A new guideline offers updated recommendations for the assessment and management of heart failure (HF). The guideline, issued by the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Failure Society of America (HFSA), combines and replaces the 2013 American College of Cardiology Foundation (ACCF)/AHA guideline for HF management and the 2017 focused update by the ACC/AHA/HFSA. The 2022 guideline was published jointly in Circulation, the Journal of the American College of Cardiology, and the Journal of Cardiac Failure.
Highlights of the new guidelines include recommendations for HF prevention; new treatments strategies for HF, including sodium-glucose cotransporter-2 inhibitors (SGLT2i) and angiotensin receptor-neprilysin inhibitors (ARNi); specific management strategies, such as cardiac amyloidosis and cardio-oncology; implantable devices; and the use of left ventricular assist devices.
Recommendations for people categorized as stage A (at risk for HF):
- The guideline committee recommends blood pressure control based on the latest guidelines.
- Normal resting blood pressure should be under 120/80 mmHg.
- Individuals with type 2 diabetes and either established cardiovascular disease or high cardiovascular risk should consider SGLT2i medicines, which are shown to promote survival in this population.
- The committee also recommends physical activity, healthy dietary patterns, refraining from smoking and maintaining a healthy body weight.
Recommendations for people categorized as stage B (pre-HF):
- Stage A recommendations are also appropriate for people in stage B.
- For individuals with stage B HF with left ventricle ejection fraction (LVEF) ≤40%, ACE-inhibitors (angiotensin-converting-enzyme inhibitors, or ACEi) are recommended for preventing HF symptoms from developing.
- The panel suggests that angiotensin receptor blockers (ARBs) may be prescribed for those with an intolerance or contraindication to ACEi.
- The panel recommends cholesterol-lowering statins for those with a history of heart attack or acute coronary syndrome.
Recommendations for people categorized as Stage C (symptomatic HF):
- The committee recommends that people in stage C with HF symptoms should undergo care from multidisciplinary teams to facilitate guideline-directed medical therapy as well as self-care support for learning to manage symptoms. Self-care support can include awareness of the importance of taking medicine as directed and maintaining healthy behaviors, including restricting sodium consumption and remaining physically active.
- Individuals in stage C should understand how to monitor themselves for manifestations of worsening HF and know what to do about these symptoms.
- The committee also recommends screenings to establish potential medical or social barriers for effective self-care and education and support to decrease re-hospitalization and improve survival.
- People in stage C HF should be fully vaccinated against respiratory illnesses such as COVID-19.
For people with stage C HF, the new guideline refines the current 4 classifications of HF according to LVEF with new terminology:
- HF with decreased ejection fraction (HFrEF) includes individuals with LVEF ≤40%.
- HF with improved ejection fraction (HFimpEF) includes individuals with prior LVEF ≤40% and a follow-up measurement of LVEF >40%.
- HF with mildly decreased ejection fraction (HFmrEF) includes individuals with LVEF 41-49% and evidence of elevated LV filling pressures.
- HF with preserved ejection fraction (HFpEF) includes individuals with LVEF ≥50% and evidence of elevated LV filling pressures.
Recommendations for pharmacological treatment in people with HFrEF:
- Diuretics for patients with fluid retention is recommended.
- The panel recommends the use of ARNi, and if not feasible, they recommend the use of ACEi.
- ARBs are recommended for people with an intolerance or potential adverse reaction to ACEi medicines.
- The panel also recommends mineralocorticoid receptor antagonists (MRA) or beta blockers, which was also recommended in the previous guideline.
- The guideline explains that SGLT2i are now recommended for individuals with symptomatic chronic HFrEF irrespective of the presence of type 2 diabetes.
Recommendations for people with HFmrEF or those with LVEF 41-49%:
- This population should be treated first with a SGLT2i and with diuretics as needed.
- ARNi, ACEi, ARB, MRA and beta blockers are regarded as weaker recommendations in this population due to less robust evidence in this population.
- The committee recommends people with HFmrEF should have repeat assessment of LVEF, since LVEF may change over time.
Recommendations for people with HFpEF:
- The panel recommends people with HFpEF and hypertension should seek blood pressure targets in accordance with clinical guidelines.
- SGLT2i may help reduce HF hospitalization and cardiovascular mortality.
- Symptoms can be improved by managing atrial fibrillation (AF).
- In certain individuals with HFpEF, MRAs, ARBs and ARNi may be considered, especially among those with LVEF on the lower end of the HFpEF spectrum.
The new guideline also includes recommendations for:
- Implantable cardiac devices and cardiac revascularization therapy
- Diagnosis and treatment of cardiac amyloidosis
- Specialty referrals for patients with stage D advanced HF
- Management of AF and valvular heart disease in HF and cardio-oncology
“The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients’ interests,” the panel wrote in their report.
Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published online April 1, 2022. https://doi.org/10.1161/CIR.0000000000001063