A new guideline on management of heart failure (HF) was jointly released by the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Failure Society of America (HFSA).
Among other changes, the new guideline refines the classifications of heart failure based on left ventricular ejection fraction (LVEF) as follows.
- HF with reduced ejection fraction (HFrEF): LVEF less than or equal to 40%;
- HF with improved ejection fraction (HFimpEF): previous LVEF less than or equal to 40% and a follow-up measurement of LVEF over 40%
- HF with mildly reduced ejection fraction (HFmrEF): LVEF of 41% to 49% and evidence of increased LV filling pressures
- HF with preserved ejection fraction (HFpEF): LVEF equal to or greater than 50% and evidence of increased LV filling pressures.
Another significant change is that the guideline now recommends sodium-glucose cotransporter-2 (SGLT-2) inhibitors for patients with symptomatic HFrEF regardless of diabetes status. Recommended pharmacological treatment for HFrEF includes four classes of medications, in addition to diuretics: angiotensin receptor-neprilysin inhibitors, or if not feasible, angiotensin-converting enzyme inhibitors; mineralocorticoid receptor antagonists and beta-blockers; and SGLT-2 inhibitors.
HFmrEF should be treated first with an SGLT-2 inhibitor along with diuretics as needed. Patients with HFpEF and hypertension should aim for blood pressure targets in accordance with clinical guidelines, and SGLT-2 inhibitors may be beneficial in decreasing their risk of HF hospitalization and cardiovascular mortality, the new guideline said.
It also includes recommendations on use of implantable cardiac devices and cardiac revascularization therapy, diagnosis and treatment of cardiac amyloidosis, referral of patients with advanced heart failure to subspecialty care, and recommendations for management of atrial fibrillation and valvular heart disease in HF and cardio-oncology.
The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure replaces the 2013 ACCF/AHA Guideline for the Management of Heart Failure and the 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure and was published simultaneously on April 1 in the Journal of the American College of Cardiology, Circulation, and the Journal of Cardiac Failure.