AHA Clinical Update

ADAPTED FROM:
2022 AHA/ACC/HFSA Guideline for
Heart Failure
 TABLE OF CONTENTS
» Definition of HF decompensated HF
» Epidemiology and Causes » Comorbidities in patients with HF
» Initial and Serial Evaluation » Special Populations
» Stage A (Patients at risk for HF) & » Quality Metrics and Reporting
Stage B (Patients with Pre-HF)
» Goals of Care
» Stage C HF & Stage D (Advanced) HF
» Patient-Reported Outcomes and Evidence Gaps
» Value Statements and Future Research Directions

» Additional Medical Therapies after GDMT Opt

imization
» Device and Interventional Therapies for HFrEF

» Valvular Heart Disease

» Recommendations for Patients with Mildly Red
uced LVEF 2
 CLASS (STRENGTH) OF RECOMMENDATION LEVEL (QUALITY) OF EVIDENCE‡

CLASS 1 (STRONG) LEVEL A

Benefit >>> Risk
• High-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 studies
• Is indicated/useful/effective/beneficial
• Should be performed/administered/other LEVEL B-R
• Comparative-Effectiveness Phrases†:
− Treatment/strategy A is recommended/indicated in preference to treatment B
(Randomized)

Table 1. − Treatment A should be chosen over treatment B • Moderate-quality evidence‡ from 1 or more RCTs
• Meta-analyses of moderate-quality RCTs

Applying Class of CLASS 2a (MODERATE)

LEVEL B-NR
(Nonrandomized)
Recommendation and Benefit >> Risk
Suggested phrases for writing recommendations:
• Moderate-quality evidence‡ from 1 or more well-designed, well-executed

Level of Evidence to
nonrandomized studies, observational studies, or registry studies
• Is reasonable • Meta-analyses of such studies
• Can be useful/effective/beneficial

Clinical Strategies,
• Comparative-Effectiveness Phrases†:
− Treatment/strategy A is probably recommended/indicated in preference to
treatment B LEVEL C-LD

Interventions, − It is reasonable to choose treatment A over treatment B (Limited Data)

• Randomized or nonrandomized observational or registry studies with
Treatments, or CLASS 2b (Weak)
Benefit ≥ Risk
limitations of design or execution
• Meta-analyses of such studies

Diagnostic Testing in
• Physiological or mechanistic studies in human subjects
Suggested phrases for writing recommendations:
• May/might be reasonable
LEVEL C-EO (Expert
Patient Care • May/might be considered
• Usefulness/effectiveness is unknown/unclear/uncertain or not well-established Opinion)
COR and LOE are determined independently (any COR may be paired with any LOE).
A•recommendation
Consensus of with
expertLOE C doesbased
opinion not imply that the recommendation
on clinical experience. is weak. Many
important clinical questions addressed in guidelines do not lend themselves to clinical trials.
CLASS 3: No Benefit (MODERATE) Although RCTs are unavailable, there may be a very clear clinical consensus that a particular
Benefit = Risk test or therapy is useful or effective.
Suggested phrases for writing recommendations: *The outcome or result of the intervention should be specified (an improved clinical outcome
• Is not recommended or increased diagnostic accuracy or incremental prognostic information).
• Is not indicated/useful/effective/beneficial †For comparative-effectiveness recommendation (COR 1 and 2a; LOE A and B only), studies
• Should not be performed/administered/other that support the use of comparator verbs should involve direct comparisons of the treatments
or strategies being evaluated.
CLASS 3: Harm (STRONG) ‡The method of assessing quality is evolving, including the application of standardized,
Risk > Benefit widely-used, and preferably validated evidence grading tools; and for systematic reviews, the
incorporation of an Evidence Review Committee.
Suggested phrases for writing recommendations: COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level
• Potentially harmful of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled trial.
• Causes harm
• Associated with excess morbidity/mortality 3
Heidenreich,
• Should not beP.performed/administered/other
A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation.
 Stages of Heart Failure
STAGE A: STAGE B: STAGE C: STAGE D:
At-Risk for Heart Failure Pre-Heart Failure Symptomatic Heart Failure Advanced Heart Failure
Patients at risk for HF but without
current or previous symptoms/signs Patients without current or previous
of HF and without symptoms/signs of HF but evidence
structural/functional heart disease or of 1 of the following: structural Marked HF symptoms that interfere
abnormal biomarkers. heart disease, increased filling Patients with current or previous with daily life and with recurrent
pressures, or risk factors and symptoms/signs of HF hospitalizations despite attempts to
Patients with HTN, CVD, diabetes, increased natriuretic peptide levels optimize GDMT
obesity, exposure to cardiotoxic or cardiac troponin (in the absence
agents, genetic variant for of competing diagnosis)
cardiomyopathy, or family history
of cardiomyopathy.

New Onset/De Novo HF

Trajectory of Resolution of Symptoms
Stage C HF
Persistent HF

Worsening HF

Abbreviations: CVD indicates cardiovascular disease; GDMT, guideline-directed medical therapy; HF, heart failure; HTN, hypertension; and NYHA, New York Heart Association.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 4
Diagnostic Algorithm for HF and LVEF
Based on HF Classification
Natriuretic peptide HF Diagnosis Confirmed
NT-proBNP > 125 pg/mL • Determine cause and classify
Assessment BNP 35 pg/mL • Evaluate for precipitating factors
• Clinical history • Initiate treatment
• Physical exam • Serial HF assessment
• ECG, labs Transthoracic Echocardiography
Additional testing, if necessary
Initial Classification Serial Assessment &
Reclassification

HFrEF HFrEF LVEF 40%

LVEF 40%
HFimpEF LVEF>40%

HFrEF LVEF 40%

HFmrEF
HFmrEF LVEF 41%-
LVEF 41%-49%
49%
*LVEF 50% * There is limited
evidence to guide
treatment for
HFrEF LVEF 40% patients who
improve their
HFpEF LVEF from mildly
HFmrEF LVEF 41%- reduced (41-49%)
LVEF 50%
49% to 50%. It is
HFpEF LVEF 50% unclear whether to
treat these patients
Abbreviations: BNP indicates B-type natriuretic peptide; ECG, electrocardiogram; HF, heart failure; HFimpEF, heart failure with improved as HFpEF or
ejection fraction; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, HFmrEF.
heart failure with reduced ejection fraction; LV, left ventricle; LVEF, left ventricular ejection fraction; and NT-proBNP, N-terminal pro-B type
natriuretic peptide.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 5
Epidemiology of Heart Failure in the United States

Increase in HF related deaths from

2009 to 2014. Racial and ethnic disparities in death resulting from
HF persist.

Age-adjusted mortality rates for HF: 92/100,000 for

Increase in HF hospitalizations from non-Hispanic Black patients
2013 to 2017. 87/100,000 for non-Hispanic White patients
53/100,000 for Hispanic patients

Disparities in racial and ethnic HF outcomes

Decline in overall HF incidence from
warrant studies and health policy changes to address
2011 to 2014 with declining incidence
health inequity.
of HFrEF but increasing incidence of
HFpEF.

Abbreviations: HF indicates heart failure; HFpEF, heart failure with preserved ejection fraction; and HFrEF, heart failure with reduced ejection fraction.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 6
Causes of Heart Failure

Ischemic Heart Disease & Myocardial Infarction

Risk Factors
Non-Ischemic Causes
• HTN
• Obesity • Chemotherapy, cardiotoxic • HTN
• Prediabetes/DM medications • Infiltrative cardiac disease
• ASCVD • Rheumatologic or autoimmune (amyloid, sarcoid, hemochromatosis)
• Endocrine or metabolic • Myocarditis
• Familial, inherited or genetic • Peripartum cardiomyopathy
heart disease • Stress cardiomyopathy
• Heart rhythm-related (Takotsubo)
(tachycardia-mediated, PVCs, RV • Substance abuse
pacing)

Abbreviations: ASCVD indicates atherosclerotic cardiovascular disease; DM, diabetes mellitus; HTN, hypertension; PVC, premature ventricular contraction; and RV, right ventricle.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 7
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 of

congestion CBC, UA, serum electrolytes, serum creatinine, BUN,
glucose, lipid profile, LFTs, iron studies, and TSH
• Evaluate for the presence of advanced HF
• In patients with cardiomyopathy use a 3-generation 12-lead ECG to optimize management
family history to screen for inherited disease
For patients presenting with HF, the specific cause of HF
• Use H&P to direct diagnostic strategies to uncover should be explored using additional laboratory testing for
causes which require disease specific management appropriate management
• Identify cardiac & non-cardiac diseases, lifestyle &
behavioral factors, and SDOH which may cause or
worsen HF

Abbreviations: BUN indicates blood urea nitrogen; CBC indicates complete blood count; ECG, electrocardiogram; H&P, history and
physical; HF, heart failure; LFTs, liver function tests; SDOH, social determinates of health; and TSH, thyroid-stimulating hormone.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 8
 Initial & Serial Evaluation: Use of Biomarkers

In patients with dyspnea In patients hospitalized for HF

COR RECOMMENDATIONS COR RECOMMENDATIONS
In patients hospitalized for HF, measurements of BNP
REMINDER
In patients presenting with dyspnea, measurement of 1 or NT-proBNP levels at admission is recommended to
1 BNP or NT-proBNP is useful to support a diagnosis or establish prognosis. Potential noncardiac causes
exclusion of HF. of elevated natriuretic
In patients hospitalized for HF, a predischarge BNP or
peptide levels may include
2a NT-proBNP level can be useful to inform the trajectory
of the patient and establish a post-discharge prognosis. advancing age, anemia,
renal failure, severe
pneumonia, obstructive
In patients at risk for HF In patients with chronic HF sleep apnea, pulmonary
embolism, pulmonary
COR RECOMMENDATIONS COR RECOMMENDATIONS arterial hypertension,
In patients with chronic HF, measurements of BNP or critical illness, bacterial
In patients at risk of developing HF, BNP or NT- 1 NT-proBNP levels are recommended for risk sepsis, and severe burns.
proBNP-based screening following team-based care, stratification.
2a including a CV specialist, can be useful to prevent
the development of LV dysfunction or new onset HF.

Abbreviations: BNP indicates B-type natriuretic peptide; CV, cardiovascular; HF, heart failure; and NT-proBNP, N-terminal prohormone of B-type natriuretic peptide.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 9
 Initial & Serial Evaluation:
Evaluation with Cardiac Imaging
Cardiac CT, CMR &
Chest X-Ray TTE SPECT/PET Ischemia Evaluation
Class 1 Recommendation Class 1 Recommendation Class 1 Recommendation Class 2a Recommendation Class 3 No Benefit

In patients with suspected or In patients with suspected or In patients for whom echo. is In patients with HF, an In patients with HF in the
new-onset HF, or those newly diagnosed HF, TTE inadequate, alternative imaging (e.g., evaluation for possible absence of:
presenting with acute should be performed during CMR, cardiac CT, radionuclide ischemic heart disease can be 1) clinical status change, 2)
decompensated HF, a chest initial evaluation to assess imaging) is recommended for useful to identify the cause treatment interventions that
x-ray should be performed to cardiac structure and assessment of LVEF. and guide management . might have had a
assess heart size and function. significant effect on cardiac
pulmonary congestion and to In patients with HF who have had a function, or 3) candidacy
detect alternative cardiac, significant clinical change, or who Class 2b Recommendation for invasive procedures or
pulmonary, and other have received GDMT and are being device therapy, routine
diseases that may cause or considered for invasive procedures or In patients with HF and CAD repeat assessment of LV
contribute to the patient’s device therapy, repeat measurement who are candidates for function is not indicated.
symptoms. of EF, degree of structural coronary revascularization,
remodeling, & valvular function are noninvasive stress imaging
useful to inform therapeutic (stress echo., single-photon
interventions. emission CT [SPECT], CMR,
or PET] may be considered
Class 2a Recommendation for detection of myocardial
ischemia to help guide
In patients with HF or coronary revascularization.
cardiomyopathy, CMR can be useful
for diagnosis or management.

Abbreviations: CAD indicates coronary artery disease; CMR, cardiac magnetic resonance; CT, computed tomography; echo, echocardiography; EF, ejection fraction; GDMT,
guideline-directed medical therapy; LVEF, left ventricular ejection fraction; PET, position emission tomography; SPECT, single-photon emission CT; and TTE, transthoracic
echocardiography.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 10
Initial & Serial Evaluation:
Invasive Evaluation of Patients with HF

Invasive Hemodynamics Endomyocardial Biopsy

COR RECOMMENDATIONS COR RECOMMENDATIONS

In select patients with HF with persistent or

worsening symptoms, signs, diagnostic In patients with HF, endomyocardial biopsy may
2a parameters, and in whom hemodynamics are 2a be useful when a specific diagnosis is suspected
uncertain, invasive hemodynamic monitoring that would influence therapy.
can be useful to guide management.

For patients undergoing routine evaluation of

3: No In patients with HF, routine use of invasive
3: Harm HF, endomyocardial biopsy should not be
Benefit hemodynamic monitoring is not recommended.
performed because of risk of complications.

Guiding Principle: Invasive evaluations are most appropriate when they will guide management and influence
therapy. Due to the risk of complications, invasive procedures should not be used for the routine evaluation of HF.

Abbreviation: HF indicates heart failure.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 11
 Initial & Serial Evaluation
Wearables & Remote Monitoring Exercise & Functional Capacity Testing

Adult patients with COR RECOMMENDATIONS

NYHA III HF
1. In patients with HF, assessment and
documentation of NYHA functional
HF hospitalization in the past 1 classification are recommended to
year or elevated natriuretic determine eligibility for
peptide levels treatments

2. In selected ambulatory patients with

HF, CPET is recommended to
Maximally tolerated stable doses
Source: Pennmedicine.org
of GDMT with optimal device
1 determine appropriateness of
advanced treatments (e.g., LVAD,
therapy heart transplant)
In patients with NYHA class III
HF with a HF hospitalization 3. In ambulatory patients with HF,
The usefulness of wireless performing a CPET or 6- minute
within the previous year, wireless monitoring of PA pressure by an 2a walk test is reasonable to assess
implanted hemodynamic monitor functional capacity
monitoring of the PA pressure by to reduce the risk of subsequent
an implanted hemodynamic HF hospitalizations is uncertain. 4. In ambulatory patients with
(Class 2b) unexplained dyspnea, CPET is
monitor provides uncertain value. 2a reasonable to evaluate the cause of
Value Statement: Uncertain Value (B-NR)
dyspnea

Abbreviations: CPET indicates cardiopulmonary exercise testing; GDMT, guideline-directed medical therapy; HF, heart failure;
LVAD, left ventricular assist device; NYHA, New York Heart Association; and PA, pulmonary artery.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 12
Initial & Serial Evaluation: Clinical Assessment
HF Risk Scoring Selected Multivariable Risk Scores to Predict Outcome in HF

COR RECOMMENDATIONS Acutely Decompensated HF Chronic HF

In ambulatory or hospitalized ADHERE Classification All patients HFpEF specific HFrEF specific
patients with HF, validated and Regression Tree
2a multivariable risk scores can be (CART) Model
Seattle Heart
useful to estimate subsequent risk
of mortality. AHA Get with The Failure model I- GUIDE-IT
Guidelines score PRESERV
E Score
MAGGIC PARADIGM -
EFFECT Risk score TOPCAT HF
Heart failure HF- ACTION
survival score
ESCAPE Risk Model and
Discharge score
CHARM Risk
score

CORONA
Risk score

Abbreviations: ADHERE indicates Acute Decompensated Heart Failure National Registry; AHA, American Heart Association; ARIC, Atherosclerosis Risk in Communities; CHARM, Candesartan in Heart
failure-Assessment of Reduction in Mortality and morbidity; CORONA, Controlled Rosuvastatin Multinational Trial in Heart Failure; EFFECT, Enhanced Feedback for Effective Cardiac Treatment;
ESCAPE, Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness; GUIDE-ID, Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment; HF,
heart failure; HFpEF, heart failure with preserved ejection fraction; HF-ACTION, Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training MAGGIC Meta-analysis Global Group in
Chronic Heart Failure; I-PRESERVE, Irbesartan in Heart Failure with Preserved Ejection Fraction Study; PCP-HF, Pooled Cohort Equations to Prevent HF; and TOPCAT, Treatment of Preserved Cardiac
Function Heart Failure with an Aldosterone Antagonist trial.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 13
 Recommendations for Patients
at Risk of HF & Pre-HF
At Risk for HF (Stage A) Pre-HF (Stage B)
Primary Prevention Preventing the Syndrome
Patients with hypertension Optimal control of BP (1)
Patients with LVEF ≤ 40% ACEi (1)

Patients with Type 2 diabetes and SGLT2i (1)

CVD or high risk for CVD Patient with recent MI and LVEF
≤ 40 % ARB if ACEi intolerant (1)

Patients with CVD Optimal management of CVD (1)

Patients with LVEF ≤ 40% Beta blocker (1)

Patients with exposure to Multidisciplinary evaluation and

cardiotoxic agents management (1) Patient with LVEF ≤ 30 %; >1 y
survival; >40 d post MI ICD (1)
First-degree relatives of patients
with genetic or inherited Genetic screening
cardiomyopathies and counselling (1) Patients with nonischemic Genetic counselling and testing
cardiomyopathy (2a)

Patients at risk for HF Natriuretic peptide screening (2a)

Validated multivariable risk score

Patients at risk for HF
(2a)

Continue Lifestyle modification and management strategies implemented in Stage A, through Stage B
Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BP, blood pressure; CVD, cardiovascular disease; HF, heart
failure; ICD, implantable cardioverter-defibrillator; LVEF, left ventricular ejection fraction; MI, myocardial infarction; and SGLT2i, sodium glucose cotransporter 2
inhibitor.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 14
 Treatment of HFrEF Stages C and D
STEP 1 STEP 2 STEP 3 STEP 4
Established diagnosis of HFrEF Titrate to Target dosing as Consider these patient Implement additional GDMT
STEP 5 STEP 6
Address congestion tolerated, labs, health scenarios Reassess symptoms, labs, Referral for HF specialty care
and device therapy, as
Initiate GDMT status, and LVEF health status, and LVEF for additional therapy
indicated

HFrEF NYHA III-IV, in African In Selected patients,

Hydral-nitrates (1) durable MCS (1)
LVEF ≤40% (Stage C) American patients

Refractory HF
ARNI in NYHA II-III; (Stage D)
NYHA I-III; LVEF
ACEi or ARB in NYHA II-IV LVEF ≤40% ≤35%; ICD (1) Cardiac transplant (1)
(1) Persistent HFrEF >1 y survival
(Stage C)
Symptoms improved
Beta blocker (1) NYHA I-III; ambulatory
IV; LVEF ≤35%; Palliative care (1)
CRT-D (1) (Can be initiated before
NSR and QRS ≥150 ms
with LBBB Stage D)

MRA (1)
LVEF >40%
HFImpEF Consider additional Investigational studies*
(Stage C) therapies
SGLT2i (1)

NOTE: *Participation in
investigational studies is
Diuretics as needed (1) appropriate for stage C,
NYHA class II and III HF.

Continue GDMT with serial reassessment and optimize dosing, adherence and patient education, address goals of
care
Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; CRT, cardiac resynchronization
therapy; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; hydral-nitrates, hydralazine and isosorbide dinitrate; ICD,
implantable cardioverter-defibrillator; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; MCS, mechanical circulatory support; MRA, mineralocorticoid receptor
antagonist; NSR, normal sinus rhythm; NYHA, New York Heart Association; SCD, sudden cardiac death; and SGLT2i, sodium-glucose cotransporter 2 inhibitor.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 15
 Value Statements for GDMT for HFrEF
An important aspect of HF care, Class 1 recommended
Take Home Point: medical therapies for HFrEF have very high value (low
cost).
In patients:
With previous or With chronic With HFrEF and With HFrEF, with With symptomatic
current symptoms of symptomatic NYHA class II to current or previous chronic HFrEF,
chronic HFrEF, in HFrEF, tx with an IV symptoms, symptoms, beta- SGLT2i therapy
whom ARNi is not ARNi instead of an MRA therapy blocker therapy provides
feasible, tx with ACEi ACEi provides high provides high provides high intermediate
or ARB provides high economic value. economic value. economic value. economic value.
economic value. Value Statement: Value Statement: Value Statement: Value Statement:
Value Statement: High Value (A) High Value (A) High Value (A) Intermediate Value (A)
High Value (A)

Self-identified as African American with NYHA class III to IV HFrEF who are receiving optimal medical therapy with
ACEi or ARB, beta blockers, and MRA, the combination of hydralazine and isosorbide dinitrate provides high
economic value.
Value Statement: High Value (B-NR)
Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HFrEF, heart failure with reduced ejection fraction;
MRA, mineralocorticoid receptor antagonist; SGLT2i, NR, non-randomized; sodium-glucose cotransporter 2 inhibitor; and tx, treatment.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 16
Value Statements for Device Therapy

A transvenous ICD provides high economic value in the primary prevention of SCD
particularly when the patient’s risk of death caused by ventricular arrythmia is
deemed high and the risk of nonarrhythmic death (either cardiac or noncardiac) is
deemed low based on the patient’s burden of comorbidities & functional status.
Value Statement: High Value (A)

For patients who have LVEF <35%, sinus rhythm, LBBB with a QRS duration of >150
ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT, CRT implantation
provides high economic value.
Value Statement: High Value (B-NR)

Abbreviations: CRT indicates cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; ICD; implantable cardioverter-defibrillator; LBBB, left
bundle branch block; LVEF, left ventricular ejection fraction; ms; millisecond; NR, nonrandomized; NYHA, New York Heart Association; and SCD, sudden
cardiac death.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 17
 Additional Medical Therapies
after GDMT Optimization
Additional medical therapies after optimizing GDMT

Ivabradine Vericiguat Potassium

Digoxin PUFA
( 2a) (2b) binders
( 2b) (2b)
(2b)

In patients with symptomatic In patients with HF and In HF patients with

In patients with LVEF ≤ In patients with LVEF ≤
HF despite GDMT or unable NYHA II-IV hyperkalemia (≥ 5.5
35% with NYHA II-III; 45%; recent HFH or IV
to tolerate GDMT. mEq/L) while taking
NSR with HR ≥ 70 bpm at diuretics; elevated NP Dose: 1 gram daily of
rest on maximally tolerated levels. n-3PUFA (850-880 mg of RAASi.
Initial dose: 0.125-0.25 mg QID EPA and DHA)
Beta- Blockers. Initial dose: 2.5 mg QID (follow monogram)
Medications:
Patiromer; sodium zirconium
Initial dose: 5 mg BID Target dose: 10 mg QID cyclosilicate
Target dose:
Target dose: 7.5 mg BID
titrate to achieve
serum concentration
0.5- <0.9 ng/ml

Abbreviations: DHA indicates docosaexaenoic acid; EPA, eicosapentaenoic acid; GDMT, guideline-directed medical therapy; HF, heart failure; HFH,
heart failure hospitalization; HR, heart rate; IV, intravenous; LVEF, left ventricular ejection fraction; NP, natriuretic peptide; NSR, normal sinus
rhythm; NYHA, New York Heart Association; PUFA, polyunsaturated fatty acid; and RAASi, renin-angiotensin-aldosterone system inhibitors.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 18
Algorithm for CRT Indications in Patients
with Cardiomyopathy or HFrEF
CRT recommendations
Patients with HF on GDMT >3mo and > 40 d if after MI, or with a special indication for pacing

Comorbidities limit Continue GDMT

General health status survival to <1 year without device

Evaluate LVEF

LVEF ≤35% LVEF 36-50%

NYHA II- Amb Class Special High degree or

NYHA I Circumstances
IV complete heart
block(2a)

LBBB ≥150ms (1) AF

LVEF≤30%; RV pacing frequent
Ischemic CM; or anticipated (2a)
LBBB≥150ms Non LBBB≥150 ms (2a)
(2b)
LBBB 120-149 ms(2a) NSR
RV pacing frequent
Non LBBB 120-149 ms or anticipated (2a)
(2b)
Abbreviations: AF indicates atrial fibrillation; Amb, ambulatory; CM, cardiomyopathy; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical
therapy; HB, heart block; HF, Heart Failure; HFH, heart failure hospitalization; HFrEF, heart failure with reduced ejection fraction; LBBB, left bundle branch
block; LVEF, left ventricular ejection fraction; NSR, normal sinus rhythm; NYHA, New York Heart Association; and RV, right ventricle.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 19
Additional Device Therapies after GDMT
Optimization
Additional Device Therapies
after optimizing GDMT

NYHA II-IV;
Severe secondary MR;
In selected patients with HF NYHA II-IV; NYHA III;
Suitable anatomy;
LVEF ≤35% and HFrEF; History of HFH or
LVEF 20-50%;
suitable coronary anatomy severe secondary MR Elevated NP levels
LVESD ≤70 mm;
PASP ≤70 mmHg

Surgical Optimization of GDMT before Transcatheter edge-to-edge MV Wireless PA pressure by

revascularization Intervention for secondary MR repair implanted hemodynamic monitor
(1) (1) (2a) ( 2b)

Abbreviations: GDMT indicates guideline-directed medical therapy; HF, heart failure; HFH, heart failure hospitalization; HFrEF, heart failure with reduced ejection
fraction; LVEF, left ventricular ejection fraction; LVESD, left ventricular end systolic dimension; MR, mitral regurgitation; MV, mitral valve; NP, natriuretic
peptide; NSR, normal sinus rhythm; NYHA, New York Heart Association; and PASP, pulmonary artery systolic pressure.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 20
 Treatment Approach in
Secondary Mitral Regurgitation
Secondary Mitral Regurgitation

GDMT supervised by HF specialist (1)

Severe Stage D MR Undergoing CABG

(Rvol ≥60 ml, RF≥50%, ERO≥0.40 cm2)

MV surgery* (2a)
LVEF ≥50% LVEF <50%

NOTE: Severe persistent Persistent symptoms on

*Chordal-sparing MV symptoms on optimal optimal GDMT
replacement may be reasonable GDMT and AF Rx
to choose over downsized
annuloplasty repair. Mitral anatomy favorable:
MV surgery (2b) LVEF 20-50%; LVESD≤70mm; NO Severe symptoms MV surgery (2b)
PASP≤70 mmHg?
Transcatheter edge-to-edge MV repair
YES (2a)
Abbreviations: AF indicates atrial fibrillation; CABG, coronary artery bypass graft; ERO, effective regurgitant orifice; GDMT, guideline-directed
medical therapy; HF, Heart Failure; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diameter; MR, mitral
regurgitation; MV, mitral valve; PASP, pulmonary artery systolic pressure; RF, regurgitant fraction; Rvol, regurgitant volume; and Rx,
medication. Guideline for Heart Failure. Circulation.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA 21
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, ACEi, ARB, MRA beta blockers
SGLT2i
as needed ARNi (2b) for HFrEF
(2a)
(1) (2b) (2b)

Abbreviations: ARB indicates angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HF, heart failure; HFpEF, heart failure with
preserved ejection fraction; LV, left ventricle; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; and SGLT2i, sodium-
glucose cotransporter-2 inhibitor.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 22
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%

Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor;
HFimpEF, heart failure with improved ejection fraction; HFmrEF, heart failure with mildly reduced ejection fraction; HFrEF, heart failure with reduced
ejection fraction; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; and SGLT2i, sodium- glucose cotransporter 2
inhibitor.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 23
 Diagnosis and Treatment of
Transthyretin Cardiac Amyloidosis
Presence of Cardiac
History, ECG, echocardiogram, cardiac Check for monoclonal monoclonal amyloidosis
MRI suggestive of cardiac amyloidosis light chains (1) light chain? unlikely

YES NO NO
Cardiac Amyloid on Hematology-oncology Tc-99m-
No evidence Check Tc-99m-
amyloidosis
of amyloid heart consultation and consider PYP scan (1)
PYP
unlikely biopsy? heart or other biopsy abnormal?
YES
Evidence
At 2020 list prices, of amyloid Perform TTR gene sequencing (1)
tafamidis provides low
economic value (>$180,000
AL-CM ATTR-CM
per QALY gained) in ATTRwt-CM ATTRv-CM
patients with HF with
wild-type or variant Anticoagulation regardless of Atrial
Treatment by CHA2DS2-VASc score (2a) fibrillation
transthyretin cardiac hematologist- • Referral to genetic
oncologist Treatment counselor
amyloidosis. Tafamidis (1)
NYHA I-III
symptoms • Potential screening
of family members
Value Statement: Individualized therapy HFrEF • TTR silencer
Low Value (B-NR) therapy if
neuropathy
Abbreviations: AF indicates atrial fibrillation; AL-CM, AL amyloid cardiomyopathy; ATTR-CM, transthyretin amyloid cardiomyopathy; ATTRV, variant transthyretin
amyloidosis; ATTRwt, wild-type transthyretin amyloidosis; CHA›DS2-VASc, congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or
transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category; ECG, electrocardiogram; H/CL, heart to contralateral chest; HFrEF, heart failure
with reduced ejection fraction; IFE, immunofixation electrophoresis; MRI, magnetic resonance imaging; NYHA, New York Heart Association; PYP, pyrophosphate: Tc.
technetium: and TTR. Transthyretin.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 24
 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 D Defibrillator shocks L Low systolic BP ≤90mmHg
persistently elevated
or cardiogenic shock, natriuretic peptides
they may no longer
quality for advanced Prognostic medication;
E End-organ dysfunction H Hospitalizations >1 P intolerance of GDMT
therapies

Abbreviations: BP indicates blood pressure; EF, ejection fraction; GDMT, guideline-directed medical therapy; and LVAD, left ventricular assist device.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 25
Non-pharmacological Management
in Advanced HF
COR RECOMMENDATIONS

Meta-analysis1 of 6 RCTs 1. For patients with advanced HF and

hyponatremia, the benefit of fluid
comparing liberal and restricted 2b restriction to reduce congestive
fluid intake symptoms is uncertain

No difference in mortality
or HF hospitalization
No difference in serum
Na+ or Cr
No difference in duration
of IV diuretics

Abbreviations: Cr indicates creatinine; HF, heart failure; IV, intravenous; Na+, sodium; and RCT, randomized clinical trial.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 26
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
2a eligible 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 for either MCS or cardiac transplantation, continuous intravenous inotropic support
2b may be considered as palliative therapy for symptom control and improvement in functional
status

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

Abbreviations: GDMT indicates guideline-directed medical therapy; HF, heart failure; and MCS, mechanical circulatory support.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 27
 Durable Mechanical Support with
Left Ventricular Assist Device
INDICATIONS CONTRAINDICATIONS

• Frequent hospitalizations for Absolute

HF
• Irreversible hepatic, renal • Severe psychosocial
• NYHA class IIIB to IV or neurological disease limitations
symptoms despite maximal
GDMT • Medical non-adherence
• Intolerance of GDMT
Relative
• Increasing diuretic
requirement • Age >80 years for • Untreated malignancy
• Symptomatic despite CRT destination therapy • Severe PVD
• Inotrope dependence • Obesity or malnutrition • Active substance abuse
• Low peak VO2 (<14-16 • Musculoskeletal disease • Impaired cognitive
ml/kg/m2) that impairs rehabilitation function
• End-organ dysfunction • Active systemic infection • Unmanaged psychiatric
SOURCE:
https://www.mayoclinic.org/tests-procedures/ventricular-assist-device
attributable to low cardiac or prolonged intubation disorder
/multimedia/left-ventricular-assist-device/img-20006714
output • Lack of social support

Abbreviations: CRT indicates cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; LVAD, left ventricular assist
device; NYHA, New York Heart Association; PVD, peripheral vascular disease; and VO2, oxygen uptake.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 28
 Mechanical Circulatory Support
Despite improving hemodynamic compromise, positive inotropic agents have not shown
improved survival in patients with HF in either the hospital or outpatient setting.

COR RECOMMENDATIONS

1. In select patients with advanced HFrEF with NYHA class IV

symptoms who are deemed to be dependent on continuous
In patients with advanced HFrEF who
1 intravenous inotropes or temporary MCS, durable LVAD
implantation is effective to improve functional status, QOL and have NYHA class IV symptoms despite
survival. GDMT, durable MCS devices provide low
to intermediate economic value based on
2. In select patients who have NYHA class IV symptoms despite
2a GDMT, durable MCS can be beneficial to improve symptoms, current costs and outcomes
functional class and reduce mortality.
Value Statement: Uncertain Value (B-NR)
3. In patients with advanced HFrEF and hemodynamic compromise
and shock, temporary MCS, including percutaneous and
2a extracorporeal ventricular assist devices, are reasonable as a
”bridge to recovery” or “bridge to decision.”

Abbreviations: GDMT indicates guideline-directed medical therapy; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; LVAD, left
ventricular assist device; MCS, mechanical circulatory support; NR, nonrandomized; NYHA, New York Heart Associations; and QOL, quality of
life.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 29
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 PATIENT SELECTION

1. For selected patients with • Minimizing waitlist
advanced HF despite GDMT, mortality while
1 cardiac transplantation is maximizing post-transplant
indicated to improve survival outcomes is a priority
and QOL (1) • CPET can refine candidate
prognosis and selection
• Appropriate patient
selection should include
In patients with stage D HF despite integration of comorbidity
GDMT, cardiac transplantation provides burden, caretaker status
and goals of care
intermediate economic value.
Value Statement: Intermediate Value (C-
LD)
Abbreviations: CPET indicates cardiopulmonary exercise test; GDMT, guideline-directed medical therapy; HF, heart failure; LD, limited data; and QOL, quality of life.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 30
Assessment of Patients Hospitalized With Decompensated HF

Evaluation Goals for GDMT

COR RECOMMENDATIONS COR RECOMMENDATIONS

1 Address precipitating factors 1 Optimize volume status

Evaluate severity of 1
1 congestion
Address reversible factors

Continue or initiate
1 Assess adequacy of perfusion 1 GDMT

COMMON FACTORS PRECIPITATING HF HOSPITALIZATION

• Acute coronary syndrome • Non-adherence to medications or diet
• Uncontrolled hypertension • Anemia
• Atrial fibrillation and arrhythmias • Hypo-/Hyperthyroidism
• Additional cardiac disease • Medications that increase sodium retention
• Acute infections • Medications with negative inotrope

Abbreviation: GDMT indicates guideline-directed medical therapy.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 31
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, advanced
AV block or ACEi/ARNi
Admission: Inpatient: Pre-Discharge: with angioedema
Continue GDMT, unless Continue diuresis Re-initiate and/or
contraindicated despite mild reduction optimize GDMT when • VTE prophylaxis is
(Class 1) in renal function and BP clinically stable recommended in all
(Class 1) (Class 1) hospitalized patients

Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; ARNi, angiotensin receptor-neprilysin inhibitor; AV, atrioventricular;
BP, blood pressure; GDMT, guideline-directed medical therapy; and VTE, venous thromboembolism.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 32
 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)

Abbreviations: BUN indicates blood urea nitrogen; GDMT, guideline-directed medical therapy IV, intravenous; and MRA; mineralocorticoid.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 33
 Hospitalized Patients with Cardiogenic Shock
Shock: Clinical Criteria Shock: Hemodynamic Criteria COR RECOMMENDATIONS
I. SBP <90 mm Hg for > 30 minutes I. SBP <90 mmHg or mean BP <60 1. Initiate ionotropic support
a. Mean BP < 60 mm Hg for >30 minutes mmHg 1 • To maintain systemic perfusion
b. Requirement of vasopressors to maintain II. Cardiac Index <2.2 L/min/m2 • To preserve end-organ function
SBP ≥ 90 mm Hg or mean BP ≥60 mm
III.PCW >15 mm Hg 2. Temporary MCS is reasonable when
Hg
end-organ function cannot be
II. Hypoperfusion: IV.Other hemodynamic considerations 2a maintained by pharmacologic means
a. Cardiac power output <0.6 W to support cardiac function
a. Decreased mentation
b. Shock index >1
b. Cold extremities, livedo reticularis 3. Management by a multidisciplinary
c. RV shock
c. Urine output < 30 mL/h
• pulmonary artery pulse index <1 2a team experienced in shock is
d. Lactate >2 mmol/L • CVP > 15 mm Hg reasonable
• CVP-PCW >0.6
4. Consider placement of PA line to
2b define hemodynamic subsets and
appropriate management strategies
5. Unable to maintain end-organ
2b function triage to centers with MCS
capabilities should be considered

Abbreviations: BP indicates blood pressure; CVP, central venous pressure; h, hour; L, liter; m2 , square meter; MCS, mechanical circulatory shock; min, minute; ml,
milliliter; ; mmHg, millimeter of mercury; mmol, a thousandth of a mole; PA, pulmonary artery; PCW, pulmonary capillary wedge, SBP, systolic blood pressure.; and
W, watts.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 34
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

Abbreviations: GDMT indicates goal-directed medical therapies; HF, heart failure; and SDOH, social determinates of health.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 35
Additional Therapies in Patients
with HF and Comorbidities 
In addition to optimized GDMT
Patients with HF and Optimal treatment according Patients with HFrEF and
IV iron replacement (2a)
hypertension to hypertension guidelines (1) iron deficiency

Patients with AF and LVEF < 50% if

Patients with HF and SGLT2i for management of rhythm control strategy fails/not AV nodal ablation and
type 2 diabetes hyperglycemia (1) desired and ventricular rates remain CRT implantation (2a)
rapid despite medical therapy 

Select patients with HF and

Surgical Patients with HF and symptoms Atrial Fibrillation
LVEF < 35% and suitable
revascularization (1) attributable to AF ablation (2a)
coronary anatomy

Patients with HF attributable Multidisciplinary Patients with HF with

CPAP (2a)
to VHD or cancer therapy Management (1) obstructive sleep apnea

In asymptomatic patients with

Select patients with ARB, ACEi, and
Anticoagulation (1) cancer therapy-related
HF and AF beta blockers (2a)
cardiomyopathy (EF < 50%)

Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin receptor blocker; AV, atrioventricular; CHA2DS2-VASc, congestive heart
failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack [TIA], vascular disease, age 65 to 74 years, sex category; CPAP, continuous positive airway
pressure; CRT, cardiac resynchronization therapy; EF, ejection fraction; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection
fraction; IV, intravenous; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; SGLT2i, sodium-glucose cotransporter-2 inhibitor; and VHD, valvular heart
disease.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 36
 Recommendations for Managing Comorbidities
in Patients With HF
Management of anemia or iron Management of sleep disorders
deficiency
COR RECOMMENDATIONS COR RECOMMENDATIONS

In patients with HFrEF and iron deficiency with or In patients with HF and suspicion of sleep-disordered breathing, a formal sleep
2a without anemia, intravenous iron replacement is 2a assessment is reasonable to confirm the diagnosis and differentiate between
reasonable to improve functional status and QOL obstructive and central sleep apnea

In patients with HF and obstructive sleep apnea, continuous positive airway

3: In patients with HF and anemia, erythropoietin-
stimulating agents should not be used to improve 2a pressure may be reasonable to improve sleep quality and decrease daytime
Harm morbidity and mortality sleepiness

3: In patients with NYHA class II to IV HFrEF and central sleep apnea, adaptive
Harm servo-ventilation causes harm

Management of hypertension  Management of diabetes 

COR RECOMMENDATIONS COR RECOMMENDATIONS

In patients with HFrEF and hypertension, uptitration In patients with HF and type 2 diabetes, the use of SGLT2i is recommended for
1 of GDMT to the maximally tolerated target dose is 1 the management of hyperglycemia and to reduce HF-related morbidity and
recommended. mortality

Abbreviations: GDMT indicates guideline directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection
fraction; NYHA, New York Heart Association; QOL, quality of life; and SGLT2i, sodium-glucose cotransporter-2 inhibitor.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 37
Recommendations for Management of AF in HF

COR RECOMMENDATIONS COR RECOMMENDATIONS

Patients with chronic HF with permanent-persistent- For patients with HF and symptoms caused by AF, AF
paroxysmal AF and a CHA2DS2-VASc score of ≥2 2a ablation is reasonable to improve symptoms and QOL.
1 (for men) and ≥3 (for women) should receive chronic
anticoagulant therapy. For patients with AF and LVEF ≤50%, if a rhythm
control strategy fails or is not desired, and ventricular
For patients with chronic HF with permanent- 2a rates remain rapid despite medical therapy, AV nodal
1 persistent-paroxysmal AF, DOAC is recommended ablation with implantation of a CRT device is reasonable.
over warfarin in eligible patients.
For patients with chronic HF and permanent-persistent-
paroxysmal AF, chronic anticoagulant therapy
2a is reasonable for men and women without additional risk
factors.

Abbreviations: AF indicates atrial fibrillation; AV, atrioventricular; CHA2DS2-VASc, congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient
ischemic attack [TIA], vascular disease, age 65 to 74 years, sex category; CRT, cardiac resynchronization therapy; DOAC, direct oral anticoagulant; LVEF, left ventricular ejection fraction;
and QOL, quality of life.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 38
Recommendations for Disparities and
Vulnerable Populations

COR RECOMMENDATIONS COR RECOMMENDATIONS

In vulnerable patient populations at risk for health disparities, Evidence of health disparities should be monitored and
HF risk assessments and multidisciplinary management 1 addressed at the clinical practice and the health care system
1 strategies should target both known risks for CVD and social levels.
determinants of health, as a means toward elimination of
disparate HF outcomes.

Abbreviations: CVD indicates cardiovascular disease; and HF, heart failure.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 39
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, ACEi,
2a 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 and

2b 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 cardiac
2b troponin might be reasonable for further risk stratification.

Abbreviations: ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BB, beta blocker; CV, cardiovascular; EF, ejection fraction; and HF, heart failure.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 40
Recommendations for HF and Pregnancy

In women with a history of In women with HF or

In women with acute HF
HF or cardiomyopathy, cardiomyopathy who are
caused by peripartum
including previous pregnant or currently
cardiomyopathy and LVEF
peripartum cardiomyopathy, planning for pregnancy,
<30%, anticoagulation may
patient-centered counseling ACEi, ARB, ARNi, MRA,
be reasonable at diagnosis,
regarding contraception and SGLT2i, ivabradine, and
until 6 to 8 weeks
the risks of cardiovascular vericiguat should not be
postpartum, although the
deterioration during administered because of
efficacy and safety are
pregnancy should be significant risks of
uncertain (2b)
provided (1) fetal harm (3 – Harm)

Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HF, heart
failure; LV, left ventricular; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; and SGLT2i, T2i, sodium-glucose
cotransporter-2 inhibitor.
Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 41
Performance Measures
• Hospitals performing well on medication-related performance
measures have better HF mortality rates.
• Hospitals participating in registries have better processes of care
and outcomes.
• Performance measures can be implemented in both inpatient and
outpatient settings.

COR RECOMMENDATIONS

1. Performance measures based on professionally developed

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

2. Participation in QI programs, including patient registries

that provide benchmark feedback on nationally endorsed,
2a CPG–based quality and PM can be beneficial in improving
the quality of care for patients with HF.

Abbreviations: CPG indicates clinical practice guideline; HF, heart failure; QI, quality improvement; and PM, performance measure.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 42
Goals of Care
COR RECOMMENDATIONS

1. For all patients with HF, palliative and supportive care-including high quality communication, conveyance
1 of prognosis, clarifying goals of care, shared decision-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
1 discontinuation should be anticipated and discussed through the continuum of care, including at the time of
initiation, and reassessed with changing medical conditions and shifting goals of care.

3. For patients with HF, execution of advance care directives can be useful to improve documentation of
2a 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, patients experiencing uncontrolled
2a 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 hospice can be useful to
2a improve QOL.

Abbreviations: HF indicates heart failure; and QOL, quality of life.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 43
 Patient Reported Outcomes
COR RECOMMENDATIONS
In patients with HF, standardized assessment of patient reported health status using a validated questionnaire can be useful to
2a provide incremental information for patient functional status, symptoms burden and prognosis.

Health status encapsulates symptoms, functional status, and

health-related QOL. Routine assessment
can identify high-risk
patients needing
closer monitoring or
referral.
NYHA-I NYHA-II NYHA-III NYHA-IV Patient-reported
Understanding health status
symptom burden assessment increases
and prognosis may the patient’s role,
improve quality of which can motivate
Comfortable at initiation and up
Comfortable at Unable to carry on treatment decisions
rest, but less than Standardized titration of medical
No limitation of rest, but ordinary any physical and QOL.
patient-reported
ordinary activity therapy.
physical activity activity results in activity with health status
results in
symptoms symptoms questionnaires are
symptoms
independently
associated with
clinical outcomes.

Abbreviations: HF indicates heart failure; NYHA, New York Heart Association; and QOL, quality of life.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 44
 Evidence Gaps and Future Research Directions
Common issues that should be addressed in future clinical research

Definitions Screening Diagnostics & Nonmedical strategies Medical therapies

• Cardiomyopathies • Cost effectiveness monitoring  • Dietary intervention
• Myocardial injury • Predict higher • Treatment based • Efficacy and • See complete list in Table
• Ejection fraction risk patients on etiology safety of 33 of guideline document
ranges based on • Using biomarkers cardiac rehab
comorbidities to optimize therapy

Device Management Clinical outcomes Systems of Care and Comorbidities Future/Novel strategies
and Advanced • Impact of therapy in SDOH • Atrial fibrillation and • Pharmacologic therapies
Therapies patient-reported • Multidisciplinary care Valvular heart disease • Device therapy
• Timely selection for outcomes models • Comorbidities and obesity • Invasive or non-invasive
invasive therapies • Addressing patient goals • Eliminating disparities • Nutritional management hemodynamics
• Interventional according to disease • Palliative care • Guideline therapy • Telehealth and
approach to trajectory institution in patients wearable
tachyarrhythmias • Generalization of therapy with chronic technologies
• Safety and efficacy not represented in trials kidney disease
of nerve stimulation/
ablation

Abbreviations: SDOH indicates social determinates of health.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 45
Acknowledgments

Many thanks to our Guideline Ambassadors who were guided by Dr. Elliott Antman in developing
this translational learning product in support of the 2022 AHA/ACC/HFSA Guideline for Heart
Failure.

Neha Chandra, MD Jennifer Maning, MD

Maxwell D. Eder, MD Sean Patrick Murphy, MD
Rishin Handa, MD Taylor Saley, MD
Gini Jeyashanmugaraja, MD Rey Sanchez, MD
Mohamed Suliman, MD

The American Heart Association requests this electronic slide deck be cited as follows:
Chandra, N., Eder, M. D., Handa, R., Jeyashanmugaraja, G., Maning, J., Medhane, F., Murphy, S. P., Saley, T.,
Sanchez, R., Suliman, M., Bezanson, J. L., & Antman, E. M. (2022). AHA Clinical Update; Adapted from: 2022
AHA/ACC/HFSA Guideline for Heart Failure. [PowerPoint slides]. Retrieved from
https://professional.heart.org/en/science-news.

Heidenreich, P. A. et al. (2022). 2022 AHA/ACC/HFSA Guideline for Heart Failure. Circulation. 46