
(/min) Metabolism
Adrenergic agonists
Dopamine NA
NA
5–10 t1/2: 2–20 min ↑ ↑
↑
↔
↑
↔
↔
T, HA, N, tissue
necrosis
Caution: MAO-I
10–15 ↑
R, H, P
Dobutamine NA 2.5–20 t1/2: 2–3 min H ↑/↓BP, HA, T, N, F,
hypersensitivity
Caution: MAO-I;
CI: sulfite allergy
↑ ↑ ↔ ↔
132

in the Management of HF (con’t.)
PDE 3 inhibitor
Milrinone NR 0.125–0.75 t1/2: 2.5 h ↑ ↑ ↓ ↓ T, ↓BP Accumulation may
occur in setting of renal
failure; monitor kidney
function and LFTs
H
133

in the Management of HF (con’t.)
Vasopressors
Epinephrine NR 5–15 mcg/min t1/2: 2–3 min ↑ ↑ ↑ (↓) ↔ HA, T
HA, T,
Caution: MAO-I
Caution: MAO-I
15–20 mcg/min t1/2: 2–3 min ↑ ↑↑
0.5–30 mcg/min t1/2: 2.5 min ↔ ↑
↑↑
↑↑
↔
↔
Norepinephrine NR ↓ HR, tissue necrosis Caution: MAO-I
BP indicates blood pressure; CI, contraindication; CO, cardiac output; F, fever; H, hepatic; HA,
headache; HF, heart failure; HR, heart rate; LFT, liver function test; MAO-I, monoamine oxidase
inhibitor; N, nausea; NA, not applicable; NR, not recommended; P, plasma; PDE, phosphodiesterase;
PVR, pulmonary vascular resistance; R, renal; SVR, systemic vascular resistance; T, tachyarrhythmias;
and t1/2,elimination half-life.
Up arrow means increase.
Side arrow means no change.
Down arrow means decrease.
Up/down arrow means either increase or decrease.
134

Mechanical Circulatory Support
Recommendationsfor MechanicalCirculatory Support
COR LOE
A
Recommendations
1. In select patients with advancedHFrEFwith NYHAclass IV symptoms
who are deemed to be dependent on continuous intravenousinotropes or
temporary MCS, durable LV
AD implantation is effective to improve
functionalstatus, QOL, and survival.
1
2. In select patients with advancedHFrEFwho have NYHAclass IV
symptoms despite GDMT, durable MCS can be beneficial to improve
symptoms, improve functionalclass, and reduce mortality.
2a B-R
135

Mechanical Circulatory Support
3. In patients with advancedHFrEFwho have NYHAclass IV symptoms
Value Statement:
despite GDMT, durable MCS devices provide low to intermediate economic
value based on current costs and outcomes.
Uncertain Value (B-
NR)
4. In patients with advancedHFrEFand hemodynamic compromise and
shock, temporary MCS, including percutaneous andextracorporeal
ventricularassist devices, are reasonable as a “bridge to recovery” or
“bridge to decision”.
2a B-NR
136

Cardiac Transplantation
Recommendation for Cardiac Transplantation
Recommendation
COR
1
LOE
1. Forselected patients with advancedHFdespite GDMT, cardiac transplantation is
indicated to improve survival and QOL(1-3).
C-LD
2. In patients with stage D (advanced)HFdespite GDMT, cardiac transplantation
provides intermediate economic value (4).
Value Statement:
Intermediate Value
(C-LD)
137

Patients Hospitalized With
Acute Decompensated HF
138

Assessment of Patients Hospitalized
With Decompensated HF
RecommendationsforAssessment of PatientsHospitalized With Decompensated HF
1. In patients hospitalized with HF, severity of congestion and adequacyof
C-LD
1
1
perfusion should be assessed to guide triage and initial therapy.
2. In patients hospitalized with HF, the common precipitating factors and the
C-LD
C-LD
overall patient trajectory should be assessed to guide appropriate therapy.
Goals for Optimization and Continuation of GDMT
3. Forpatientsadmittedwith HF, treatment should addressreversible factors,
1 establish optimal volume status, and advance GDMT towardtargets for
outpatient therapy.
139

ACS
Uncontrolled hypertension
AF and other arrhythmias
Additional cardiac disease (e.g., endocarditis)
Table 21.
Common Factors
Precipitating HF
Hospitalization
With Acute
Acute infections (e.g., pneumonia, urinary tract)
Decompensated
HF
Nonadherence with medication regimen or dietary intake
Anemia
Hyper- or hypothyroidism
Medications that increase sodium retention (e.g., NSAID)
ACS indicates acute coronary
syndrome; AF, atrial
fibrillation; and NSAID,
nonsteroidal anti-
Medications with negative inotropic effect (e.g., verapamil)
inflammatory drug.
140

Maintenance or Optimization of
GDMT During Hospitalization
RecommendationsforMaintenanceorOptimization of GDMTDuring Hospitalization
COR
1
LOE Recommendations
1. In patients with HFrEFrequiring hospitalization, preexisting GDMTshould be
B-NR
continued and optimized to improve outcomes, unless contraindicated.
2. In patients experiencing mild decrease of renalfunction orasymptomatic reduction of
1 B-NR blood pressure during HFhospitalization, diuresis and otherGDMTshould not
routinely be discontinued.
3. In patients with HFrEF,GDMTshould be initiated during hospitalization after
1
1
B-NR
B-NR
clinical stability is achieved.
4. In patients with HFrEF,if discontinuation of GDMT is necessary during
hospitalization, it should be reinitiated and furtheroptimized as soon as possible.
141

Diuretics in Hospitalized Patients:
DecongestionStrategy
RecommendationsforDiuretics in Hospitalized Patients: Decongestion Strategy
Recommendations
COR LOE
1. Patientswith HFadmitted with evidence of significant fluid overload should be
promptlytreated with intravenous loop diuretics to improve symptoms and reduce
1 B-NR
morbidity.
2. Forpatientshospitalized with HF, therapy with diuretics and otherguideline-
directed medications should be titrated with a goal to resolve clinical evidence of
congestion to reduce symptoms and rehospitalizations.
1 B-NR
142

Diuretics in Hospitalized Patients:
DecongestionStrategy (con’t.)
3. Forpatientsrequiring diuretic treatment during hospitalization for HF, the
1 B-NR discharge regimenshould include a plan for adjustment of diuretics to decrease
rehospitalizations.
4. In patients hospitalized with HF when diuresis is inadequate to relieve
symptoms and signs of congestion,it is reasonable to intensifythe diuretic
regimen using either:
2a B-NR
a. higherdoses of intravenous loop diuretics; or
b. addition of a second diuretic.
143

Parenteral Vasodilation Therapy in
Patients Hospitalized With HF
Recommendation for ParenteralVasodilation Therapyin Patients Hospitalized With HF
Recommendation
COR
2b
LOE
1. In patients who are admittedwith decompensatedHF, in the absence of systemic
hypotension, intravenous nitroglycerin ornitroprusside maybe considered as an
adjuvant to diuretic therapy for relief of dyspnea.
B-NR
144

VTE Prophylaxis in Hospitalized
Patients
Recommendation forVTE Prophylaxis in Hospitalized Patients
Recommendation
COR LOE
B-R
1. In patients hospitalized with HF, prophylaxis forVTE is recommended to
prevent venous thromboembolic disease.
1
145

Evaluation and Management of
Cardiogenic Shock
RecommendationsforEvaluation and Management of Cardiogenic Shock
COR
1
LOE Recommendations
1. In patients with cardiogenic shock, intravenous inotropic supportshould
be used to maintain systemic perfusion and preserve end-organ
performance.
B-NR
2. In patients with cardiogenic shock, temporary MCS is reasonable when
end-organ function cannot be maintainedby pharmacologic means to
support cardiac function.
2a B-NR
146

Evaluation and Management of
Cardiogenic Shock(con’t.)
3. In patients with cardiogenic shock, management bya multidisciplinary team
experienced in shock in reasonable.
2a
2b
2b
B-NR
4. In patients presenting with cardiogenic shock, placementof a PAline may be
considered to define hemodynamic subsets and appropriate management
strategies.
B-NR
C-LD
5. For patientswho are notrapidly responding to initial shockmeasures, triage
to centers that can provide temporary MCS maybe considered to optimize
management.
147

Table 22. Suggested Shock Clinical Criteria*
SBP <90 mm Hg for >30 min:
a. Or mean BP <60 mm Hg for >30 min
b. Or requirement of vasopressors to maintain systolic BP
≥90 mm Hg or mean BP ≥60 mm Hg
Hypoperfusion de fine d by:
c. Decreased mentation
d. Cold extremities, livedo reticularis
e. Urine output <30 mL/h
f. Lactate >2 mmol/L
BP indicates blood pressure; and SBP, systolic blood pressure.
*Systolic BP and hypoperfusion criteria need to be met for
the shock diagnosis.
148

Table 23. Suggested Shock Hemodynamic Criteria*
1. SBP <90 mm Hg or mean BP<60 mm
Hg
2. Cardiac index <2.2 L/min/m2
3. Pulmonarycapillary wedge pressure >15 mm Hg
4. Other hemodynamic considerations
a. Cardiac power output ([CO xMAP]/451) <0.6 W
b. Shock index (HR/systolic BP) >1.0
BP indicates blood pressure; CO, cardiac output;
c. RV shock
i. Pulmonary artery pulse index[(PASP-
CVP, central venous pressure; HR, heart rate;
MAP, mean arterial pressure; PADP, pulmonary
artery diastolic pressure; PASP, pulmonary
artery systolic pressure; PCW, pulmonary
capillary wedge; RV, right ventricular; and SBP,
systolic blood pressure. PADP)/CVP] <1.0
i. CVP >15 mm Hg
i. CVP-PCW>0.6
*Diagnosis of shock requires ≥1 criteria to be
present along with cardiac index <2.0 L/min/m2
and SBP <90 mm Hg.
149

Table 24. Society for Cardiovascular Angiography
and Interventions (SCAI) Cardiogenic Shock Criteria
Stage Bedside Findings Selected Laboratory
Markers
Hemodynamics
A: At risk --Normal venous pressure
--Clear lungs
--Normal renal function --SBP >100 mm Hg
--Normal lactate --Hemodynamics: Normal
--Normotensive --Warm extremities
--Normal perfusion --Strong palpable pulses
--Cause for risk for --Normal mentation
shock such as large
myocardial infarction
or HF
150

Table 24. Society for Cardiovascular Angiography and
Interventions (SCAI) CardiogenicShock Criteria(con’t.)
B: Beginning
shock (“pre-
shock”)
--Elevated venous
pressure
--Preserved renal
function
a) SBP <90 mm Hg
b) MAP <60 mm Hg or
c) >30 mm Hg decrease
from baseline SBP
--HR >100 bpm
--Rales present
--Warm extremities
--Strong pulses
--Normal mentation
--Normal lactate
--Elevated BNP
--Hypotension
--Normal --Hemodynamics: CI ≥2.2
L/min/m2
perfusion
151

C: Classic
cardiogenic
shock
--Elevated venous
pressure
--Impaired renal
function
--SBP <90 mm Hg; MAP
<60 mm Hg; >30 mm Hg
--Rales present
--Cold, ashen, livedo
--Increased lactate from baseline SBP despite
--Elevated BNP drugs and temporary
MCS
--Hypotension --Weak or nonpalpable --Increased LFTs
--Acidosis
--Hypoperfusion pulses
--Altered mentation
--HR >100 bpm
--Hemodynamics: CI ≤2.2
L/min/m2; PCW >15 mm
Hg; CPO <0.6 W; PAP i
<2.0; CVP-PCW >1.0
--Decreased urine
output
--Respiratory distress
152

D: Deteriorating Same as stage C
--Worsening
--Persistent or
worsening values of
stage C
Escalating use of pressors or
MCS to maintain SBPand
end-organ perfusion in
setting of stage C
hypotension
BNP indicates brain
natriuretic peptide; CI,
cardiac index; CPO,
cardiac power output;
CPR, cardiopulmonary
resuscitation; CVP,
central venous pressure;
HR, heart rate; LFT, liver
function test; MAP,
mean arterial blood
pressure; MCS,
--Worsening
hypoperfusion hemodynamics
E: Extremis
--Refractory
hypotension
--Refractory
hypoperfusion
--Cardiac arrest
--CPR
--Worsening values of --SBPonlywith resuscitation
mechanical circulatory
support; PAPi,
pulmonary artery
stage C laboratories --PEA
pulsatility index; PCW,
pulmonary capillary
wedge pressures; PEA,
pulseless electrical
activity; SBP, systolic
blood pressure; VF,
ventricular fibrillation;
and VT, ventricular
tachycardia.
--Recurrent VT/VF
153

Integration of Care: Transitions and
Team-Based Approaches
RecommendationsforIntegration of Care:Transitions and Team-BasedApproaches
COR LOE
B-R
Recommendations
1. In patients with high-risk HF, particularly those with recurrent hospitalizations for
HFrEF, referralto multidisciplinary HFdisease managementprogramsis
recommended to reduce the risk of hospitalization.
1
154

Integration of Care: Transitions and
Team-Based Approaches (con’t.)
2. In patients hospitalized with worsening HF, patient-centereddischarge
1 B-NR instructions with a clearplan for transitional care should be provided before
hospital discharge.
3. In patients hospitalized with worsening HF, participation in systems that allow
benchmarking to performance measures is reasonable to increase use of
evidence-based therapy, and to improve quality of care.
2a B-NR
4. In patients being discharged afterhospitalization for worsening HF, an early
follow-up, generally within 7 days of hospital discharge, is reasonable to
optimize care and reduce rehospitalization.
2a B-NR
155

Atransitional care plan, communicated with the patient and their outpatient clinicians before hospital discharge, should clearly outline plans
for:
 
 
 
 
Addressing any precipitating causesof worseningHF identified in the hospital;
Adjusting diuretics basedon volume status (including weight) and electrolytes;
Coordination of safety laboratorychecks(e.g., electrolytes after initiation or intensification of GDMT);
Further changes to optimize GDMT, including:
Table 25.
Important
Components
of a
Transitional
Care Plan
a. Plansfor resuming medications held in the hospital;
b. Plansfor initiating new medications;
c. Plansfor titration of GDMT to goal doses as tolerated;
 
 
Reinforcing HF educationand assessing compliance with medical therapyand lifestyle modifications, including dietary restrictions and
physical activity;
Addressing high-risk characteristicsthat may be associated with poor postdischargeclinical outcomes, such as:
a. Comorbidconditions (e.g., renal dysfunction, pulmonarydisease, diabetes, mental health, and substanceuse disorders);
b. Limitations in psychosocialsupport;
c. Impairedhealth literacy, cognitive impairment;
GDMT indicates
guideline-directed
medical therapy;
and HF, heart
failure.
 
 
Additional surgical or device therapy, referralto cardiac rehabilitation in the future, where appropriate;
Referral to palliative care specialists and/or enrollment in hospice in selected patients.
156

Comorbidities in Patients With HF
157

Management of Comorbidities in
Patients With HF
Recommendationsfor the Management of Comorbidities in Patients With HF
COR LOE
B-R
B-R
Recommendations
Management ofAnemia orIron Deficiency
1. In patients with HFrEFand iron deficiency with orwithout anemia,
2a intravenous iron replacement is reasonable to improve functionalstatus
and QOL.
2. In patients with HFand anemia, erythropoietin-stimulating agentsshould
not be used to improve morbidity and mortality.
3: Harm
158

Patients With HF (con’t.)
Management of Hypertension
3. In patients with HFrEFand hypertension,uptitration of GDMTto the
1 C-LD
maximally tolerated targetdose is recommended.
Management of Sleep Disorders
4. In patients with HFand suspicion of sleep-disordered breathing,a formal sleep
assessment is reasonable to confirm the diagnosis and differentiate between
obstructive and centralsleep apnea.
2a C-LD
159

Patients With HF (con’t.)
5. In patients with HFand obstructive sleep apnea,continuous positive
airway pressure maybe reasonable to improve sleep quality and decrease
2a B-R
B-R
daytime sleepiness.
6. In patients with NYHAclass II to IV HFrEFand centralsleep apnea,
adaptive servo-ventilation causes harm.
3: Harm
Management of Diabetes
7. In patients with HFand type 2 diabetes, the use of SGLT2i is
recommended for the management of hyperglycemia and to reduce HF-
related morbidity and mortality.
1 A
160

ACEi indicates
Figure 14.
angiotensin-converting
enzyme inhibitor; AF,
atrial fibrillation; ARB,
angiotensin receptor
blocker; AV,
Recommendations
for Treatment of
Patients With HF
and Selected
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,
Comorbidities
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
Recommendations for treatment of
patients with HF and select
comorbidities are displayed.
*Patients with chronic HF with
permanent-persistent-paroxysmal
AF and a CHA2DS2-VASc score of ≥2
(for men) and ≥3 (for women).
cotransporter 2 inhibitor;
and VHD, valvular heart
disease.
161

Table 26. Most CommonCo-Occurring Chronic Conditions
Among Medicare Beneficiaries With HF (N=4,947,918), 2011
Be ne ficiarie s Age ≥65 y
(n=4,376,150)∗
Beneficiaries Age <65 y (n=571,768)†
n % n %
Hypertension 3,685,373 84.2 Hypertension 461,235
365,889
80.7
Ischemic heart
disease
Ischemic heart disease 3,145,718 71.9 64.0
Hyperlipidemia
Anemia
2,623,601
2,200,674
60.0
50.3
Diabetes 338,687 59.2
56.9
Hyperlipidemia 325,498
162

Table 26. Most CommonCo-Occurring Chronic Conditions
Among Medicare Beneficiaries With HF (N=4,947,918), 2011
(con’t.)
Diabetes
Arthritis
2,027,875
1,901,447
46.3
43.5
Anemia
CKD
284,102
257,015
49.7
45.0
CKD 1,851,812 42.3 Depression 207,082 36.2
COPD
AF
1,311,118 30.0
28.5
Arthritis
COPD
201,964
191,016
35.3
33.4
AF indicates
atrial
fibrillation; CKD,
chronic kidney
disease; COPD,
chronic
1,247,748
∗
Mean No. of
conditions is 6.1;
median is 6.
†Mean No. of
conditions is 5.5;
median is 5.
obstructive
pulmonary
disease; and HF,
heart failure.
Alzheimer’s disease or dementia 1,207,704 27.6 Asthma 88,816 15.5
163

Management of AF in HF
RecommendationsforManagement ofAFin HF
COR
1
LOE
A
Recommendations
1. Patients with chronic HFwith permanent-persistent-paroxysmalAF and a
CHA DS -VASc score of ≥2 (for men) and ≥3 (for women) should re c eive c
hronic
2 2
anticoagulanttherapy.
2. Forpatientswith chronic HFwith permanent-persistent-paroxysmalAF, DOAC
1 A is recommended over warfarin in eligible patients.
164

2022 Heart Failure Guideline Slide Set.pptx

2022 Heart Failure Guideline Slide Set.pptx

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to 2022 Heart Failure Guideline Slide Set.pptx

Similar to 2022 Heart Failure Guideline Slide Set.pptx (20)

Recently uploaded

Recently uploaded (20)

2022 Heart Failure Guideline Slide Set.pptx