Heart Failure Management: A Report on Clinical Practice Guidelines

The ACC/AHA published the 2022 AHA/ACC/Heart Failure Society of America (HFSA) Guideline for the Management of HF: A Report of the ACC/AHA Joint Committee on Clinical Practice Guidelines earlier this year during ACC 2022. It replaces the 2013 ACC Foundation (ACCF)/AHA Guideline for the Management of HF and the 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline. The 2022 AHA/ACC/HFSA Guideline offers updated, evidence-based, patient-centric clinical practice guidance for clinicians to prevent, diagnose and manage patients with HF.

Understanding the revised 2022 heart failure guideline structure

The 2022 Guideline Writing Committee developed the 2022 Guideline Recommendations in reference to patients and their conditions. Although not intended as a procedural-based ‘manual’ outlining HF best practices, the 2022 Guideline contains certain practices associated with improved clinical outcomes. Furthermore, it is organized to provide clinicians with the latest evidence, forming the basis of a shared decision-making process with patients.

Modifications to the 2022 Guideline include shortening the document itself and enhancing ‘user friendliness’. Also, Recommendations now comprise a table of recommendations, a synopsis, “Recommendation-Specific Supportive Text,” and where appropriate, additional flow diagrams and/or tables. Furthermore, the ACC/AHA Class of Recommendation (CoR) and Level of Evidence (LoE) definitions used in the 2022 Guideline were updated in 2019. These definitions qualify the latest scientific evidence in the 2022 Guideline Recommendations, allowing practitioners to discern best practices for their patients.

What do the 2022 heart failure guideline recommendations address?

The 2022 Heart Failure Guideline’s areas of focus include the prevention of HF and specific management strategies not previously presented. For example, recommendations provide specific management approaches in stage C HF, including those for cardiac amyloidosis and cardio-oncology. The document also addresses HF/atrial fibrillation (AF), including AF ablation, implantable devices, and left ventricular assist devices (LVAD; stage D HF). As well, the Guideline focusses on new treatment strategies in HF, including sodium-glucose cotransporter-2 inhibitors (SGLT2i) and angiotensin receptor-neprilysin inhibitors (ARNi).

Emphasizing updated evidence for clinicians to improve clinical outcomes

The 2022 Guideline provides clinicians with ten key take-home messages on heart failure management:

1. Guideline-directed medical therapy (GDMT) for patients with HF with reduced ejection fraction (HFrEF) discusses four medication classes. These include SGLT2i, ARNi, mineralcorticoid receptor agonists (MRA), and angiotensin-converting enzyme inhibitors (ACEi), and angiotensin (II) receptor blocks (ARB).
2. SGLT2i have a ‘Class of Recommendation (CoR)’ of 2a in patients with HF and mildly reduced EF (HFmrEF). Yet, weaker recommendations are indicated for ARNi, ACEi, ARB, MRA, and beta blockers (BB) in this patient population.
3. New recommendations for patients with HF and preserved EF (HFpEF) include for SGLT2i (CoR 2a), MRAs and ARNi (CoR 2b). Several recommendations from previous Guidelines have been renewed, including treatment of hypertension (CoR 1); AF (CoR 2a); use of ARBs (CoR 2b); routine use avoidance of nitrates/phosphodiesterase-5 inhibitors (PH-5s; CoR 3: No benefit)
4. The term, “Improved left ventricular EF [LVEF]),” will now be used to describe patients with previous HFrEF who now have LVEF >40%. These patients should continue their HFrEF treatment.
5. In select Recommendations, where cost-effective studies of the intervention have been published, specific value statements are added.
6. New amyloid heart disease recommendations focus on screening (serum, urine, genetic testing), imaging and therapy, including tetramer stabilizer therapy and anticoagulation.
7. Evidence supporting increased filling pressures can be obtained from non-invasive or invasive testing; the Guideline Writing Committee considers this evidence important for HF diagnosis if the LVEF is >40%.
8. Patients with advanced HF wishing to prolong their survival should be referred to an HF speciality team that can review the patient’s HF management, assesses their suitability for advanced HF therapy and manage palliative care when consistent with patient’s goals of care.
9. The Committee revised the terminology for the ACC/AHA stages of HF to emphasize the importance of primary prevention for “at risk” patients with HF (stage A) and with pre-HF (stage B).
10. Recommendations are offered for select patients with HF and various comorbidities, including iron deficiency, AF, coronary artery disease (CAD), sleep disorders, and malignancy, etc.

The 2022 ACC/AHA/HFSA Guideline for HF Management focusses on earlier prevention and diagnosis, with more precise management approaches. Furthermore, it aligns with established evidence-based approaches and shared decision-making strategies intended to improve quality of care for patients with HF. Therefore, the 2022 Guideline is a powerful tool for clinicians involved in the management of patients with HF.

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Author: Saskia van Tetering

Reference: Heidenreich PA et al. Circulation. 2022 May 3;145(18):e895-e1032.