Transcatheter mitral valve repair or mitral valve surgery for functional mitral insuf ciency is of uncertain bene t and should only be considered after careful candidate selection and with a background of GDMT (357 360). (Level of Evidence: B) 3. Surgical reverse remodeling or LV aneurysmectomy may be considered in carefully selected patients with HFrEF for speci c indications, including intractable HF and ventricular arrhythmias (361). (Level of Evidence: B) 10. Coordinating Care for Patients With Chronic HF: Recommendations CLASS I 1. Effective systems of care coordination with special atten- tion to care transitions should be deployed for every patient with chronic HF that facilitate and ensure effective care that is designed to achieve GDMT and prevent hospitalization (333,336,362 377). (Level of Evidence: B) 2. Every patient with HF should have a clear, detailed, and evidence-based plan of care that ensures the achievement of GDMT goals, effective management of comorbid condi- tions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease. This plan of care should be updated regularly and made readily available to all members of each patient s healthcare team (14). (Level of Evidence: C) 3. Palliative and supportive care is effective for patients with symptomatic advanced HF to improve quality of life (31,378 381). (Level of Evidence: B) 11. Quality Metrics/Performance Measures: Recommendations CLASS I 1. Performance measures based on professionally developed clinical practice guidelines should be used with the goal of improving quality of care for HF (334,343,382). (Level of Evidence: B) CLASS IIa 1. Participation in quality improvement programs and patient registries based on nationally endorsed, clinical practice guidelineLbased quality and performance measures can be bene cial in improving quality of HF care (334,343). (Level of Evidence: B) See Table 26 for a revised ACCF/AHA/PCPI 2011 HF measurement set. 12. Evidence Gaps and Future Research Directions Despite the objective evidence compiled by the writing committee on the basis of hundreds of clinical trials, there are huge gaps in our knowledge base about many fundamental aspects of HF care. Some key examples include an effective management strategy for patients with HFpEF beyond blood pressure control; a convincing method to use biomarkers in the optimizationofmedicaltherapy;therecognitionandtreatmentof cardiorenalsyndrome; andthe critical needfor improving patient adherence to therapeutic regimens. Even the widely embraced dictum of sodium restriction in HF is not well supported by current evidence. Moreover, the majority ofthe clinical trials that inform GDMT were designed around the primary endpoint of mortality, so that there is less certainty about the impact of therapies on the health-related quality of life of patients. It is also ofmajorconcernthatthemajorityofrandomizedcontrolledtrials failed to randomize a suf cient number of the elderly, women, and underrepresented minorities, thus limiting our insight into these important patient cohorts. A growing body of studies on patient-centered outcomes research is likely to address some of these de ciencies, but time will be required. HF is a syndrome with a high prevalence of comorbidities and multiple chronic conditions, but most guidelines are developed for patients with a single disease. Nevertheless, the coexistence of additional diseases such as arthritis, renal Table 25. Recommendations for Surgical/Percutaneous/Transcatheter Interventional Treatments of HF Recommendations COR LOE References CABG or percutaneous intervention is indicated for HF patients on GDMT with angina and suitable coronary anatomy, especially significant left main stenosis or left main equivalent I C 11,13,15,348 CABG to improve survival is reasonable in patients with mild to moderate LV systolic dysfunction and significant multivessel CAD or proximal LAD stenosis when viable myocardium is present IIa B 348 350 CABG or medical therapy is reasonable to improve morbidity and mortality for patients with severe LV dysfunction (EF <35%), HF, and significant CAD IIa B 351,352 Surgical aortic valve replacement is reasonable for patients with critical aortic stenosis and a predicted surgical mortality of no greater than 10% IIa B 353 Transcatheter aortic valve replacement is reasonable for patients with critical aortic stenosis who are deemed inoperable IIa B 354 CABG may be considered in patients with ischemic heart disease, severe LV systolic dysfunction, and operable coronary anatomy whether or not viable myocardium is present IIb B 352,355,356 Transcatheter mitral valve repair or mitral valve surgery for functional mitral insufficiency is of uncertain benefit IIb B 357 360 Surgical reverse remodeling or LV aneurysmectomy may be considered in HFrEF for specific indications, including intractable HF and ventricular arrhythmias IIb B 361 CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COR, Class of Recommendation; EF, ejection fraction; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LAD, left anterior descending; LOE, Level of Evidence; and LV, left ventricular. Yancy et al. JACC Vol. 62, No. 16, 2013 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary October 15, 2013:1495 539 insuf ciency, diabetes mellitus, or chronic lung disease with the HF syndrome should logically require a modi cation of treatment, outcome assessment, or follow-up care. About 25% of Americans have multiple chronic conditions; this gure rises to 75% in those >65 years of age, including the diseases referred to above, as well as asthma, hypertension, cognitive disorders, or depression (347). Most randomized controlled trials in HF speci cally excluded patients with signi cant Table 26. ACCF/AHA/AMA-PCPI 2011 HF Measurement Set Measure Description* Care Setting Level of Measurement 1. LVEF assessment Percentage of patients aged 18 y with a diagnosis of HF for whom the quantitative or qualitative results of a recent or prior (any time in the past) LVEF assessment is documented within a 12-mo period Outpatient Individual practitioner 2. LVEF assessment Percentage of patients aged 18 y with a principal discharge diagnosis of HF with documentation in the hospital record of the results of an LVEF assessment performed either before arrival or during hospitalization, OR documentation in the hospital record that LVEF assessment is planned for after discharge Inpatient  Individual practitioner  Facility 3. Symptom and activity assessment Percentage of patient visits for patients aged 18 y with a diagnosis of HF with quantitative results of an evaluation of both current level of activity and clinical symptoms documented Outpatient Individual practitioner 4. Symptom managementy Percentage of patient visits for patients aged 18 y with a diagnosis of HF and with quantitative results of an evaluation of both level of activity AND clinical symptoms documented in which patient symptoms have improved or remained consistent with treatment goals since last assessment OR patient symptoms have demonstrated clinically important deterioration since last assessment with a documented plan of care Outpatient Individual practitioner 5. Patient self-care educationyz Percentage of patients aged 18 y with a diagnosis of HF who were provided with self-care education on 3 elements of education during 1 visits within a 12-mo period Outpatient Individual practitioner 6. Beta-blocker therapy for LVSD (outpatient and inpatient setting) Percentage of patients aged 18 y with a diagnosis of HF with a current or prior LVEF <40% who were prescribed beta-blocker therapy with bisoprolol, carvedilol, or sustained-release metoprolol succinate either within a 12-mo period when seen in the outpatient setting or at hospital discharge Inpatient and outpatient  Individual practitioner  Facility 7. ACE inhibitor or ARB therapy for LVSD (outpatient and inpatient setting) Percentage of patients aged 18 y with a diagnosis of HF with a current or prior LVEF <40% who were prescribed ACE inhibitor or ARB therapy either within a 12-mo period when seen in the outpatient setting or at hospital discharge Inpatient and outpatient  Individual practitioner  Facility 8. Counseling about ICD implantation for patients with LVSD on combination medical therapyyz Percentage of patients aged 18 y with a diagnosis of HF with current LVEF 35% despite ACE inhibitor/ARB and beta-blocker therapy for at least 3 mo who were counseled about ICD placement as a treatment option for the prophylaxis of sudden death Outpatient Individual practitioner 9. Postdischarge appointment for HF patients Percentage of patients, regardless of age, discharged from an inpatient facility to ambulatory care or home health care with a principal discharge diagnosis of HF for whom a follow-up appointment was scheduled and documented, including location, date, and time for a follow-up office visit or home health visit (as specified) Inpatient Facility N.B., Regarding test measure no. 8, implantation of an ICD must be consistent with published guidelines. This measure is intended to promote counseling only. *Refer to the complete measures for comprehensive information, including measure exception. yTest measure designated for use in internal quality improvement programs only. These measures are not appropriate for any other purpose (e.g., pay for performance, physician ranking, or public reporting programs). zNew measure. ACCF indicates American College of Cardiology Foundation; ACE, angiotensin-converting enzyme; AHA, American Heart Association; AMA-PCPI, American Medical AssociationPhysician Consortium for Performance Improvement; ARB, angiotensin-receptor blocker; HF, heart failure; ICD, implantable cardioverter-defibrillator; LVEF, left ventricular ejection fraction; and LVSD, left ventricular systolic dysfunction. Adapted from Bonow et al. (383). JACC Vol. 62, No. 16, 2013 Yancy et al. October 15, 2013:1495 539 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary other comorbidities from enrollment, thus limiting our ability to generalize our recommendations to many real-world patients. Therefore, the clinician must, as always, practice the art of using the best of the guideline recommendations as they apply to a speci c patient. Future research will need to focus on novel pharmacolog- ical therapies, especially for patients hospitalized with HF; regenerative cell-based therapies to restore myocardium; and new device platforms that will either improve existing tech- nologies (e.g., CRT, ICD, left ventricular assist device) or introduce simpler, less morbid devices that are capable of changing the natural history of HF. What is critically needed is an evidence base that clearly identi es best processes of care, especially in the transition from hospital to home. Finally, preventing the burden of this disease through more successful risk modi cation, sophisticated screening, perhaps using speci c omics technologies (i.e., systems biology), or effective treatment interventions that reduce the progression from stage A to stage B is an urgent need. Presidents and Staff American College of Cardiology Foundation John Gordon Harold, MD, MACC, President Shalom Jacobovitz, Chief Executive Of cer William J. Oetgen, MD, MBA, FACC, Senior Vice President, Science and Quality Charlene L. May, Senior Director, Science and Clinical Policy American College of Cardiology Foundation/ American Heart Association Lisa Brad eld, CAE, Director, Science and Clinical Policy Debjani Mukherjee, MPH, Associate Director, Evidence- Based Medicine Ezaldeen Ramadhan III, Specialist, Science and Clinical Policy Sarah Jackson, MPH, Specialist, Science and Clinical Policy American Heart Association Donna K. 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