Heart failure HF occurs when the heart's ability to pump blood is compromised. This guideline article provides up-to-date recommendations on the prevention, diagnosis, and management of patients with HF.

The American College of Cardiology (ACC), American Heart Association (AHA), and Heart Failure Society of America (HFSA) recently published a 2022 joint guideline focused on the management of heart failure (HF). These updated recommendations replace the 2013 ACCF/AHA Guidelines 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.

The new guidelines emphasise preventing HF in individuals showing signs of “pre-heart failure.” They also include SGLT-2 inhibitors as a treatment option for patients with symptomatic HF.

“One primary goal with the new guideline was to use recently published data to update our recommendations for the evaluation and management of heart failure,” said Paul A. Heidenreich, MD, MS, guideline writing committee chair, in a press release.“One focus was the prevention of heart failure through optimising blood pressure control and adherence to a healthy lifestyle.”

We have highlighted specific updates to break it down for you.

Revision to ACC/AHA heart failure stages

The new guidance revises the ACC/AHA stages of heart failure to allow clinicians to identify patients at risk for HF, recommending treatment before signs of reduced heart function even occur.

The updated stages are:

Stage A- Includes patients at risk for HF who aren’t showing symptoms, structural heart disease, or indications of heart muscle injury. This category includes patients with high blood pressure, diabetes and obesity, those who are taking medications that may damage the heart (chemotherapeutic agents), and people who may be genetically predisposed to heart failure.

Stage B- Includes patients defined as “Pre-HF” who don’t show any HF symptoms but present with one of the following: structural heart disease, increased filling pressures as determined by ultrasound, or risk factors from stage A plus other indicators of heart muscle injury.

Stage C- Patients in this category are defined as having symptomatic HF characterised by the presence of structural heart disease with symptoms of heart failure such as shortness of breath, persistent cough, swelling, fatigue, and nausea.

Stage D- Includes patients with advanced HF who are showing symptoms that decrease quality of life, are hard to control and lead to recurrent hospitalisations despite medication.

Updates to left ventricular ejection fraction terminology

Left ventricular ejection fraction (LVEF) is defined as the percentage of blood that’s pumped out of the left ventricle. An LVEF of ≥ 50–55% is considered normal.

For individuals with symptomatic HF (stage C), the new guidance made the following updates to LVEF terminology:

1. HF with reduced ejection fraction (HFrEF) includes individuals with an LVEF ≤ 40%.
2. HF with improved ejection fraction (HFimpEF) will now include patients with a previous LVEF ≤ 40% and a follow-up measurement of LVEF > 40%.
3. HF with mildly reduced ejection fraction (HFmrEF) includes individuals with LVEF between 41–49% who have increased left ventricular filling pressures.
4. HF with preserved ejection fraction (HFpEF) includes patients with an LVEF ≥ 50% who have increased left ventricular filling pressures.

Treatment options

The guidelines recommend that clinicians consider guideline-directed medical therapy (GDMT) for all patients with current or prior HF, regardless of LVEF status.

GDMT has been expanded to include the following four drug classes:

• Angiotensin receptor-neprilysin inhibitors (ARNi), angiotensin-converting enzyme inhibitors (ACEi), or angiotensin (II) receptor blockers (ARBBeta-blockers
• Beta-blockers
• Mineralocorticoid receptor antagonists (MRA)
• Sodium-glucose cotransporter-2 inhibitors (SGLT2i)

ARNi is recommended as a first-line renin-angiotensin system inhibitor (RASi) to decrease the risk of morbidity and death in patients with HFrEF (Class 1a recommendation). For patients who cannot take ARNi, ACEi is recommended instead, followed by ARB for patients who are ACEi-intolerant and cannot take ARNi. ARNi is recommended for additional reductions in morbidity and mortality for patients who have HFrEF and can tolerate ACEi or ARB.

The guidelines also made new recommendations for use of SGLT2i in patients with HF. Specifically, in symptomatic patients with chronic HFrEF, the use of SGLT2i is recommended to reduce the risk of hospitalisation and cardiovascular death, irrespective of a diagnosis of type 2 diabetes (class 1a recommendation). The guidance also acknowledges that SGLT2i may be helpful for patients with HFmrEF and HFpEF (class 2a recommendation). To prevent relapse of HF, it is recommended that patients with HFimpEF continue GDMT.

This story is contributed by Samar Mahmoud, MS and is a part of our Global Content Initiative, where we feature selected stories from our Global network which we believe would be most useful and informative to our doctor members.