Standard requests through patient assistance programs allow for 90-day supplies with 3 re lls to provide coverage for 1 year. However, income veri cation and reordering procedures are among the most challenging aspects of patient assis- tance programs for patients and clinicians (149). Many pharmaceutical companies accept signed letters from clinicians indicating that the patient has no known in- come. This can be used in place of of cial income docu- mentation, although this option is not clearly apparent on many of the patient assistance program websites. Like- wise, patients and clinicians need to be cognizant of reordering procedures, which becomes especially impor- tant if doses are changed re lls/reorders are not always sent and, unfortunately, re lls/reorders cannot be requested before the 60-day post-approval date. Supplemental Appendix 2 provides product-speci c in- formation on assistance in payment for newer HF thera- pies and appropriate use criteria to assist in the prior authorization process. 5.8. How to Manage the Increasing Complexity of HF Management The 2017 HF ECDP was motivated by an increasingly complex HFrEF management environment and the need to assist clinicians in navigating it (2). In the 3 years since its publication, GDMT for HFrEF now has additional medications that improve patient outcomes, thus further increasing the complexity of achieving target GDMT in all TABLE 12 Strategies to Reduce Patients Cost of Care n Coordinate care (including labs and imaging) among clinicians to mini- mize unnecessary duplication n Consider limitations of medication coverage (insurance, Medicaid, etc.) when prescribing n Use generic equivalents for GDMT whenever possible n Work with a pharmacist, social worker, or patient navigator to identify and navigate Patient Assistance Programs n Request price matching if a drug is found at a lower cost at another pharmacy GDMT guideline-directed medical therapy. Helpful Information for Completion of Prior Authorization Forms* Patient Criteria n Include HF phenotype: HFrEF; HFpEF n Identify NYHA functional class n Include recent measurement of LVEF with source documentation if requested n Identify the treatment requested or the additional testing required, with indications supported by evidence and/or guideline statements where applicable; clinical judgment, especially for testing requests, is an appropriate rationale n Address previous therapies used and the rationale for switching to or adding the requested treatment n Address known contraindications to use, adverse effects, and steps intended to minimize the risks of drugs or procedures n Document, when appropriate, that delays or interruptions in therapy may cause harm to the patient n Work with local pharmacy resources and pharmacy professionals to jointly address prior authorization requirements; do not hesitate to ap- peal decisions that are contrary to the best patient care. Document all steps taken in the patient s health record. *Required information may vary depending on payer and state. HF heart failure; HFpEF heart failure with preserved ejection fraction; HFrEF heart failure with reduced ejection fraction, LVEF left ventricular ejection fraction; NYHA New York Heart Association. Maddox et al. J patients with HFrEF. As detailed in Table 14, the modu- lation of 12 pathophysiological targets has now been shown to improve symptoms and/or outcomes for pa- tients with HFrEF. These targets include not only those modulated by the recommended treatments in this document, but also emerging treatments. For example, vericiguat, a soluble guanylyl cyclase stimulator, has demonstrated bene t for the combined outcome of death from CV causes or rst hospitalization for HF (150). The large and growing target and therapy list in HFrEF signi cantly complicates HF management for both patients and their care teams. However, several guiding principles can improve decision-making for and adherence to GDMT, which, in turn, is likely to improve patient outcomes. Principle 1: GDMT is the foundation of HF care, and the GDMT with the highest expected bene t should be prioritized. Based on large randomized trials for HFrEF, ARNIs, evidence-based beta-blockers, aldosterone antag- onists, and SGLT2 inhibitors are rst-line medications for all populations. HYD/ISDN is also a rst-line medication for self-identi ed African Americans. Ivabradine is a second-line medication for select populations. Principle 2: Target doses are associated with best outcomes. Attempt to achieve target doses of all recom- mended therapies in the absence of contraindications and/or intolerance. Titration should occur even if the patient appears stable or their symptoms and/or EF improve. Principle 3: Start GDMT immediately. Delayed initia- tion of GDMT is associated with never initiating GDMT (151). Principle 4: Attention to the clinical, social, and nancial barriers to achieving GDMT should be priori- tized. Multidisciplinary care should be targeted to the individual patient s barriers. Consider early referral to an HF team for assistance. Principle 5: Diligent management of volume status will reduce patient symptoms. Congestion drives symp- toms and hospitalizations. If the volume status is unclear, consider performing right heart catheterization and/or referral to an HF specialist. Chronic ambulatory pulmo- nary artery pressure monitoring may be considered in patients with hospitalizations in the past year who have persistent symptoms with minimal exertion. Principle 6: Tolerability and side effects depend, in part, on how and when GDMT is prescribed. Scenario: Worsening renal function or hyperkalemia. Use less than target doses of an ARNI/ACEI/ARB and discontinue aldosterone antagonist if estimated creati- nine clearance <30 ml/min or serum potassium >5.0 mEq/L. Available data support a survival bene t even with a low-dose ACEI, which may be the default choice in the setting of renal insuf ciency and marginal blood pressure. Scenario: Symptomatic hypotension. Hypotensive symptoms may be due to over-diuresis, use of non-CV drugs with hemodynamic effects (e.g., anticholinergic agents, treatments for prostate enlarge- ment, others), autonomic dysfunction, or simultaneous administration of multiple HF medications. All of these should be addressed before deciding to lower doses of evidence-based therapies. After excluding other causes of hypotension, use best-tolerated doses of GDMT, accept- ing that less data exist for the impact of lower doses in HF management. Clinical comorbidities and clinical judge- ment should be used to guide which GDMTs are reduced. For persistent hypotension, consider referral to an advanced HF specialist. Principle 7: Primary prevention implantable cardioverter-de brillator and cardiac resynchronization therapy should be considered after consistent use of optimal doses of all GDMTs for at least 3 to 6 months, followed by reassessment of EF and other indications for device therapy. Principle 8: Transcatheter mitral valve repair may be considered among symptomatic patients with chronic moderate-severe to severe mitral regurgitation despite optimal doses of all GDMTs. Principle 9: Focus on the patient s symptoms, func- tional capacity, and cardiac function. Maintain surveil- lance of the patient s health status using validated symptom questionnaires (e.g., the Kansas City Important Pathophysiological Targets in Chronic, Hemodynamically Stable HFrEF and Treatments Target Therapy Renin-angiotensin-aldosterone system ARNIs/ACEIs/ARBs, aldosterone antagonists Sympathetic nervous system Beta-blockers Natriuretic and other vasodilator peptides Neprilysin inhibitor (ARNI) Balanced vasodilation and oxidative stress modulation HYD/ISDN Elevated heart rate Beta-blocker, ivabradine Guanylyl cyclase Soluble guanylyl cyclase stimulators Relief of congestion Diuretic agents Ventricular arrhythmias Implantable cardioverter- de brillators Ventricular dyssynchrony due to conduction abnormalities Cardiac resynchronization therapy Mitral regurgitation Surgical or percutaneous mitral valve repair Reduced aerobic capacity Aerobic exercise training ACEI angiotensin-converting enzyme inhibitor; ARB angiotensin receptor blocker; ARNI angiotensin receptor-neprilysin inhibitor; HFrEF heart failure with reduced ejection fraction; HYD/ISDN hydralazine/isosorbide dinitrate; SGLT2 sodium- glucose cotransporter-2. J Maddox et al. Cardiomyopathy Questionnaire). This could be achieved during cardiac rehabilitation, which should be used to improve patient-reported outcomes, reduce hospitaliza- tions, and improve aerobic tness. Principle 10: The value of a therapy to a patient is the combination of bene ts and burdens as they relate to that patient s values, goals, and preferences. Shared decision-making will help patients and the healthcare team reach the best treatment plan for the individual patient. Principle 11: Team-based care is critical to optimizing GDMT and may include frequent follow-up visits, tele- health visits, and remote monitoring. Employ multidisciplinary teams that include advanced practice professionals, clinical nurses, and pharmacists to help titrate GDMT. Team management also facilitates se- rial assessments and longitudinal care, including man- agement of comorbidities. 5.9. How to Manage Common Comorbidities In many cases, there is a bidirectional relationship be- tween HF and certain comorbidities whereby the pres- ence of one may increase the risk of the other, and the prognosis for the patient may be worse if both are present simultaneously. Patients with HF, particularly older patients, frequently have other CV and non-CV comorbidities that affect their prognosis. The presence of multiple chronic conditions is associated with increased symptom burden, may contribute to progression of underlying disease, and often plays a role in a large proportion of hospitalizations in patients with HF. Furthermore, these comorbid con- ditions can greatly affect the treatment of HF and the ability to optimize therapies. To optimally manage these patients and improve clinical outcomes, clinicians must increasingly consider diagnosis and treatment of relevant comorbidities alongside the use of evidence-based HF therapies. Appropriate referral to clinicians with experi- ence treating the various comorbidities is another important aspect of management and lays the foundation for effective team-based care. Diabetes is a common comorbidity that deserves care- ful attention (152,153). Diabetes is strongly associated with the risk of both incident HF and adverse clinical outcomes and is also closely linked to other relevant co- morbid conditions such as hypertension, coronary artery disease, and chronic kidney disease. Treatment of pa- tients with T2D with SGLT2 inhibitors improves glycemic control but also signi cantly reduces HF events in pa- tients with established CV disease or CV risk factors (154 156). Among patients with chronic kidney disease, SGLT2 inhibitors also decrease the risk of renal disease progres- sion in a manner additive to renin-angiotensin- aldosterone system inhibitors (145). As already indicated, the recent DAPA-HF and EMPEROR-Reduced trials demonstrated that SGLT2 in- hibitor therapy reduced the risk of the composite of CV death or worsening HF in patients with HFrEF, regardless of whether they had T2D (12,44). Dapagli ozin is now approved for this indication, and the role of empagli ozin is under review by the Food and Drug Administration. SGLT2 inhibitors must now be included among the established, evidence-based therapies available to clini- cians managing patients with HFrEF. Dapagli ozin has also demonstrated ef cacy among patients with chronic kidney disease in reducing the composite of disease pro- gression, end-stage kidney disease, or death from renal or CV causes. This effect was independent of the presence of diabetes (157). In a similar manner, empagli ozin slowed the decline of kidney function among patients treated in the EMPEROR-Reduced study (13). Table 15 classi es comorbidities into CV and non-CV processes and provides guidance on appropriate management options. Finally, the recent COVID-19 pandemic has illustrated an association between underlying CV disease, including HF, and worse clinical outcomes (171). It is now known that in patients with HFrEF, renin-angiotensin- aldosterone system inhibition is not associated with risk of infection or severity of disease and should be continued, even in the setting of COVID-19 infection, as long as hemodynamically tolerated (172 176). As ap- proaches to management continue to evolve, readers are encouraged to follow the scienti c literature for updated evidence and recommendations for optimal management of these patients. 5.10. How to Integrate Palliative Care and Transition to Hospice Care Advances in care have delayed the progression of disease but rarely lead to a cure, such that the palliative care needs of patients, caregivers, and healthcare systems are as great as ever. Most palliative care is provided by non- palliative care specialists. Accordingly, such clinicians shoulder the primary responsibility for coordinating an end-of-life plan consistent with values and goals expressed by patient and family. The following are important points to consider regarding palliative care and transition to hospice. Principle 1: Palliative care strives to reduce suffering through the relief of pain and other distressing symptoms while integrating psychological and spiritual aspects of care. Action: Soliciting goals of care and focusing on quality of life are appropriate throughout the clinical course of HF and become increasingly important as the disease progresses. Principle 2: Good HF management is the cornerstone of symptom palliation. Maddox et al. J TABLE 15 Common Cardiovascular and Noncardiovascular Comorbidities Encountered in Patients With HFrEF Comorbidity Association With Heart Failure Outcomes Clinical Trial Evidence for Modulating Comorbidity Suggested Action Cardiovascular Coronary artery disease Strong Strong n Evaluate and revascularize in appropriate patients Atrial brillation/ utter Strong Intermediate n Treat according to the current AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation (158,159) Mitral regurgitation Strong Intermediate n Refer to a structural heart disease expert n Treat according to the current AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease (160,161) and ACC ECDP on the Management of MR (162) n Consider transcatheter intervention in carefully selected patients with symptomatic HF and secondary MR (163) Aortic stenosis Strong Strong n Refer to a structural heart disease expert n Treat according to current AHA/ACC Guidelines for the Management of Patients with Valvular Heart Disease Hypertension Uncertain Strong for prevention n Treat according to current ACC/AHA Guidelines for the Pre- vention, Detection, Evaluation, and Management of High Blood Pressure in Adults (164) Dyslipidemia Uncertain Strong for prevention n Treat according to current AHA/ACC Guidelines on the Man- agement of Blood Cholesterol (165) and the ACC ECDP on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of ASCVD Risk (166) Peripheral vascular disease Moderate None n Treat according to current AHA/ACC Guidelines on the Man- agement of Patients With Lower Extremity Peripheral Artery Cerebrovascular disease Moderate Weak n Treat according to current ASA/AHA Guidelines for the Early Management of Patients with Acute Ischemic Stroke (168) Noncardiovascular Obesity Moderate (inverse association) Weak n Further data needed Chronic lung disease Strong Weak n Smoking cessation n Optimize therapy n Consider pulmonary consultation Diabetes Strong Strong n Optimize therapy n Administer SGLT2 inhibitor n Consider consult with endocrinologist n Treat according to the ACC ECDP on Novel Therapies for CV Risk Reduction in Patients with T2D (31) and ADA Standards of Medical Care in Diabetes (169) Chronic kidney disease Strong Strong n Optimize RAAS inhibitor therapy n Use hydralazine/ISDN if an ARNI/ACEI/ARB cannot be used n Administer SGLT2 inhibitor n Consider nephrology consult Anemia Moderate Weak n Evaluate secondary causes n Consider transfusion in severe cases Iron de ciency Strong Intermediate n Consider intravenous iron replacement for symptom improvement Thyroid disorder (hypo or hyper) Strong Weak n Evaluate and initiate treatment n Consider referral to endocrinologist Sleep disordered breathing Strong Intermediate; note that in patients with symptomatic HFrEF and central sleep apnea, adaptive servo- ventilation is harmful (170) n Refer for sleep study n Treat severe obstructive sleep apnea n Consider referral to sleep medicine specialist Hyperkalemia Uncertain; may limit initiation and titration of GDMT Weak n Recommend dietary modi cations n Consider treating with patiromer (note: data regarding clin- ical outcomes are pending [NCT03888066]) or sodium zir- conium cyclosilicate ACC American College of Cardiology; ACEI angiotensin-converting enzyme inhibitors; ADA American Diabetes Association; AHA American Heart Association; ARB angiotensin receptor blocker; ARNI angiotensin receptor-neprilysin inhibitor; ASCVD atherosclerotic cardiovascular disease; CV cardiovascular; ECDP Expert Consensus Decision Pathway; GDMT guideline-directed medical therapy; HF heart failure; HFrEF heart failure with reduced ejection fraction; HRS Heart Rhythm Society; ISDN iso- sorbide dinitrate; LDL low-density lipoprotein; MR mitral regurgitation; RAAS renin-angiotensin-aldosterone system; SGLT2 sodium-glucose cotransporter-2; T2D type 2 diabetes. J Maddox et al. Action: Meticulous management of HF therapies particularly diuretic agents is a critical component of symptom management and should continue through the end of life. Principle 3: Palliative care consultation and comple- mentary approaches to care may further ameliorate re- fractory HF symptoms of dyspnea, fatigue, and pain, although study results have been mixed. These ap- proaches also improve patient satisfaction and quality-of- life metrics. Action: Targeted specialty palliative care consultation can be helpful for especially complex decisions, refractory symptoms, and end of life. Palliative care teams should have expertise in management of both HF- and non HF- related symptoms. Principle 4: Patients with HF often face major treat- ment decisions over time and should be provided with support when thinking through the bene ts and burdens of each treatment option. Action: Decision support tools (patient decision aids) help frame options, which should then be followed by dynamic and personalized conversations. Principle 5: Proactive shared decision-making discus- sions simplify dif cult decisions in the future. Action: Preparedness planning discussions should occur at least annually between patients and clinicians, leading to review of clinical status and current thera- pies, estimates of prognosis, clari cation of patient values and beliefs, anticipation of treatment decisions, and advanced care directives that identify surrogate decision-makers and healthcare proxies (3). Resources to assist patients in these dif cult discussions may be useful (e.g., the Advanced Care Training module from HFSA: hfsa.org). Similar preparedness-planning discus- sions should occur at the time of major procedural in- terventions (e.g., LV assist device implantation, heart transplantation). Principle 6: Attention to the clinical trajectory is required to calibrate expectations and guide timely de- cisions, but prognostic uncertainty is inevitable and should be included in discussions with patients and caregivers. Action: Worsening disease and milestone events (e.g., recurrent hospitalization or progressive intolerance of medications due to hypotension and kidney dysfunc- tion) should trigger heightened preparation with patients and families, but without speci c estimates of how much time remains due to high levels of unpredictability in the clinical course of HF. Principle 7: The transition from do everything to comfort only/hospice is often bridged through a phase of quality survival, during which time patients increasingly weigh the bene ts, risks, and burdens of initiating or continuing life-sustaining treatments. Action: Revising the medical regimen for symptom relief and quality of life may involve discontinuation of some recommended therapies (e.g., reducing neurohor- monal antagonists in the setting of symptomatic hypo- tension, deactivation of de brillator therapy) and the addition of therapies not usually recommended (e.g., opioids for refractory dyspnea). These decisions should be individualized and made in partnership with the patient, their caregivers, and their care team. 6. DISCUSSIONS AND IMPLICATIONS OF PATHWAY The primary objective of this updated ECDP is to provide a framework for the many decisions required in the man- agement of patients with HFrEF. Most importantly, the checklists and algorithms provided in this ECDP should be applied only in the context of the most recent update to the AHA/ACC guidelines for management of adults with chronic HF and, in this case, patients with HFrEF. No guideline, pathway, or algorithm should ever supersede clinical judgment. Management of HFrEF often involves multidisciplinary care, may require complex decision-making, and bene ts from a solid foundation of knowledge to manage these occasionally fragile patients. HF is a major public health concern, one in which broader clinician experience in GDMT would be expected to signi cantly bene t affected patients. With recent changes in available diagnostics and therapeutics for HFrEF, along with the evolution in rec- ommended management strategies for affected patients, many questions have emerged regarding optimal deploy- ment of these newer approaches to patient care. Addi- tionally, clinical practice guidelines continue to evolve. In this context, we have highlighted important literature ci- tations explaining the rationale for this changing picture in HFrEF care, candidate best practices, and, where evidence or best practices are lacking, templates for clinical decision-making to manage patients rationally. As more evidence emerges, many more topics will be clari ed ACC PRESIDENT AND STAFF Athena Poppas, MD, FACC, President Cathleen C. Gates, Chief Executive Of cer John Rumsfeld, MD, PhD, FACC, Chief Science and Quality Of cer Joseph M. Allen, MA, Team Leader, Clinical Standards and Solution Sets Amy Dearborn, Team Leader, Clinical Policy Content Development Ashleigh M. Covington, MA, Team Leader, Clinical Pathways and Heart House Roundtables Severa Chavez, Manager, Clinical Pathways and Policy Grace D. Ronan, Team Lead, Clinical Policy Publication Maddox et al. J R E F E R E N C E S 1. Januzzi JL Jr., Ahmad T, Binder LG, et al. 2019 methodology for creating expert consensus decision pathways: a report of the American College of Cardi- ology. J Am Coll Cardiol. 2019;74:1138 50. 2. 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JAMA Car- diol. 2020;5:1020 6. 175. de Abajo FJ, Rodriguez-Martin S, Lerma V, et al. Use of renin-angiotensin-aldosterone system inhibitors and risk of COVID-19 requiring admission to hospital: a case-population study. Lancet. 2020;395:1705 14. 176. BRACE CORONA: does temporarily suspending RAAS inhibitors show clinical bene t in hospitalized COVID-19 patients? ACC News Story. Published September 1, 2020. Available at: https://www.acc.org/ ace-inhibitors-arbs-esc-2020. Accessed October 10, 2020. KEY WORDS ACC Expert Consensus Decision Pathway, ARNI, heart failure, HFrEF, SGLT2 inhibitor Maddox et al. J Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Thomas M. Maddox (Chair) BJC HealthCare and Washington University School of Medicine Executive Director, Healthcare Innovation Lab; Professor of Medicine None None None None None None James L. Januzzi Jr. (Vice Chair) Harvard Medical School Hutter Family Professor of Medicine; Director, Dennis and Marilyn Barry Fellowship in Cardiology Research; Senior Cardiometabolic Faculty, Baim Institute for Clinical Research n Abbott n Roche Diagnostics* None None n Abbott* n Amgen (DSMB)* n Boehringer Ingel- heim (DSMB)* n Janssen Pharmaceu- ticals (DSMB)* n Novartis* None None Larry A. Allen University of Colorado School of Medicine Associate Professor of Medicine n Abbott n Amgen n Boston Scienti c n Novartis None None None n Janssen None Khadijah Breathett University of Arizona College of Medicine Assistant Professor of Medicine, Division of Cardiology, Advanced Heart Failure and Transplant None None None None None None Javed Butler University of Mississippi Medical Center Patrick H. Lehan Professor; Chairman, Department of Medicine n Abbott n AstraZeneca n Boehringer Ingelheim* n Eli Lilly* n Janssen* n Medtronic n Novartis* n Relypsa* n Roche Diagnostics n Janssen* n Novartis* None n Amgen (DSMB) n Bristol-Myers Squibb (DSMB) None None Leslie L. Davis University of North Carolina at Chapel Hill Associate Professor of Nursing None None None None n AANP None Gregg C. Fonarow David Geffen School of Medicine, UCLA Division of Cardiology Professor of Medicine n Abbott* n Amgen n AstraZeneca n CHF Solutions Lifesciences* n Janssen n Medtronic n Novartis* None None None n Boston Scienti c None Continued on the next page APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT) 2021 UPDATE TO THE ACC EXPERT CONSENSUS DECISION PATHWAY ON OPTIMIZATION OF HEART FAILURE TREATMENT: ANSWERS TO 10 PIVOTAL QUESTIONS ABOUT HEART FAILURE WITH REDUCED EJECTION FRACTION To avoid actual, potential, or perceived con icts of interest that may arise as a result of industry relationships or personal interests among the writing committee, all members of the writing committee, as well as peer reviewers of the document, are asked to disclose all current healthcare-related relationships, including those existing 12 months before initiation of the writing effort. The ACC Task Force on Expert Consensus Decision Pathways reviews these disclosures to determine what companies make products (on market or in development) that pertain to the document under development. Based on this information, a writing committee is formed to include a majority of members with no relevant relationships with industry (RWI), led by a chair with no relevant RWI. RWI is reviewed on all conference calls and updated as changes occur. Author RWI pertinent to this document is disclosed in the table below and peer reviewer RWI is disclosed in Appendix 2. Addi- tionally, to ensure complete transparency, authors comprehensive disclosure information including RWI not pertinent to this document is available in a Supplemental Appendix 1. Disclosure information for the ACC Task Force on Expert Consensus Decision Pathways is also available online at http://www.acc.org/guidelines/about-guidelines-and-clinical- documents/guidelines-and-documents-task-forces, as well as the ACC disclosure policy for document development at http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy. J Maddox et al. Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Nasrien E. Ibrahim Massachusetts General Hospital Assistant Professor of Medicine, Harvard Medical School; Associate Director, Resynchronization and Advanced Cardiac Therapeutics Program, Massachusetts General Hospital n Roche Diagnostics None None n Boehringer Ingelheim n Novartis None None JoAnn Lindenfeld Vanderbilt University Director, Heart Failure and Transplantation Program n Abbott n AstraZeneca n Boehringer Ingelheim n Edwards Lifesciences n Novartis None None n AstraZeneca None None Frederick A. Masoudi University of Colorado Anschutz Medical Campus Professor of Medicine None None None None None None Shweta R. Motiwala Beth Israel Deaconess Medical Center, Harvard Medical School Instructor in Medicine n Eli Lilly None None n Relypsa None None Estefania Oliveros Temple University Hospital Pulmonary Hypertension, Right Heart Failure and CTEPH Program None None None None None None J. Herbert Patterson University of North Carolina Eshelman School of Pharmacy Professor of Pharmacy and Research Professor of Medicine n Novartis* None None n Amgen n Boehringer Ingelheim n Novartis None None Mary Norine Walsh St. Vincent Heart Center of Indiana Medical Director, Heart Failure and Cardiac Transplantation None None None None None None Alan Wasserman The George Washington University School of Medicine and Health Sciences Eugene Meyer Professor of Medicine; Chairman, Department of Medicine None None None None None None Clyde W. Yancy Northwestern University, Feinberg School of Medicine Vice Dean, Diversity and Inclusion; Magerstadt Professor of Medicine; Chief, Division of Cardiology None None None None None None Quentin R. Youmans Northwestern University Feinberg School of Medicine Fellow, Division of Cardiology, Department of Medicine None None None None None None This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily re ect relationships with industry at the time of publication. A person is deemed to have a signi cant interest in a business if the interest represents ownership of $5% of the voting stock or share of the business entity, or ownership of $$5,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. Relationships that exist with no nancial bene t are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACC, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document or makes a competing drug or device addressed in the document; or c) the person or a member of the person s household has a reasonable potential for nancial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Signi cant relationship No nancial bene t. AANP American Association of Nurse Practitioners; ACC American College of Cardiology; DSMB Data Safety Monitoring Board; CTEPH chronic thromboembolic pulmonary hypertension; UCLA University of California, Los Angeles. APPENDIX 1. CONTINUED Maddox et al. 