Guideline sources The following summarized guidelines for the evaluation and management of heart failure are prepared by our editorial team based on guidelines from the Heart Failure Society of America (HFSA/AHA/ACC 2022), the European Society of Cardiology (ESC 2022; 2021), the The Japanese Society for Vascular Surgery (JSVS/JSCVS/JATS/JCS 2022), the European Society of Cardiology (ESC/ERS 2022), the American College of Emergency Physicians (ACEP 2022), the Canadian Cardiovascular Society (CCS 2022), the American Heart Association (AHA/HRS/ACC 2018), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the American Heart https://web.pathway.md/diseases/rectslm30dGoeF3RH 1/28 6/24/23, 12:32 PM Heart failure Pathway Association (AHA/ACC 2017; 2013), and the American College of Endocrinology (ACE/AACE 2016). 1 2 3 4 5 6 7 8 9 10 11 12 13 13 13 13 13 14 15 Definition HF is a clinical syndrome that results from structural or functional impairment of filling or ejection of blood from the heart. HF can be associated with either reduced ejection fraction ( 40%), preserved ejection fraction ( 50%), or borderline ejection fraction (41-50%). 13 Epidemiology The most common causes of HF include ischemic heart disease, hypertensive heart disease, valvular and rheumatic heart disease, genetic cardiomyopathies, and congenital heart disease. 13 Pathophysiology In the United States, the age and sex-adjusted incidence of HF is estimated at 219.3 cases per 100,000 person-years. Its prevalence is estimated at 1915 persons per 100,000 population. 13 14 Disease course Clinical manifestations relate to pulmonary edema (dyspnea, orthopnea, paroxysmal nocturnal dyspnea), peripheral edema (ankle swelling, abdominal bloating), and activation of inflammatory pathways (early satiety, cachexia). Severe HF leads to manifestations related to hypoperfusion, spanning from mild fatigue and exertional intolerance to cardiogenic shock. 15 Prognosis and risk of recurrence The 1-year and 5-year mortality associated with HF are estimated at 20.2% and 56.2%, respectively. Death is due to non-cardiovascular events in over 50% of patients. 13 13 CalculatorAssessment of diastolic dysfunc CalculatorAssessment of diastolic functio CalculatorKillip class Guidelines 1. Classification and risk stratification Risk stratification: consider using validated multivariable risk scores to estimate subsequent risk of incident HF in the general population and mortality in ambulatory or hospitalized patients with HF. C https://web.pathway.md/diseases/rectslm30dGoeF3RH 2/28 6/24/23, 12:32 PM Heart failure Pathway 2. Diagnostic investigations Clinical evaluation: Elicit a thorough history and perform physical examination in patients presenting with HF in order to: direct diagnostic strategies to uncover specific causes likely to warrant disease-specific management B identify cardiac and noncardiac disorders, lifestyle and behavioral factors and social determinants of health likely to cause or accelerate the development or progression of HF. B Show 5 more Laboratory evaluation: As per ACC 2022 guidelines: Evaluate for the specific cause of HF using additional laboratory testing for appropriate management of patients presenting with HF. B Obtain the following laboratory tests to optimize management of patients with HF: CBC urinalysis serum electrolytes BUN serum creatinine glucose lipid profile LFTs iron studies TSH. B As per ESC 2021 guidelines, obtain the following routine blood tests for comorbidities in all patients with suspected chronic HF: CBC electrolytes BUN thyroid function tests fasting glucose and Hgb A1C lipids iron status (transferrin saturation and ferritin). B Electrocardiogram: As per ACC 2022 guidelines, obtain a 12-lead ECG at the initial encounter in all patients presenting with HF, to optimize management. B As per ESC 2021 guidelines, obtain 12-lead ECG in all patients with suspected chronic HF. B Cardiopulmonary exercise testing: https://web.pathway.md/diseases/rectslm30dGoeF3RH 3/28 6/24/23, 12:32 PM Heart failure Pathway As per ACC 2022 guidelines, obtain cardiopulmonary exercise testing to determine appropriateness of advanced treatments (such as LV assist device, heart transplant) in selected ambulatory patients with HF. B Show 2 more As per ESC 2021 guidelines, consider obtaining exercise testing to detect reversible myocardial ischemia and investigate the cause of dyspnea. C Show 3 more Natriuretic peptide biomarkers: consider obtaining BNP or N-terminal pro-BNP to support a diagnosis or exclusion of HF in patients presenting with dyspnea. B Show 4 more Chest radiography: As per ACC 2022 guidelines, obtain a CXR to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary and other diseases likely to cause or contribute to the symptoms in patients with suspected or new-onset HF or presenting with acute decompensated HF. B As per ESC 2021 guidelines, obtain CXR to assess for comorbidities in all patients with suspected chronic HF. B Transthoracic echocardiogram: As per ACC 2022 guidelines, obtain TTE in the initial evaluation to assess cardiac structure and function in patients with suspected or newly diagnosed HF. B Show 2 more As per ESC 2021 guidelines, obtain TTE in all patients with suspected chronic HF. B Advanced cardiac imaging: As per ACC 2022 guidelines, obtain alternative imaging such as cardiac MRI, cardiac CT, or radionuclide imaging for assessment of LV ejection fraction, if echocardiography is inadequate. B Show 3 more As per ESC 2021 guidelines, obtain cardiac MRI for the assessment of myocardial structure and function in patients with poor echocardiogram acoustic windows. B Show 4 more Lung ultrasound: obtain point-of-care lung ultrasound as an imaging modality in conjunction with medical history and physical examination to diagnose acute HF syndrome when diagnostic uncertainty exists. B Psychosocial assessment: consider screening adult patients with HF for depression, social isolation, frailty and low health literacy as risk factors for poor self-care to improve management. C Show 2 more 3. Diagnostic procedures https://web.pathway.md/diseases/rectslm30dGoeF3RH 4/28 6/24/23, 12:32 PM Heart failure Pathway Coronary angiography: As per ESC 2021 guidelines: Perform invasive coronary angiography in patients with angina despite pharmacological therapy or symptomatic ventricular arrhythmias. B Consider performing invasive coronary angiography in patients with HF with reduced ejection fraction with an intermediate-to-high pretest probability of coronary artery disease and the presence of ischemia in noninvasive stress tests. C As per ACC 2017 guidelines, consider performing coronary angiography in patients eligible for revascularization when ischemia may be contributing to HF. C Right heart catheterization: perform right heart catheterization in patients with severe HF being evaluated for heart transplantation or mechanical circulatory support. B Show 3 more Endomyocardial biopsy: As per ACC 2022 guidelines: Do not perform endomyocardial biopsy in patients undergoing routine evaluation of HF because of the risk of complications. D Consider performing endomyocardial biopsy when a specific diagnosis is suspected that would influence therapy in patients with HF. C As per ESC 2021 guidelines, consider performing endomyocardial biopsy in patients with rapidly progressive HF despite standard therapy, if there is a probability of a specific diagnosis to be confirmed only in myocardial samples. C 4. Respiratory support Supplemental oxygen: administer oxygen to correct hypoxemia in patients with SpO < 90% or PaO < 60 mmHg. B Mechanical ventilation: Perform intubation for progressive respiratory failure persisting in spite of oxygen administration or noninvasive ventilation. B Consider initiating noninvasive positive pressure ventilation in patients with respiratory distress (respiratory rate > 25 breaths/min, SpO < 90%) and starting as soon as possible to decrease respiratory distress and reduce the rate of mechanical endotracheal intubation. C 5. Medical management General principles: As per ACC 2022 guidelines, provide multidisciplinary cate in patients with HF to: facilitate the implementation of guideline-directed medical therapy address potential barriers to self-care https://web.pathway.md/diseases/rectslm30dGoeF3RH 5/28 6/24/23, 12:32 PM Heart failure Pathway reduce the risk of subsequent re-hospitalization for HF improve survival. A Show 7 more As per ESC 2021 guidelines, enroll patients with HF in a multidisciplinary HF management program to reduce the risk of HF hospitalization and mortality. A Renin-angiotensin system inhibitors: As per ESC 2022 guidelines, initiate ACEIs/ARBs/angiotensin receptor neprilysin inhibitors and mineralocorticoid receptor antagonists in all patients with HF with reduced ejection fraction. A As per ACC 2022 guidelines, initiate angiotensin receptor-neprilysin inhibitors to reduce morbidity and mortality in patients with HF with reduced ejection fraction and NYHA class II-III symptoms. A Show 7 more Landmark trials: V-HeFT II In male patients with HF and LV dilation or an LV ejection fraction < 45%, enalapril was superior to hydralazine-isosorbide dinitrate arm with respect to death at 2 years. Cohn JN et al. N Engl J Med. 1991 Aug 1. As per ESC 2021 guidelines, initiate ACEIs to reduce the risk of HF hospitalization and death in patients with NYHA class II-IV HF with reduced ejection fraction with reduced ejection fraction (LV ejection fraction 40%). A Show 2 more As per AHA 2018 guidelines, initiate mineralocorticoid receptor antagonists and either ACEIs, angiotensin-receptor blockers, or angiotensin receptor-neprilysin inhibitors to reduce sudden cardiac death and all-cause mortality in patients with HF with reduced ejection fraction (LV ejection fraction 40%). A Aldosterone receptor antagonists: As per ACC 2022 guidelines, initiate mineralocorticoid receptor antagonists (spironolactone or eplerenone) to reduce morbidity and mortality in patients with HF with reduced ejection fraction and NYHA class II-IV symptoms, if estimated GFR is > 30 mL/min/1.73 m and serum potassium is < 5.0 mEq/L. Obtain careful monitoring of potassium, renal function and diuretic dosing at initiation and closely monitor thereafter to minimize risk of hyperkalemia and renal insufficiency. A Show 2 more Landmark trials: TOPCAT In patients with HF and a preserved LV ejection fraction, spironolactone was not superior to placebo with respect to death from cardiovascular causes, aborted cardiac arrest, or https://web.pathway.md/diseases/rectslm30dGoeF3RH 6/28 6/24/23, 12:32 PM Heart failure Pathway hospitalization for HF. Pitt B et al. N Engl J Med. 2014 Apr 10. As per ESC 2021 guidelines, initiate mineralocorticoid receptor antagonists to reduce the risk of HF hospitalization and death in patients with NYHA class II-IV HF with reduced ejection fraction with reduced ejection fraction (LV ejection fraction 40%). A Hydralazine and isosorbide dinitrate: As per ACC 2022 guidelines, initiate the combination of hydralazine and isosorbide dinitrate to improve symptoms and reduce morbidity and mortality in patients self-identified as African American with NYHA class III-IV HF with reduced ejection fraction receiving optimal medical therapy. A Show 2 more Landmark trials: V-HeFT In patients with chronic HF and LV ejection fraction < 45%, the combination of hydralazine and isosorbide dinitrate reduced mortality 2 years (25.6% vs. 34.3%, p<0.028; RRR 34%) as compared with prazosin or with placebo. LV ejection fraction rose significantly in the group treated with hydralazine/isosorbide dinitrate, but not in the placebo or prazosin groups. Cohn JN et al. N Engl J Med. 1986 Jun 12. As per ESC 2021 guidelines: Consider initiating hydralazine and isosorbide dinitrate to reduce the risk of HF hospitalization and death in self-identified black patients with LV ejection fraction 35% or with an LV ejection fraction < 45% combined with a dilated left ventricle in NYHA class III-IV despite treatment with an ACEI (or angiotensin receptor-neprilysin inhibitor), a -blocker and an mineralocorticoid receptor antagonist. C Consider initiating hydralazine and isosorbide dinitrate to reduce the risk of death in patients with symptomatic HF with reduced ejection fraction unable to tolerate any of ACEIs, angiotensin-receptor blockers or angiotensin receptor-neprilysin inhibitors (or they are contraindicated). C Beta-blockers: As per ESC 2022 guidelines, initiate -blockers in all patients with HF with reduced ejection fraction. A As per ACC 2022 guidelines: Initiate one of the three beta blockers proven to reduce mortality (bisoprolol, carvedilol, sustained-release metoprolol succinate) to reduce mortality and hospitalizations in patients with HF with reduced ejection fraction with current or previous symptoms. A Recognize that -blocker therapy provides high economic value in patients with HF with reduced ejection fraction with current or previous symptoms. A https://web.pathway.md/diseases/rectslm30dGoeF3RH 7/28 6/24/23, 12:32 PM Heart failure Pathway Landmark trials: COMET In patients chronic HF (NYHA II-IV), previous cardiovascular admission, and LV ejection fraction < 35% on optimal medical treatment, carvedilol was superior to metoprolol with respect to a all-cause death. Poole-Wilson PA et al. Lancet. 2003 Jul 5. As per ESC 2021 guidelines, initiate -blockers to reduce the risk of HF hospitalization and death in patients with stable NYHA class II-IV HF with reduced ejection fraction with reduced ejection fraction (LV ejection fraction 40%). A As per AHA 2018 guidelines, initiate -blockers to reduce sudden cardiac death and all-cause mortality in patients with HF with reduced ejection fraction (LV ejection fraction 40%). A Calcium channel blockers: do not use dihydropyridine D or nondihydropyridine CCBs in patients with HF with reduced ejection fraction. D Ivabradine: As per ACC 2022 guidelines, consider initiating ivabradine to reduce HF hospitalizations and cardiovascular death in patients with symptomatic (NYHA class II-III) stable chronic HF with reduced ejection fraction (LV ejection fraction 35%) receiving guideline-directed medical therapy including a beta blocker at maximum tolerated dose and having sinus rhythm with a HR of 70 bpm at rest. C Landmark trials: SHIFT In patients with symptomatic HF and a left-ventricular ejection fraction < 35% who were in sinus rhythm with HR 70 beats/min and had been admitted to hospital for HF within the previous year, ivabradine was superior to placebo with respect to cardiovascular death or hospital admission for worsening HF. Swedberg K et al. Lancet. 2010 Sep 11. As per ESC 2021 guidelines: Consider initiating ivabradine to reduce the risk of HF hospitalization and cardiovascular death in symptomatic patients with LV ejection fraction 35%, in sinus rhythm and a resting HR 70 bpm despite treatment with an evidence-based dose of -blocker (or maximum tolerated dose below that), ACEI or angiotensin receptor-neprilysin inhibitor and an mineralocorticoid receptor antagonist. C Consider initiating ivabradine to reduce the risk of HF hospitalization and cardiovascular death in symptomatic patients with LV ejection fraction 35%, in sinus rhythm and a resting HR 70 bpm unable to tolerate or having contraindications to a -blocker. Initiate ACEIs (or https://web.pathway.md/diseases/rectslm30dGoeF3RH 8/28 6/24/23, 12:32 PM Heart failure Pathway angiotensin receptor-neprilysin inhibitors) and mineralocorticoid receptor antagonists in these patients. C Diuretics: As per ACEP 2022 guidelines: Consider initiating early diuretics when indicated for emergency department patients with acute HF syndrome to reduce the length of stay and in-hospital mortality. C Verify the diagnosis of acute HF syndrome with volume overload before administering diuretics to avoid causing harm in patients with an alternative diagnosis. B As per ACC 2022 guidelines: Initiate diuretics to relieve congestion, improve symptoms and prevent worsening HF in patients with HF having fluid retention. B Reserve adding thiazide (such as metolazone) to treatment with a loop diuretic for patients with HF and congestive symptoms not responding to moderate- or high-dose loop diuretics, to minimize electrolyte abnormalities. B Landmark trials: TRANSFORM-HF In in-hospital patients with new or worsening HF, torsemide was not superior to furosemide with respect to death from all causes. Frederik H Verbrugge et al. Eur Heart J Acute Cardiovasc Care. 2022 Dec 27. As per ESC 2021 guidelines, initiate diuretics to alleviate HF symptoms, improve exercise capacity and reduce HF hospitalizations in patients with NYHA class II-IV HF with reduced ejection fraction with reduced ejection fraction (LV ejection fraction 40%) with signs and/or symptoms of congestion. B Digoxin: As per ACC 2022 guidelines, consider initiating digoxin to decrease hospitalizations for HF in patients with symptomatic HF with reduced ejection fraction despite guideline-directed medical therapy or unable to tolerate guideline-directed medical therapy. C Landmark trials: DIG In patients with an LV ejection fraction 0.45 being treated with diuretics and ACE inhibitors, digoxin was not superior to placebo with respect to death from all causes. Digitalis Investigation Group. N Engl J Med. 1997 Feb 20. As per ESC 2021 guidelines, consider initiating digoxin to reduce the risk of hospitalization (both all-cause and HF hospitalizations) in patients with symptomatic HF with reduced ejection https://web.pathway.md/diseases/rectslm30dGoeF3RH 9/28 6/24/23, 12:32 PM Heart failure Pathway fraction in sinus rhythm despite treatment with an ACEI (or angiotensin receptor-neprilysin inhibitor), a -blocker and a mineralocorticoid receptor antagonist. C Sodium-glucose cotransporter-2 inhibitors: As per CCS 2022 guidelines: Initiate SGLT-2 inhibitors to reduce all-cause and cardiovascular mortality, hospitalization for HF, and the composite endpoint of significant decline in estimated GFR, progression to end- stage kidney disease, or death due to kidney disease in adult patients with HF and LV ejection fraction 40%. B Initiate SGLT-2 inhibitors to reduce hospitalization for HF in adult patients with HF and LV ejection fraction > 40%. B Landmark trials: EMPULSE In patients with a primary diagnosis of acute de novo or decompensated chronic HF regardless of LV ejection fraction, empagliflozin was superior to placebo with respect to clinical benefit at day 90. Adriaan A Voors et al. Nat Med. 2022 Mar. As per ESC 2022 guidelines, initiate SGLT-2 inhibitors in all patients with HF with reduced ejection fraction. A As per ACC 2022 guidelines: Initiate SGLT-2 inhibitors to reduce hospitalization for HF and cardiovascular mortality, irrespective of the presence of T2DM in patients with symptomatic chronic HF with reduced ejection fraction. A Recognize that SGLT-2 inhibitor therapy provides intermediate economic value in patients with symptomatic chronic HF with reduced ejection fraction. A Landmark trials: DAPA-HF In adult patients with NYHA class II, III, or IV HF and an ejection fraction < 40%, dapagliflozin was superior to placebo with respect to worsening HF or cardiovascular death. John J V McMurray et al. N Engl J Med. 2019 Nov 21. As per ESC 2021 guidelines: Initiate dapagliflozin or empagliflozin to reduce the risk of HF hospitalization and death in patients with NYHA class II-IV HF with reduced ejection fraction with reduced ejection fraction (LV ejection fraction 40%). A Initiate SGLT-2 inhibitors (dapagliflozin, empagliflozin, and sotagliflozin) to reduce hospitalizations for HF and cardiovascular death in patients with T2DM mellitus and HF with https://web.pathway.md/diseases/rectslm30dGoeF3RH 10/28 6/24/23, 12:32 PM Heart failure Pathway reduced ejection fraction. A Landmark trials: EMPEROR-Reduced In adult patients with chronic HF and an ejection fraction 40% who were receiving recommended therapy, empagliflozin was superior to placebo with respect to cardiovascular death or hospitalization for worsening HF. Milton Packer et al. N Engl J Med. 2020 Oct 8. Soluble guanylate cyclase stimulators: As per ACC 2022 guidelines, consider initiating an oral soluble guanylate cyclase stimulator (vericiguat) to reduce HF hospitalization and cardiovascular death in selected high-risk patients with HF with reduced ejection fraction and recent worsening of HF already on guideline-directed medical therapy. C As per ESC 2021 guidelines, consider initiating vericiguat to reduce the risk of cardiovascular mortality or HF hospitalization in patients with NYHA class II-IV HF with reduced ejection fraction (LVEF 40%) with worsening HF despite treatment with an ACEI (or angiotensin receptor- neprilysin inhibitor), a -blocker and an mineralocorticoid receptor antagonist. C Anticoagulation therapy: do not initiate anticoagulation in patients with chronic HF with reduced ejection fraction without a specific indication, such as VTE, AF, a previous thromboembolic event or a cardioembolic source. D Medications to avoid: recognize that class IC antiarrhythmic medications and dronedarone may increase the risk of mortality in patients with HF with reduced ejection fraction. B Show 3 more Management of pre-HF: initiate ACEIs to prevent symptomatic HF and reduce mortality in patients with LV ejection fraction 40%. A Show 7 more Management of HFmrEF: As per ACC 2022 guidelines: Consider initiating SGLT-2 inhibitors to decrease HF hospitalizations and cardiovascular mortality in patients with HF with mildly reduced ejection fraction. C Consider initiating the following agents in patients with current or previous symptomatic HF with mildly reduced ejection fraction (LV ejection fraction 41-49%) to reduce the risk of HF hospitalization and cardiovascular mortality, particularly among patients with LV ejection fraction on the lower end of this spectrum: evidence-based -blockers for HF with reduced ejection fraction angiotensin receptor-neprilysin inhibitors ACEIs ARBs https://web.pathway.md/diseases/rectslm30dGoeF3RH 11/28 6/24/23, 12:32 PM Heart failure Pathway mineralocorticoid receptor antagonists. C Landmark trials: DELIVER In patients with HF and a LV ejection fraction > 40%, dapagliflozin was superior to placebo with respect to worsening HF or cardiovascular death. Scott D Solomon et al. N Engl J Med. 2022 Sep 22. As per ESC 2021 guidelines: Initiate diuretics to alleviate symptoms and signs in patients with congestion and HF with mildly reduced ejection fraction. B Consider initiating the following agents to reduce the risk of HF hospitalization and death in patients with HF with mildly reduced ejection fraction: ACEIs, angiotensin-receptor blockers or sacubitril/valsartan mineralocorticoid receptor antagonists -blockers. C Management of HFimpEF: continue guideline-directed medical therapy to prevent relapse of HF and LV dysfunction in patients with HF with improved ejection fraction after treatment, even in patients becoming asymptomatic. B Management of HFpEF: As per ACC 2022 guidelines, titrate medication to attain BP targets in accordance with published clinical practice guidelines to prevent morbidity in patients with HFpEF and hypertension. B Show 6 more Landmark trials: EMPEROR-Preserved In patients with NYHA class II-IV HF and an ejection fraction > 40%, empagliflozin was superior to placebo with respect to cardiovascular death or hospitalization for HF. Stefan D Anker et al. N Engl J Med. 2021 Oct 14. As per ESC 2021 guidelines: Screen for and treat etiologies and cardiovascular and non-cardiovascular comorbidities in patients with HFpEF. B Initiate diuretics to alleviate symptoms and signs in patients with HFpEF with congestion. B Management of hypertension: As per AHA 2022 guidelines: Titrate guideline-directed medical therapy to the maximally tolerated target dose in patients with HF with reduced ejection fraction and hypertension. B https://web.pathway.md/diseases/rectslm30dGoeF3RH 12/28 6/24/23, 12:32 PM Heart failure Pathway Titrate medication to attain BP targets in accordance with published clinical practice guidelines to prevent morbidity in patients with HFpEF and hypertension. B As per JCS 2022 guidelines: Consider offering proactive use of medications, mainly cardioprotective antihypertensive agents, to achieve a mean BP < 90 mmHg (< 80 mmHg if tolerated) in patients with HF. C Encourage and educate patients to measure their BP at home and to record it as a daily self- management goal. B As per AAPA 2018 guidelines, titrate guideline-directed medical therapy titrated to attain a BP of < 130/80 mmHg in adult patients with HF with reduced ejection fraction and hypertension. B Show 3 more Management of atrial fibrillation, anticoagulation: As per HFSA/ACC/AHA 2022 guidelines, initiate chronic anticoagulant therapy in patients with chronic HF with permanent-persistent-paroxysmal AF and a CHA2DS2-VASc score of 2 (for males) and 3 (for females). A Show 4 more As per ESC 2021 guidelines, initiate long-term oral anticoagulation in all patients with AF, HF and CHA2DS2-VASc score 2 in males or 3 in females. A Show 2 more Management of atrial fibrillation (rate control): Consider initiating -blockers for short- and long-term rate control in patients with HF and AF. C Consider initiating digoxin when the ventricular rate remains high despite -blockers or when - blockers are contraindicated or not tolerated. C Management of atrial fibrillation (cardioversion): Perform urgent electrical cardioversion in patients with acute worsening of HF presenting with rapid ventricular rates and hemodynamic instability. B Consider performing cardioversion if there is an association between AF and worsening of HF symptoms despite optimal medical treatment. C Management of atrial fibrillation, catheter ablation: As per HFSA/ACC/AHA 2022 guidelines: Consider performing AF ablation to improve symptoms and quality of life in patients with HF and symptoms caused by AF. C Consider performing atrioventricular nodal ablation with implantation of a cardiac resynchronization therapy device in patients with AF and LV ejection fraction 50%, if a rhythm control strategy fails or is not desired and ventricular rates remain rapid despite medical therapy. C As per ESC 2021 guidelines, consider performing catheter ablation for the prevention or treatment of AF if there is a clear association between paroxysmal or persistent AF and worsening of HF symptoms persisting despite medical therapy. C Management of valvular heart disease: https://web.pathway.md/diseases/rectslm30dGoeF3RH 13/28 6/24/23, 12:32 PM Heart failure Pathway Manage VHD in a multidisciplinary manner in accordance with clinical practice guidelines for VHD to prevent worsening of HF and adverse clinical outcomes in patients with HF. B Optimize guideline-directed medical therapy before any intervention for secondary MR related to LV dysfunction in patients with chronic severe secondary MR and HF with reduced ejection fraction. B Management of hyperkalemia: insufficient evidence to support the use of potassium binders (patiromer, sodium zirconium cyclosilicate) to improve outcomes in patients with HF experiencing hyperkalemia (serum potassium level 5.5 mEq/L) while taking a RAAS inhibitor. I Management of anemia: As per ACC 2022 guidelines: Consider initiating IV iron replacement to improve functional status and quality of life in patients with HF with reduced ejection fraction and iron deficiency with or without anemia. C Do not use ESAs to improve morbidity and mortality in patients with HF and anemia. D Landmark trials: FAIR-HF In patients with chronic HF, reduced LV ejection fraction, and iron deficiency, with or without anemia, ferric carboxymaltose was superior to placebo with respect to the percentage of patients achieving good or moderate improvement on the self-reported Patient Global Assessment at 24 weeks. Anker SD et al. N Engl J Med. 2009 Dec 17. As per ESC 2021 guidelines, obtain periodic screening for anemia and iron deficiency with a CBC, serum ferritin concentration and transferrin saturation in all patients with HF. B Show 3 more Management of sleep disorders: consider obtaining a formal sleep assessment in patients with HF and suspicion of sleep-disordered breathing to confirm the diagnosis and differentiate between obstructive and central sleep apnea. C Show 2 more 6. Inpatient care General principles: continue and optimize preexisting guideline-directed medical therapy to improve outcomes, unless contraindicated, in patients with HF with reduced ejection fraction requiring hospitalization. B Show 6 more Invasive hemodynamic monitoring: Do not obtain routine invasive hemodynamic monitoring in patients with HF. D Consider obtaining invasive hemodynamic monitoring to guide management in selected patients with HF with persistent or worsening symptoms, signs, diagnostic parameters and, if https://web.pathway.md/diseases/rectslm30dGoeF3RH 14/28 6/24/23, 12:32 PM Heart failure Pathway hemodynamics are uncertain. C Venous thromboprophylaxis: As per ACC 2022 guidelines, administer venous thromboprophylaxis to prevent venous thromboembolic disease in patients hospitalized with HF. B As per ESC 2021 guidelines, administer thromboprophylaxis, such as with low-molecular-weight heparin, to reduce the risk of DVT and pulmonary embolism in patients not already anticoagulated and with no contraindication to anticoagulation. A Intravenous diuretics: As per ACC 2022 guidelines, administer prompt IV loop diuretics to improve symptoms and reduce morbidity in patients with HF admitted with evidence of significant fluid overload. B Show 3 more Landmark trials: ADVOR In patients with acute decompensated HF, clinical signs of volume overload, and N-terminal pro-BNP level > 1,000 pg/mL or BNP level > 250 pg/mL, acetazolamide was superior to placebo with respect to successful decongestion at 3 days. Wilfried Mullens et al. N Engl J Med. 2022 Sep 29. As per ESC 2021 guidelines: Administer IV loop diuretics to improve symptoms in all patients with acute HF admitted with signs/symptoms of fluid overload. B Consider combining a loop diuretic with a thiazide-type diuretic in patients with resistant edema not responding to an increase in loop diuretic doses. C Updated evidence: CLOROTIC In hospitalized adult patients with acute decompensated HF, hydrochlorothiazide was superior to placebo with respect to weight reduction at 72 hours. Joan Carles Trull s et al. Eur Heart J. 2022 Nov 24. As per ACC 2017 guidelines, obtain daily serum electrolytes, urea nitrogen, and creatinine measurements during the use of IV diuretics or active titration of HF medications. B Intravenous inotropes: As per ACC 2022 guidelines, consider administering continuous IV inotropic support as "bridge therapy" in patients with advanced (stage D) HF refractory to guideline-directed medical therapy and device therapy being eligible for and awaiting mechanical circulatory support or cardiac transplantation. C Show 2 more https://web.pathway.md/diseases/rectslm30dGoeF3RH 15/28 6/24/23, 12:32 PM Heart failure Pathway As per ESC 2021 guidelines, do not administer routine inotropic agents because of safety concerns unless the patient has symptomatic hypotension and evidence of hypoperfusion. D Show 2 more Intravenous nitrates: As per ACEP 2022 guidelines, consider administering high-dose nitroglycerin in patients with acute HF syndrome and elevated BP. C As per ACC 2022 guidelines, consider administering IV nitroglycerin or nitroprusside as an adjuvant to diuretic therapy to relieve dyspnea in patients admitted with decompensated HF, in the absence of systemic hypotension. C As per ESC 2021 guidelines, consider administering IV vasodilators as initial therapy to improve symptoms and reduce congestion in patients with acute HF and systolic BP > 110 mmHg. C Opioids: do not use routine opioids unless in selected patients with severe/intractable pain or anxiety. D Management of cardiogenic shock (general principles): Consider managing patients with cardiogenic shock by a multidisciplinary team experienced in shock. C Consider placing a pulmonary artery line to define hemodynamic subsets and appropriate management strategies in patients presenting with cardiogenic shock. C Management of cardiogenic shock, inotropes and vasopressors: As per HFSA/ACC/AHA 2022 guidelines, administer IV inotropic support to maintain systemic perfusion and preserve end-organ performance in patients with cardiogenic shock. B As per ESC 2021 guidelines, consider administering a vasopressor, preferably norepinephrine, to increase BP and vital organ perfusion in patients with cardiogenic shock. C Management of cardiogenic shock, mechanical circulatory support: As per HFSA/ACC/AHA 2022 guidelines: Consider triaging patients not rapidly responding to initial shock measures to centers providing temporary mechanical circulatory support to optimize management. C Consider initiating temporary mechanical circulatory support in patients with cardiogenic shock when end-organ function cannot be maintained by pharmacologic means to support cardiac function. C As per ESC 2021 guidelines, consider initiating short-term mechanical circulatory support in patients with cardiogenic shock as a bridge to recovery, bridge to decision, bridge to bridge or to treat the cause of cardiogenic shock or long-term mechanical circulatory support or transplantation. C Management of cardiogenic shock (intra-aortic balloon pump): Consider performing intra-aortic balloon pump therapy in patients with cardiogenic shock as a bridge to recovery, bridge to decision, bridge to bridge including the treatment of cardiogenic shock (mechanical complication of acute myocardial infarction) or long-term mechanical circulatory support or transplantation. C https://web.pathway.md/diseases/rectslm30dGoeF3RH 16/28 6/24/23, 12:32 PM Heart failure Pathway Do not perform intra-aortic balloon pump therapy routinely in patients with post-myocardial infarction cardiogenic shock. D Management of cardiogenic shock (coronary revascularization): transfer suitable patients with STEMI developing cardiogenic shock or acute severe HF, irrespective of the time delay from myocardial infarction onset, immediately to a PCI-capable hospital for coronary angiography. B Show 6 more 7. Nonpharmacologic interventions Lifestyle modifications: As per AHA 2017 guidelines, control or avoid other conditions likely to lead or contribute to HF, including obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents. B As per AACE 2016 guidelines, do not offer weight loss for the expressed purpose of preventing cardiovascular events or to extend life in patients with congestive HF, although evidence suggests that weight loss can improve myocardial function and congestive HF symptomatology in the short term. D Self-management programs: Offer self-management strategies in patients with HF to reduce the risk of HF hospitalization and mortality. A Offer either home-based and/or clinic-based programs to improve outcomes and to reduce the risk of HF hospitalization and mortality. A Exercise: As per ACC 2022 guidelines, advise participating in exercise training or practicing regular physical activity to improve functional status, exercise performance and quality of life in patients with HF able to participate. A As per ESC 2021 guidelines, advise exercising in all patients able in order to improve exercise capacity, quality of life and reduce HF hospitalization. A Cardiac rehabilitation: As per ACC 2022 guidelines, consider offering participation in cardiac rehabilitation programs to improve functional capacity, exercise tolerance and health-related quality of life in patients with HF. C As per ESC 2021 guidelines, consider offering a supervised, exercise-based, cardiac rehabilitation program in patients with more severe disease, frailty or with comorbidities. C Fluid and sodium restriction: Advise avoiding excessive sodium intake to reduce congestive symptoms in patients with stage C HF. B Insufficient evidence to recommend fluid restriction to reduce congestive symptoms in patients with advanced HF and hyponatremia. I https://web.pathway.md/diseases/rectslm30dGoeF3RH 17/28 6/24/23, 12:32 PM Heart failure Pathway Landmark trials: SODIUM-HF In adult patients with chronic HF receiving optimally tolerated medical treatment, reduced sodium intake was not superior to usual sodium intake with respect to a composite of admission to hospital for cardiovascular causes, emergency department visit for cardiovascular causes, or death from all causes at 12 months. Justin A Ezekowitz et al. Lancet. 2022 Apr 9. Nutritional supplements: Consider offering omega-3 PUFA supplementation as adjunctive therapy to reduce mortality and cardiovascular hospitalizations in patients with HF and NYHA class II-IV symptoms. C Do not offer vitamins, nutritional supplements or hormonal therapy in patients with HF with reduced ejection fraction other than to correct specific deficiencies. D 8. Therapeutic procedures Cardiac resynchronization therapy: As per ACC 2022 guidelines, perform cardiac resynchronization therapy to reduce total mortality and hospitalizations and improve symptoms and quality of life in patients with LV ejection fraction 35%, sinus rhythm, LBBB with a QRS duration 150 ms and NYHA class II, III or ambulatory IV symptoms on guideline-directed medical therapy. B Show 10 more As per ESC 2021 guidelines, perform cardiac resynchronization therapy to improve symptoms and reduce morbidity and mortality in symptomatic patients with HF in sinus rhythm with a QRS duration 150 ms and LBBB QRS morphology and with LV ejection fraction 35% despite optimal medical therapy. A Show 6 more Implantable cardioverter-defibrillator: As per ACC 2022 guidelines, perform placement of an ICD for primary prevention of sudden cardiac death to reduce total mortality in patients with non-ischemic dilated cardiomyopathy or ischemic heart disease at least 40 days post-myocardial infarction with LV ejection fraction 35% and NYHA class II-III symptoms on chronic guideline-directed medical therapy having a reasonable expectation of meaningful survival for > 1 year. A Show 4 more As per ESC 2021 guidelines, perform placement of an ICD to reduce the risk of sudden death and all-cause mortality in patients recovered from a ventricular arrhythmia causing hemodynamic instability and expected to survive for > 1 year with good functional status, in the absence of reversible causes or unless the ventricular arrhythmia has occurred < 48 hours after a myocardial infarction. A Show 6 more