Heart Failure Clinical Practice Guidelines (ACC/AHA/HFSA, 2022)

American College of Cardiology, American Heart Association, and Heart Failure Society of America

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

May 19, 2022

Updated and revised guidelines on the management of heart failure (HF) were published in May 2022 by the American College of Cardiology, American Heart Association, and Heart Failure Society of America (ACC/AHA/HFSA) in Circulation.[1,2,3,4] These guidelines replace the 2013 and 2017 recommendations with significant and paradigm-shifting additional treatment options that include new/repurposed drug therapies that benefit almost without regard to ejection fraction (EF); additional disease-staging terminology that characterizes HF as a continuum; updated recommendations for advanced HF, acute HF, and comorbidities; as well as other guidance.

Top 10 Key Points

  1. Four core foundational medication classes (sodium-glucose cotransporter-2 inhibitors [SGLT2Is], beta blockers, mineralocorticoid receptor antagonists [MRAs], and renin-angiotensin system [RAS] inhibitors) are now included in guideline-directed medical therapy (GDMT) for HF with reduced EF (HFrEF).

  2. SGLT2Is are a class 2a (moderate) recommendation in HF with mildly reduced EF (HFmrEF), whereas angiotensin receptor-neprilysin inhibitors (ARNIs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), MRAs, and beta blockers are class 2b (weak) recommendations for this patient population.

  3. There are new recommendations for HF with preserved EF (HFpEF) for SGLT2Is (class 2a), MRAs (class 2b), and ARNIs (class 2b). Renewed recommendations include those for treatment of hypertension (class 1 [strong]) and of atrial fibrillation (AF) (class 2a); use of ARBs (class 2b); as well as avoidance of the routine use of nitrates or phosphodiesterase-5 (PDE5) inhibitors (class 3 [no benefit]).

  4. Patients with previous HFrEF who now have a left ventricular (LV) EF above 40% should be referred to as having improved LVEF; they should continue their HFrEF treatment.

  5. The ACC/AHA/HFSA created value statements for select recommendations in which there are high-quality, cost-effectiveness studies of the intervention published.

  6. New amyloid heart disease treatment recommendations include screening for serum and urine monoclonal light chains, bone scintigraphy, genetic sequencing, tetramer stabilizer therapy, and anticoagulation.

  7. It is important for evidence to support increased filling pressures for the diagnosis of HF if the LVEF is over 40%. Such evidence can be obtained from noninvasive (eg, natriuretic peptide, diastolic function on imaging) or invasive testing (eg, hemodynamic measurement).

  8. Refer those with advanced HF who desire prolonged survival to a team that specializes in HF. These teams review HF management, assess candidacy for advanced HF therapies, and use palliative care such as palliative inotropes when it is consistent with the patient’s goals of care.

  9. Primary prevention is crucial for those at risk for HF (stage A) or pre-HF (stage B). The revised stages of HF emphasize the new terminologies of “at risk” for HF for stage A and pre-HF for stage B.

  10. Updated and new recommendations cover select patients with HF and iron deficiency, anemia, coronary artery disease, AF, valvular heart disease, cardiomyopathy, hypertension, type 2 diabetes, sleep disorders, and malignancy.

For more information, please go to Heart Failure, Atrial Fibrillation, Cardiac Amyloidosis, Dilated Cardiomyopathy, Hypertrophic Cardiomyopathy, Pacemakers and Implantable Cardioverter-Defibrillators, and Cardiac Resynchronization Therapy.


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