2022 AHA / ACC GUIDELINES

– HEART FAILURE

Presentor : Dr. SREELEKKHA .M

Moderator : Dr. HALESHA B.R
Chair Person : Dr. SURESH R.M
 CLASS (STRENGTH) OF RECOMMENDATION LEVEL (QUALITY) OF EVIDENCE‡

CLASS 1 (STRONG) Benefit >>> LEVEL A

Risk
• Hi gh-quality evidence‡ from more than 1 RCT
Suggested phrases for writing recommendations: • Meta -analyses of high-quality RCTs
• Is recommended • One or more RCTs corroborated by high-quality registry s tudies
• Is i ndicated/useful/effective/beneficial
• Should be performed/administered/other LEVEL B-R (Randomized)
Class of • Compa rative-Effectiveness Phrases†:
− Trea tment/strategy A i s recommended/indicated i n preference to treatment • Modera te-quality evi dence‡ from 1 or more RCTs
• Meta -analyses of moderate-quality RCTs
Recommendation B
− Trea tment A s hould be chosen over treatment B
LEVEL B-NR (Nonrandomized)

• Modera te-quality evi dence‡ from 1 or more well-designed, well-

CLASS 2a (MODERATE) Benefit >>
executed nonrandomized studies, observa tional studies, or registry
Level of Evidence Risk s tudies
• Meta -analyses of such studies
Suggested phrases for writing recommendations:
• Is reasonable
• Ca n be useful/effective/beneficial LEVEL C-LD (Limited Data)
• Compa rative-Effectiveness Phrases†:
• Ra ndomized or nonrandomized observational or registry s tudies with
− Trea tment/strategy A i s probably recommended/indicated i n preference to
l i mitations of design or execution
-Clinical Strategies, trea tment B
− It i s reasonable to choose treatment A over treatment B
• Meta -analyses of such studies
• Phys i ological or mechanistic studies in human s ubjects

-Interventions, CLASS 2b (Weak) Benefit ≥ LEVEL C-EO (Expert Opinion)

-Treatments, Risk
Suggested phrases for writing recommendations:
• Cons ensus of expert opinion based on clinical experience.

-Diagnostic Testing • Ma y/mi ght be reasonable

• Ma y/mi ght be considered
• Us efulness/effectiveness is unknown/unclear/uncertain or not well-established
in Patient Care
CLASS 3: No Benefit (MODERATE) Benefit =
Risk
Suggested phrases for writing recommendations:
• Is not recommended
• Is not indicated/useful/effective/beneficial
• Should not be performed/administered/other

CLASS 3: Harm (STRONG) Risk >

Benefit
2
Suggested phrases for writing recommendations:
• Potentially harmful
ACC/AHA Stages of HF

• STAGE A:
• At-Risk for Heart Failure
• STAGE B:
• Pre-Heart Failure
• STAGE C:
• Symptomatic Heart Failure
• STAGE D:
• Advanced Heart Failure
 STAGE A: STAGE B: STAGE C: STAGE D:
At-Risk for Heart Failure Pre-Heart Failure Symptomatic Heart Failure Advanced Heart Failure

Stages of Heart Failure

- without current or Marked HF symptoms that

previous symptoms/signs interfere with daily life and
with current or previous
of HF symptoms/signs of HF with recurrent
without current or previous hospitalizations despite
symptoms/signs of HF but attempts to optimize GDMT
-without structural/functional
evidence of 1 of the following:
heart disease or abnormal
biomarkers.
- structural heart disease,
Patients with HTN, CVD, New Onset/De Novo
- increased filling pressures,
diabetes, obesity, exposure to HF
cardiotoxic agents, Resolution of
- increased natriuretic peptide Symptoms
&
levels or cardiac troponin
genetic variant for
cardiomyopathy, or family Persistent HF
history of cardiomyopathy.
Worsening HF
7
Classification of HF by LVEF
Diagnostic Algorithm for HF and LVEF Based on
HF Classification
Natriuretic peptide
NT-proBNP > 125 pg/mL HF Diagnosis Confirmed
Assessment
BNP ≥ 35 pg/mL
• Determine cause and classify
• Clinical
history • Evaluate for precipitating
factor
• Physical
exam • Initiate treatment
• ECG, labs • Serial HF assessment
Transthoracic
Echocardiography

Additional testing, if
necessary

10
Initial Evaluation of Patients with Heart Failure
History and Physical exam Laboratory and ECG testing

Class 1 Recommendations: Class 1 Recommendations:

• Measure vitals signs and assess for evidence CBC, UA, serum electrolytes, serum
of congestion creatinine, BUN, glucose, lipid profile, LFTs,
iron studies, and TSH
• In patients with cardiomyopathy use a 3-
generation family history to screen for 12-lead ECG to optimize management
inherited disease
• lifestyle & behavioral factors which may
cause or worsen HF

11
Initial & Serial Evaluation: Use of Biomarkers
In patients with dyspnea In patients hospitalized for HF
COR RECOMMENDATIONS
COR RECOMMENDATIONS
BNP or NT-proBNP levels at admission is
1
measurement of BNP or NT- recommended to establish prognosis.
1 proBNP is useful to support a
diagnosis or exclusion of HF. predischarge BNP or NT-proBNP level can be
2a useful to inform the trajectory of the patient
and establish a post-discharge prognosis.

In patients at risk for HF

In patients with chronic HF
COR RECOMMENDATIONS

COR RECOMMENDATIONS
BNP or NT-proBNP-based
screening team-based care, to measurements of BNP or NT-
2a
prevent the development of LV proBNP levels are
dysfunction 1
recommended for risk
12
stratification.
Initial & Serial Evaluation:
Evaluation with Cardiac Imaging TTE
Chest X-Ray
Class 1 Recommendation
Class 1 Recommendation

I new-onset HF, or those presenting

with acute decompensated HF, In patients with suspected or
newly diagnosed HF,
a chest x-ray should be performed to
assess TTE should be performed during
initial evaluation to assess
- heart size
- pulmonary congestion cardiac structure and function.
- detect alternative cardiac, pulmonary,
and other diseases that may cause or
contribute to the patient’s symptoms.
 Cardiac CT, CMR Ischemia Evaluation
& SPECT/PET
Class 2a Recommendation
Class 1 Recommendation
echo. is inadequate, alternative imaging (e.g., CMR, In patients with HF, to identify the cause
cardiac CT, radionuclide imaging) is recommended and guide management .
for assessment of LVEF.

received GDMT and are being considered for invasive Class 2b Recommendation
procedures or device therapy, repeat measurement
of EF, degree of structural remodeling, & valvular In patients with HF and CAD who are
function are useful to inform therapeutic candidates for coronary revascularization,
interventions. noninvasive stress imaging (stress echo.,
single-photon emission CT [SPECT], CMR,
or PET]
Class 2a Recommendation
detection of myocardial ischemia to help
In patients with HF or cardiomyopathy, CMR can be guide coronary revascularization.
useful for diagnosis or management.
Invasive Evaluation of Patients with HF
Invasive Hemodynamics Endomyocardial Biopsy

COR RECOMMENDATIONS COR RECOMMENDATIONS

persistent or worsening symptoms,
2a signs, diagnostic parameters, and in specific diagnosis is suspected that
whom hemodynamics are uncertain 2a
would influence therapy.
In patients with HF, routine use of
3: No Benefit invasive hemodynamic monitoring is For patients undergoing routine
not recommended. evaluation of HF, endomyocardial
3: Harm
biopsy should not be performed
because of risk of complications.

15
Recommendations forandPatients
Continue Lifestyle modification withimplemented
management strategies all Stages
in Stageof
A, through
Stage B
Heart Failure
At Risk for HF (Stage A) Primary Prevention

Patients with hypertension Optimal control of BP (1)

Patients with Type 2 diabetes and CVD

SGLT2i (1)
or high risk for CVD
Patients with CVD Optimal management of CVD (1)
Patients with exposure to cardiotoxic Multidisciplinary evaluation and
agents management (1)
First-degree relatives of patients with Genetic screening
genetic or inherited cardiomyopathies and counselling (1)
Patients at risk for HF Natriuretic peptide screening (2a)

16
 Pre-HF (Stage B)
Preventing the Syndrome

Patients with LVEF ≤ 40% ACEi (1)

Patient with recent MI and LVEF ≤ 40 % ARB if ACEi intolerant (1)

Patients with LVEF ≤ 40% Beta blocker (1)

Patient with LVEF ≤ 30 %; >1 y survival;

>40 d post MI ICD (1)

Patients with nonischemic Genetic counselling and testing (2a)

cardiomyopathy
Treatment of HFrEF Stages C and D
STEP 1 STEP 2 STEP 4
Established diagnosis of STEP 3 STEP 5 STEP 6
Titrate to Target Implement
HFrEF Consider these Reassess symptoms, Referral for HF
dosing as tolerated, additional GDMT
Address congestion patient scenarios labs, health status, specialty care for
labs, health and device therapy,
Initiate GDMT status, and LVEF as indicated and LVEF additional therapy
NYHA III-IV, in Hydral-nitrates
HFrEF African American In Selected
LVEF ≤40% (Stage C) (1) Refractory HF
patients patients, durable
ARNI in NYHA II-III; LVEF ≤40% (Stage D) MCS (1)
ACEi or ARB in NYHA Persistent HFrEF NYHA I-III; LVEF ICD (1)
II-IV (1) (Stage C) ≤35%; Cardiac
>1 y survival transplant (1)
Beta blocker (1) Symptoms
CRT-D (1) improved
Palliative care (1)
MRA (1) NYHA I-III; (Can be initiated
ambulatory before Stage D)
LVEF >40% IV; LVEF ≤35%;
HFImpEF NSR and QRS Consider
SGLT2i (1)
(Stage C) ≥150 ms additional
with LBBB therapies NOTE:Investigational
Diuretics as needed studies*
*Participation in
(1)
investigational
studies is
appropriate for
Continue GDMT with serial reassessment and optimize dosing, adherence and patient education, address
stage C, NYHA class
goals of care II and III HF.

18
Additional Medical Therapies
after GDMT Optimization
Additional medical therapies after optimizing GDMT

Vericiguat Potassium
Ivabradine Digoxin PUFA
(2b) binders
( 2a) ( 2b) (2b) (2b)
In patients with In patients with In HF patients
In patients with symptomatic HF HF and NYHA II- with
In patients with
LVEF ≤ 45%; despite GDMT or IV hyperkalemia (≥
LVEF ≤ 35% with
NYHA II-III; NSR
recent HFH or IV unable to tolerate 5.5 mEq/L)
with HR ≥ 70 bpm diuretics; GDMT.
at rest on elevated NP
maximally levels. Target dose:
tolerated Beta- titrate to achieve
Blockers. serum
concentration
0.5- <0.9 ng/ml

19
Additional Device Therapies after
GDMT Optimization
Additional Device Therapies
after optimizing GDMT

In selected patients with

NYHA II-IV; NYHA II-IV;
HF LVEF ≤35% and NYHA III;
HFrEF; Severe secondary MR;
suitable coronary Elevated NP levels
severe secondary MR Suitable anatomy;
anatomy
LVEF 20-50%

Optimization of GDMT Wireless PA pressure by

Surgical Transcatheter edge-to-
before Intervention for implanted
revascularization edge MV repair
secondary MR hemodynamic monitor
(1) (2a)
(1) ( 2b)

20
Recommendations for Patients
with Mildly Reduced LVEF
Patients With HFimpEF
Treatment for HFmrEF
COR RECOMMENDATIONS

1. In patients with HFimpEF after

treatment, GDMT should be
Symptomatic HF with LVEF 41-49% continued to prevent relapse of HF
1 and LV dysfunction, even in
patients who may become
asymptomatic. (1)

Evidence-based
Diuretics, MRA beta blockers
SGLT2i ACEi, ARB, ARNi
as needed (2b)
(2a) (2b) for HFrEF
(1) (2b)

21
Recommendations for Patients
with Preserved LVEF
Treatment for HFpEF

Symptomatic HF with LVEF ≥50%

Diuretics, MRA* ARB*

SGLT2i ARNi*
as needed (2b) (2b)
(2a) (2b)
(1)

NOTE: *Greater benefit in patients with LVEF closer to 50%

22
Recommendation for Specialty Referral to
Advanced HF COR RECOMMENDATIONS
1. In patients with advanced HF, when consistent with the patient’s goals of care, timely referral for HF specialty
1 care is recommended to review HF management and assess suitability for advanced HF therapies (e.g., LVAD,
cardiac transplantation, palliative care, and palliative inotropes).

Consider if “I-Need-Help” to aid with recognition of patients with advanced HF:

• Complete assessment Edema despite
is not required before I Intravenous inotropes E EF ≤35% E escalating diuretics
referral

• After patients develop New York Heart Association

end-organ dysfunction N class IIIB or IV, or persistently D Defibrillator shocks L Low systolic BP ≤90mmHg
elevated natriuretic peptides
or cardiogenic shock,
they may no longer
quality for advanced Prognostic medication;
E End-organ dysfunction H Hospitalizations >1 P intolerance of GDMT
therapies

23
Inotropic Support
Despite improving hemodynamic compromise, positive inotropic agents have not shown
improved survival in patients with HF in either the hospital or outpatient setting.

COR RECOMMENDATIONS

1. In patients with advanced (stage D) HF refractory to GDMT and device therapy who are eligible
2a for and awaiting MCS or cardiac transplantation, continuous intravenous inotropic support is
reasonable as “bridge therapy” (Class 2a)

2. In select patients with stage D HF, despite optimal GDMT and device therapy who are ineligible
2b for either MCS or cardiac transplantation, continuous intravenous inotropic support may be
considered as palliative therapy for symptom control and improvement in functional status

3. In patients with HF, long-term use of either continuous or intermittent intravenous inotropic
3:
agents, for reasons other than palliative care or as a bridge to advanced therapies, is
Harm
potentially harmful

24
Cardiac Transplantation
Median survival of adult transplant recipients is >12 years; versus <2 years for patients with stage D
HF without advanced therapies.

COR RECOMMENDATIONS
1. For selected patients with In patients with stage D HF despite GDMT,
advanced HF despite GDMT, cardiac transplantation provides
intermediate economic value.
1 cardiac transplantation is
indicated to improve Value Statement: Intermediate Value (C-LD)
survival and QOL (1)

25
GDMT During Hospitalization
Oral GDMT should be continued and optimized on admission,
as doing so is associated with lower post-discharge death and
readmission. Special considerations
• Consider discontinuation of
beta blockers in patients with

low cardiac output,

severe volume overload,
Admission: Inpatient: Pre-Discharge:
Continue GDMT, unless Continue diuresis Re-initiate and/or advanced AV block or
contraindicated despite mild reduction optimize GDMT when
(Class 1) in renal function and BP clinically stable ACEi/ARNi with angioedema
(Class 1) (Class 1)
• VTE prophylaxis is
recommended in all
hospitalized patients

26
Decongestion Strategy
MONITORING INITIAL TITRATE** DISCHARGE
MANAGEMENT
Double IV loop diuretic dose
(Class 2a)
• Fluid intake and output
• Standardize daily Loop diuretic infusion
weight (Class 2a)
• Clinical signs of
congestion IV Loop Diuretic Sequential nephron blockade Provide diuretic
(Class 1) (e.g. thiazide) adjustment plan
• Hypoperfusion (Class 1)
(Class 2a)
• Labs:
– Electrolytes
– BUN Additional of MRA
– Creatinine
Low-dose dopamine

**Titration of diuretics and GDMT during hospitalization to resolve congestion, reduce symptoms and prevent
readmission (Class 1)

IV nitroglycerin or nitroprusside may be added as an adjunct to diuretics for dyspnea in the absence of hypotension
(Class 2b)
27
Hospitalized Patients with Cardiogenic Shock COR RECOMMENDATIONS
1. Initiate ionotropic support
• To maintain systemic
Shock: Clinical Criteria Shock: Hemodynamic Criteria 1 perfusion
I. SBP <90 mm Hg for > 30 I. SBP <90 mmHg or mean • To preserve end-organ
function
minutes BP <60 mmHg
2. Temporary MCS is reasonable
a. Mean BP < 60 mm Hg II. Cardiac Index <2.2 when end-organ function cannot
for >30 minutes L/min/m2 2a be maintained by pharmacologic
means to support cardiac
b. Requirement of III.PCW >15 mm Hg function
vasopressors to IV.Other hemodynamic 3. Management by a
maintain SBP ≥ 90 mm considerations multidisciplinary team
Hg or mean BP ≥60 mm 2a
a. Cardiac power output experienced in shock is
Hg reasonable
<0.6 W
II. Hypoperfusion: 4. Consider placement of PA line to
b. Shock index >1 define hemodynamic subsets
a. Decreased mentation 2b
and appropriate management
c. RV shock
b. Cold extremities, livedo •pulmonary artery strategies
reticularis pulse index <1 5. Unable to maintain end-organ
function triage to centers with
c. Urine output < 30 mL/h •CVP > 15 mm Hg 2b
MCS capabilities should be
d. Lactate >2 mmol/L •CVP-PCW >0.6 considered
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Transitions of Care A transition of care plan should be
communicated prior to discharge (1)

This should include…

1 Early follow-up, ideally within 7 days (Class 2a)

Referrals to multidisciplinary HF management programs

2 (Class 1)

Participation in benchmarking programs to improve GDMT

3 and quality of care (Class 2a)

Addressing precipitating causes and high-risk factors (e.g.

4 co-morbidities and SDOH)

5 Adjusting diuretics

6 Coordination of safety laboratory checks

29
Recommendations for Management of AF in HF
COR RECOMMENDATIONS COR RECOMMENDATIONS
Patients with chronic HF with For patients with HF and
permanent-persistent- symptoms caused by AF, AF
2a ablation is reasonable to improve
paroxysmal AF and a
symptoms and QOL.
1 CHA2DS2-VASc score of ≥2
(for men) and ≥3 (for women) For patients with AF and LVEF
should receive chronic ≤50%, if a rhythm control strategy
anticoagulant therapy. fails or is not desired, and
2a ventricular rates remain rapid
For patients with chronic HF despite medical therapy, AV nodal
with permanent-persistent- ablation with implantation of a
1 paroxysmal AF, DOAC is CRT device is reasonable.
recommended over warfarin For patients with chronic HF and
in eligible patients. permanent-persistent-paroxysmal
2a AF, chronic anticoagulant therapy
is reasonable for men and women
without additional risk factors. 30
Recommendations for Cardio-Oncology
COR RECOMMENDATIONS
In patients who develop cancer therapy–related cardiomyopathy or HF, a multidisciplinary
1 discussion involving the patient about the risk-benefit ratio of cancer therapy interruption,
discontinuation, or continuation is recommended to improve management.
In asymptomatic patients with cancer therapy–related cardiomyopathy (EF <50%), ARB,
2a
ACEi, and BBs are reasonable to prevent progression to HF and improve cardiac function.
In patients with CV risk factors or known cardiac disease being considered for potentially
2a cardiotoxic anticancer therapies, pretherapy evaluation of cardiac function is reasonable to
establish baseline cardiac function and guide the choice of cancer therapy.
In patients with CV risk factors or known cardiac disease receiving potentially cardiotoxic
2a anticancer therapies, monitoring of cardiac function is reasonable for the early
identification of drug-induced cardiomyopathy.
In patients at risk of cancer therapy–related cardiomyopathy, initiation of beta blockers
2b and ACEi-ARB for the primary prevention of drug-induced cardiomyopathy is of uncertain
benefit.
In patients being considered for potentially cardiotoxic therapies, serial measurement of
2b 31
cardiac troponin might be reasonable for further risk stratification.
Recommendations for HF and Pregnancy
In women with a In women with acute
In women with HF or
history of HF HF caused by
cardiomyopathy, cardiomyopathy who
peripartum
are pregnant or
including previous cardiomyopathy and
currently planning for
peripartum LVEF <30%,
pregnancy,
cardiomyopathy,

patient-centered anticoagulation may

ACEi, ARB, ARNi, MRA,
counseling regarding be reasonable at
SGLT2i, ivabradine, and
contraception diagnosis,
vericiguat should not
and
be administered
until 6 to 8 weeks
risks of because of
postpartum,(
cardiovascular
deterioration during (although the efficacy
significant risks of
pregnancy should be and safety are
fetal harm (3 – Harm)
provided (1) uncertain (2b))
32
Additional Therapies in Patients
with HF and Comorbidities
In addition to optimized GDMT

Patients with HF and hypertension Optimal treatment according to

hypertension guidelines (1)

Patients with HF and SGLT2i for management of hyperglycemia

type 2 diabetes (1)

Select patients with HF and LVEF < 35% and Surgical

suitable coronary anatomy revascularization (1)

Patients with HF attributable to VHD or Multidisciplinary

cancer therapy Management (1)

Select patients with

Anticoagulation (1)
HF and AF
33
 Patients with HFrEF and IV iron replacement (2a)
iron deficiency

Patients with AF and LVEF < 50% if rhythm

control strategy fails/not desired and AV nodal ablation and
ventricular rates remain rapid despite CRT implantation (2a)
medical therapy

Patients with HF and symptoms attributable Atrial Fibrillation

to AF ablation (2a)

Patients with HF with CPAP (2a)

obstructive sleep apnea

In asymptomatic patients with

cancer therapy-related cardiomyopathy (EF ARB, ACEi, and
< 50%) beta blockers (2a)
Performance Measures
• Performance measures can be implemented in both inpatient and outpatient settings
• Hospitals performing well on medication-related performance measures have better HF mortality
rates.
• Hospitals participating in registries have better processes of care and outcomes.

COR RECOMMENDATIONS

IMPROVING THE 1. Performance measures based on professionally developed

QUALITY OF CARE 1 CPGs should be used with the goal of improving quality of
care for patients with HF.

2. Participation in QI ( Quality Improvement )programs,

2a including patient registries can be beneficial in improving
the quality of care for patients with HF.

35
Goals of Care
COR RECOMMENDATIONS
1. For all patients with HF, palliative and supportive care-including high quality
communication, conveyance of prognosis, clarifying goals of care, shared decision-
1
making, symptom management, and caregiver support-should be provided to improve
QOL and relieve suffering.
2. For patients with HF being considered for, or treated with, life-extending therapies, the
option for discontinuation should be anticipated and discussed through the continuum
1
of care, including at the time of initiation, and reassessed with changing medical
conditions and shifting goals of care.
3. For patients with HF, execution of advance care directives can be useful to improve
2a documentation of treatment preference, delivery of patient-centered care, and dying in
preferred place.
4. For patients with HF– particularly stage D HF patients being evaluated for advanced
therapies, patients requiring inotropic support or temporary mechanical support,
2a patients experiencing uncontrolled symptoms, major medical decisions, or
multimorbidity, frailty, and cognitive impairment – specialist palliative care consultation
can be useful to improve QOL and relieve suffering.
5. In patients with advanced HF with expected survival <6 months, timely referral to
2a Abbreviations: HF indicates heart failure; and QOL, quality of life.

hospice can be useful to improve QOL.

36
Patient Reported Outcomes
COR RECOMMENDATIONS
In patients with HF, standardized assessment of patient reported health status using a validated questionnaire can
2a
be useful to provide incremental information for patient functional status, symptoms burden and prognosis.

Health status encapsulates symptoms, functional status, and

health-related QOL.

NYHA-I NYHA-II NYHA-III NYHA-IV

Comfortable
No Comfortable Unable to
at rest, but
at rest, but
limitation of ordinary
less than carry on any
physical ordinary physical
activity activity with
activity activity
results in symptoms
results in
symptoms
symptoms

37
REFERENCES
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063
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