Treating Hypertension in Stage C HFrEF: Recommendation Recommendation for Hypertension in Stage C HFrEF COR LOE Recommendation Comment/Rationale I C-EO Patients with HFrEF and hypertension should be prescribed GDMT titrated to attain systolic blood pressure less than 130 mm Hg.191 NEW: Recommendation has been adapted from recent clinical trial data but not specifically tested per se in a randomized trial of patients with HF. See Online Data Supplements E and F. Clinical trials evaluating goal blood pressure reduction and optimal blood pressure lowering agents in the setting of HFrEF and concomitant hypertension have not been done. However, it is apparent that in those patients at higher risk, blood pressure lowering is associated with fewer adverse cardiovascular events. GDMT for HFrEF with agents known to lower blood pressure should consider a goal blood pressure reduction consistent with a threshold now associated with improved clinical outcomes but not yet proven by RCTs in a population with HF. 9.5.3. Treating Hypertension in Stage C HFpEF: Recommendation Recommendation for Hypertension in Stage C HFpEF COR LOE Recommendation Comment/Rationale I C-LD Patients with HFpEF and persistent hypertension after management of volume overload should be prescribed GDMT titrated to attain systolic blood pressure less than 130 mm Hg.9,167,169,170,195 199 NEW: New target goal blood pressure based on updated interpretation of recent clinical trial data. See Online Data Supplements E and F. The use of nitrates in the setting of HFpEF is associated with a signal of harm and, in most situations, should be avoided. For many common antihypertensive agents, including alpha blockers, beta blockers, and calcium channel blockers, there are limited data to guide the choice of antihypertensive therapy in the setting of HFpEF.172 Nevertheless, RAAS inhibition with ACE inhibitor, ARB (especially mineralocorticoid receptor antagonists), and possibly ARNI would represent the preferred choice. A shared decision-making discussion with the patient influenced by physician judgment should drive the ultimate choice of antihypertensive agents. 9.6. Sleep-Disordered Breathing: Recommendations (Moved from Section 7.3.1.4, Treatment of Sleep Disorders in the 2013 HF guideline.) Recommendations for Treatment of Sleep Disorders COR LOE Recommendations Comment/Rationale IIa C-LD In patients with NYHA class II IV HF and suspicion of sleep-disordered breathing or excessive daytime sleepiness, a formal sleep assessment is NEW: Recommendation reflects clinical necessity to distinguish obstructive versus central sleep apnea. See Online Data Supplement G. Sleep disorders are common in patients with HF. A study of adults with chronic HF treated with evidence-based therapies found that 61% had either central or obstructive sleep apnea.202 It is clinically important to distinguish obstructive sleep apnea from central sleep apnea, given the different responses to treatment. Adaptive servo-ventilation for central sleep apnea is associated with harm.203 Continuous positive airway pressure (CPAP) for obstructive sleep apnea improves sleep quality, reduces the apnea-hypopnea index, and improves nocturnal oxygenation.200,201 IIb B-R In patients with cardiovascular disease and obstructive sleep apnea, CPAP may be reasonable to improve sleep quality and daytime NEW: New data demonstrate the limited scope of benefit expected from CPAP for obstructive sleep apnea. See Online Data Supplement G. In patients with sleep apnea, a trial evaluated the impact of CPAP with usual therapy versus usual therapy alone on subsequent cardiovascular events, including In this RCT of >2700 patients, there was no evidence of benefit on cardiovascular events at a mean follow-up of 3.7 years for CPAP plus usual care compared with usual care alone. Improvements in sleep quality were noteworthy and represented the primary indication for initiating CPAP treatment.204 However, in patients with atrial fibrillation (AF) (a frequent comorbidity noted with HF), the use of CPAP for obstructive sleep apnea was helpful. In a trial of 10132 patients with AF and obstructive sleep apnea, patients on CPAP treatment were less likely to progress to more permanent forms of AF than were patients without CPAP.205 Yancy et al ACC/AHA TASK FORCE MEMBERS Glenn N. Levine, MD, FACC, FAHA, Chair; Patrick T. O Gara, MD, FACC, FAHA, Chair-Elect; Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair*; Sana M. Al-Khatib, MD, MHS, FACC, FAHA; Kim K. Birtcher, PharmD, MS, AACC; Bi- ykem Bozkurt, MD, PhD, FACC, FAHA; Ralph G. Brindis, MD, MPH, MACC*; Joaquin E. Cigarroa, MD, FACC; Lesley H. Cur- tis, PhD, FAHA; Lee A. Fleisher, MD, FACC, FAHA; Federico Gentile, MD, FACC; Samuel Gidding, MD, FAHA; Mark A. Hlatky, MD, FACC; John Ikonomidis, MD, PhD, FAHA; Jos Joglar, MD, FACC, FAHA; Susan J. Pressler, PhD, RN, FAHA; Duminda N. Wijeysundera, MD, PhD PRESIDENTS AND STAFF American College of Cardiology Mary Norine Walsh, MD, FACC, President Shalom Jacobovitz, Chief Executive Officer William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publishing Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing American College of Cardiology/ American Heart Association Katherine Sheehan, PhD, Director of Guideline Strategy and Operations Lisa Bradfield, CAE, Director, Guideline Methodology and Policy Abdul R. Abdullah, MD, Science and Medicine Advisor Morgane Cibotti-Sun, MPH, Project Manager, Clinical Practice Guidelines Sam Shahid, MBBS, MPH, Associate Science and Medicine Advisor American Heart Association Steven R. Houser, PhD, FAHA, President Nancy Brown, Chief Executive Officer Rose Marie Robertson, MD, FAHA, Chief Science and Medicine Officer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice Presi- dent, Office of Science Operations Jody Hundley, Production Manager, Scientific Publications, Office of Science Operations FOOTNOTES This document was approved by the American College of Cardiology Clinical Policy Approval Committee, the American Heart Association Science Advisory and Coordinating Com- mittee, the American Heart Association Executive Committee, and the Heart Failure Society of America Executive Committee in April 2017. The Comprehensive RWI Data Supplement table is avail- able with this article at http://circ.ahajournals.org/lookup/ suppl/doi:10.1161/CIR.0000000000000509/-/DC1. The Data Supplement is available with this article at CIR.0000000000000509/-/DC2. This article has been copublished in the Journal of the American College of Cardiology and the Journal of Cardiac Failure. Copies:ThisdocumentisavailableontheWorldWideWeb sites of the American College of Cardiology (www.acc.org), the American Heart Association (professional.heart.org), and the Heart Failure Society of America (www.hfsa.org). A copy of the document is available at http://professional. heart.org/statements by selecting either the By Topic link or the By Publication Date link. To purchase addi- tional reprints, call 843-216-2533 or e-mail kelle.ramsay@ wolterskluwer.com. Expert peer review of AHA Scientific Statements is con- ducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http:// professional.heart.org/statements and select the Policies and Development link. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright- Permission-Guidelines_UCM_300404_Article.jsp. A link to the Copyright Permissions Request Form appears on the right side of the page. Circulation is available at http://circ.ahajournals.org. *Former Task Force member; current member during the writing effort. III: Harm B-R In patients with NYHA class II IV HFrEF and central sleep apnea, adaptive servo-ventilation causes harm.203 NEW: New data demonstrate a signal of harm when adaptive servo-ventilation is used for central sleep apnea. See Online Data Supplement G. Mortality rate (all cause and cardiovascular) was higher with adaptive servo-ventilation plus GDMT than with GDMT alone in a single RCT to test the addition of adaptive servo-ventilation ( 5 hours/night, 7 days/week) to GDMT in patients with HFrEF and central sleep apnea.203 A similar risk has been seen in another trial, and a third trial of adaptive servo-ventilation in central sleep apnea and HF was aborted because of ethical concerns. The weight of evidence does not support the use of adaptive servo-ventilation for central sleep apnea in HFrEF. Recommendations for Treatment of Sleep Disorders (Continued) COR LOE Recommendations Comment/Rationale 2017 ACC/AHA/HFSA Heart Failure Focused Update CLINICAL STATEMENTS AND GUIDELINES REFERENCES 1. Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Institute of Medicine (US). Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press, 2011. 2. 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Impact of obstructive sleep apnea and continuous positive airway pressure therapy on outcomes in pa- tients with atrial fibrillation-Results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Am Heart J. 2015;169:647 54. Yancy et al Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure (December 2015) Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals By Section* Clyde W. Yancy, Chair Northwestern University Feinberg School of Medicine, Division of Cardiology Professor of Medicine and Chief; Diversity and Inclusion Vice Dean None None None None None None None Mariell Jessup, Vice Chair Fondation Leducq Chief Scientific Officer None None None None None None None Biykem Bozkurt Baylor College of Medicine, Department of Medicine Professor of Medicine; Cardiology Section, DeBakey VA Medical Center Chief; The Mary and Gordon Cain Chair & W.A. Tex and Deborah Moncrief, Jr. Chair; Winters Center for Heart Failure Research Director; Cardiovascular Research Institute Associate Director None None None Novartis None None 7.3.2.10, 9.5. Javed Butler Stony Brook University Division Chief of Cardiology Bayer Boehringer Ingelheim CardioCell Luitpold Medtronic Merck Novartis Relypsa Takeda Trevena Z Pharma Zensun Novartis None Amgen (DSMB) None None 7.3.2.10, 9.5. Donald E. Casey, Jr Thomas Jefferson College of Population Health Faculty; Alvarez & Marsal Founder None None None None None None None Monica M. Colvin University of Michigan Associate Professor of Medicine, Cardiology None None None None None None None Mark H. Drazner University of Texas Southwestern Medical Center Professor, Internal Medicine None None None None None None None Gerasimos S. Filippatos National and Kapodistrian University of Athens; Attikon University Hospital, Department of Cardiology, Heart Failure Unit Professor of Cardiology None None None Bayer Bayer (DSMB) Novartis Servier Pharmaceuticals Vifor None None 7.3.2.10, and 9.5. Gregg C. Fonarow Ahmanson-UCLA Cardiomyopathy Center Director; UCLA Division of Cardiology Co-Chief Amgen Janssen Pharmaceuticals Novartis None None Novartis None None 7.3.2.10, 9.5. (Continued) 2017 ACC/AHA/HFSA Heart Failure Focused Update CLINICAL STATEMENTS AND GUIDELINES Michael M. Givertz Brigham and Women's Hospital Professor of Medicine Merck Novartis None None None None None 7.3.2.10, 9.5. Steven M. Hollenberg Cooper University Hospital Director, Coronary Care Unit, Professor of Medicine None None None None None None None JoAnn Lindenfeld Vanderbilt Heart and Vascular Institute Director, Advanced Heart Failure and Transplant Section Professor of Medicine Abbott Janssen Pharmaceuticals Novartis Relypsa ResMed None None AstraZeneca Novartis None None 6.3, and 9.6. Frederick A. Masoudi University of Colorado, Anschutz Medical Campus Professor of Medicine, Division of Cardiology None None None None None None None Patrick E. McBride University of Wisconsin School of Medicine and Public Health Professor of Medicine and Family Medicine; Associate Director, Preventive Cardiology None None None None None None None Pamela N. Peterson University of Colorado, Denver Health Medical Center Associate Professor of Medicine, Division of Cardiology None None None None None None None Lynne Warner Stevenson Brigham and Women s Hospital Cardiovascular Division Director, Cardiomyopathy and Heart Failure Program None None None Novartis PARENT trial (PI) NHLBI INTERMACS (Co PI) None None 7.3.2.10, 9.5. Cheryl Westlake Azusa Pacific University, School of Nursing, Doctoral Programs Professor None 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 reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $5000 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 financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACC/AHA, 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; or 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 financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply. Significant relationship. ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; DCRI, Duke Clinical Research Institute; DSMB, data safety monitoring board; HFSA, Heart Failure Society of America; NHLBI, National Heart, Lung, and Blood Institute; INTERMACS, Interagency Registry for Mechanically Assisted Circulatory Support; PARENT, Pulmonary artery pressure reduction with entresto; UCLA, University of California, Los Angeles; and VA, Veterans Affairs. Appendix 1. Continued Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals By Section* Yancy et al Appendix 2. Reviewer Relationships With Industry and Other Entities (Comprehensive) 2017 ACC/AHA/ HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure (October 2016) Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Kim K. Birtcher Official Reviewer ACC/AHA Task Force on Clinical Practice Guidelines University of Houston College of Pharmacy Clinical Professor Jones & Bartlett Learning None None None None None Akshay S. Desai Official Reviewer HFSA Brigham and Women s Hospital Director, Heart Failure Disease Management, Advanced Heart Disease Section, Cardiovascular Division; Associate Professor of Medicine, Harvard Medical School Medscape Cardiology* Merck Novartis* Relypsa* St. Jude Medical* None None None Novartis* Thoratec None Anita Deswal Official Reviewer AHA Michael E. DeBakey VA Medical Center Chief of Cardiology; Director, Heart Failure Program; Baylor College of Medicine Professor of Medicine None None None NIH* AHA AHA (GWTG Steering Committee) HFSA None Dipti Itchhaporia Official Reviewer ACC Board of Trustees Newport Coast Cardiology Robert and Georgia Roth Endowed Chair for Excellence in Cardiac Care; Director of Disease Management None None None None St. Jude Medical None Ileana L. Pi a Official Reviewer AHA Montefiore Medical Center Associate Chief for Academic Affairs, Cardiology; Professor of Medicine & Epidemiology and Population Health Albert Einstein College of Medicine Relypsa None None None None None Geetha Raghuveer Official Reviewer ACC Board of Governors University of Missouri- Kansas City School of Medicine Professor of Pediatrics; Children's Mercy Hospital Pediatric Cardiology None None None None None None James E. Udelson Official Reviewer HFSA Tufts Medical Center Chief, Division of Cardiology Lantheus Medical Imaging None None Gilead (DSMB) GlaxoSmithKline (DSMB) NHLBI Otsuka Abbott Laboratories AHA* Circulation/ Circulation: Heart Failure HFSA (Executive Council) Pfizer/ GlaxoSmithKline Sunshine Heart None Mary Norine Walsh Official Reviewer ACC Board of Trustees St Vincent Heart Center of Indiana Medical Director, Heart Failure and Cardiac Transplantation None None None None Corvia Medical Otsuka PCORI Thoratec None (Continued) 2017 ACC/AHA/HFSA Heart Failure Focused Update CLINICAL STATEMENTS AND GUIDELINES David A. Baran Organizational Reviewer ISHLT Newark Beth Israel Medical Center Director of Heart Failure and Transplant Research Maquet Otsuka* Novartis None XDx* NIH* None None Kenneth Casey Organizational Reviewer CHEST Wm. S. Middleton Memorial Veterans Hospital Director, Sleep Medicine None None None None CHEST None M. Fuad Jan Organizational Reviewer CHEST Aurora Advanced Healthcare Cardiologist None None None None None None Kenneth W. Lin Organizational Reviewer AAFP Georgetown University School of Medicine Clinician Educator Track, Associate Professor None None None None None None Joaquin E. Cigarroa Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Oregon Health & Science University Clinical Professor of Medicine None None None None ACC/AHA AHA ASA Catheterization and Cardiovascular Intervention NIH Portland Metro Area AHA (President) SCAI Quality Interventional Council None Lee A. Fleisher Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines University of Pennsylvania Health System Robert Dunning Dripps Professor of Anesthesiology and Critical Care; Chair, Department of Anesthesiology & Critical Care Blue Cross/Blue Shield* NQF Yale University None None Johns Hopkins (DSMB) Association of University Anesthesiologists NIH None Samuel S. Gidding Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Nemours/Alfred I. duPont Hospital for Children Chief, Division of Pediatric Cardiology FH Foundation International FH Foundation None None FH Foundation NIH* None None James L. Januzzi Content Reviewer Massachusetts General Hospital Hutter Family Professor of Medicine in the Field of Cardiology Critical Diagnostics* Novartis* Phillips Roche Diagnostics* Sphingotec* None None Amgen (DSMB) Boeringer Ingelheim (DSMB)* Janssen Pharmaceuticals (DSMB) Prevencio* None None Jos A. Joglar Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines UT Southwestern Medical Center Professor of Internal Medicine; Clinical Cardiac Electrophysiology Program Director None None None None None None Edward K. Kasper Content Reviewer Johns Hopkins Cardiology E. Cowles Andrus Professor in Cardiology None None None None None None (Continued) Appendix 2. Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Yancy et al Wayne C. Levy Content Reviewer University of Washington Professor of Medicine Abbott Laboratories Biotronik GE Healthcare HeartWare PharminIN None None NIH Novartis* St. Jude Medical* Amgen* AHA HeartWare* Novartis* Resmed* Thoratec None Judith E. Mitchell Content Reviewer SUNY Downstate Medical Center Director/Heart Failure Center; SUNY Downstate College of Medicine Associate Professor of Medicine None None None None Association of Black Cardiologists None Sean P. Pinney Content Reviewer ACC Heart Failure and Transplant Council Mount Sinai School of Medicine Associate Professor of Medicine, Cardiology Acorda Therapeutics Thoratec XDx None None Thoratec NIH None None Randall C. Starling Content Reviewer ACC Heart Failure and Transplant Council Cleveland Clinic Department of Cardiovascular Medicine Vice Chairman, Department of Cardiovascular Medicine; Section Head,Heart Failure & Cardiac Transplant BioControl Medtronic Novartis None None Medtronic NIH* Novartis St. Jude Medical St. Jude Medical None W.H. Wilson Tang Content Reviewer Cleveland Clinic Foundation Assistant Professor of Medicine None None None NIH* Alnylam Pharmaceuticals NIH NHLBI Roche Novartis Thoratec None Emily J. Tsai Content Reviewer Columbia University College of Physicians & Surgeons Assistant Professor of Medicine, Division of Cardiology None None None Bayer Bristol-Myers Squib NHLBI* None None Duminda N. Wijeysundera Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Li Ka Shing Knowledge Institute of St. Michael s Hospital Scientist; University of Toronto Assistant Professor, Department of Anesthesia and Institute of Health Policy Management and Evaluation None None None CIHR (DSMB) CIHR* Heart and Stroke Foundation of Canada* Ministry of Health & Long- term Care of Ontario* PCORI DSMB) None None This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review, including those not deemed to be relevant to this document. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $5000 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. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review. American College of Physicians did not provide a peer reviewer for this document. *Significant relationship. No financial benefit. AAFP indicates American Academy of Family Physicians; ACC, American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; ASA, American Stroke Association; CHEST, American College of Chest Physicians; CIHR, Canadian Institutes of Health Research; DSMB, data safety monitoring board; FH, familial hypercholesterolemia; GWTG, Get With The Guidelines; HFSA, Heart Failure Society of America; ISHLT, International Society for Heart and Lung Transplantation; NIH, National Institutes of Health; NHLBI, National Heart, Lung, and Blood Institute; NQF, National Quality Forum; PCORI, Patient-Centered Outcomes Research Institute; SCAI, Society for Cardiac Angiography and Interventions; SUNY, State University of New York; UT, University of Texas; and VA, Veterans Affairs. Appendix 2. 