CHF guidelines 2013seminar

2013 ACCF/AHA Guideline for the
Management of Heart Failure
Developed in Collaboration With the American Academy of Family Physicians,
American College of Chest Physicians, Heart Rhythm Society, and International Society
for Heart and Lung Transplantation
Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation
© American College of Cardiology Foundation and American Heart Association, Inc.
Dr Manish Ruhela

Clyde W. Yancy and Mariell Jessup
ACCF/AHA Heart Failure Guideline Writing Committee Members
Clyde W. Yancy, MD, MSc, FACC, FAHA, Chair†‡
Mariell Jessup, MD, FACC, FAHA, Vice Chair*†
*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal
information.
†ACCF/AHA Representative. ‡ACCF/AHA Task Force on Practice Guidelines Liaison. §American College of Physicians Representative. ║American College of Chest Physicians
Representative. ¶International Society for Heart and Lung Transplantation Representative. #ACCF/AHA Task Force on Performance Measures Liaison. **American Academy of Family
Physicians Representative. ††Heart Rhythm Society Representative.

Practice Guidelines
• ACC/AHA: 1995, 2001, 2005, 2009
my.americanheart.org

Classification of Recommendations and Levels of Evidence
A recommendation with
Level of Evidence B or C
does not imply that the
recommendation is weak.
Many important clinical
questions addressed in
the guidelines do not lend
themselves to clinical
trials. Although
randomized trials are
unavailable, there may be
a very clear clinical
consensus that a
particular test or therapy
is useful or effective.
*Data available from
clinical trials or registries
about the usefulness/
efficacy in different
subpopulations, such as
sex, age, history of
diabetes, history of prior
myocardial infarction,
history of heart failure,
and prior aspirin use.
†For comparative
effectiveness
recommendations (Class I
and IIa; Level of Evidence
A and B only), studies
that support the use of
comparator verbs should
involve direct
comparisons of the
treatments or strategies
being evaluated.

Definition
 HF is a complex clinical syndrome that results from any structural or functional
impairment of ventricular filling or ejection of blood.
 The cardinal manifestations of HF are dyspnea and fatigue, which may limit
exercise tolerance, and fluid retention, which may lead to pulmonary and/or
splanchnic congestion and/or peripheral edema.
 Some patients have exercise intolerance but little evidence of fluid retention,
whereas others complain primarily of edema, dyspnea, or fatigue. Because some
patients present without signs or symptoms of volume overload, the term “heart
failure” is preferred over “congestive heart failure.”
 There is no single diagnostic test for HF because it is largely a clinical diagnosis
based on a careful history and physical examination.

Classification of Heart Failure
ACCF/AHA Stages of HF NYHA Functional Classification
A At high risk for HF but without structural
heart disease or symptoms of HF.
None
B Structural heart disease but without signs
or symptoms of HF.
I No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
C Structural heart disease with prior or
current symptoms of HF.
I No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
II Slight limitation of physical activity.
Comfortable at rest, but ordinary physical
activity results in symptoms of HF.
III Marked limitation of physical activity.
Comfortable at rest, but less than ordinary
activity causes symptoms of HF.
IV Unable to carry on any physical activity
without symptoms of HF, or symptoms of
HF at rest.
D Refractory HF requiring specialized
interventions.

Definition of Heart Failure
Classification Ejection
Fraction
Description
I. Heart Failure with
Reduced Ejection Fraction
(HFrEF)
≤40% Also referred to as systolic HF. Randomized clinical trials have
mainly enrolled patients with HFrEF and it is only in these patients
that efficacious therapies have been demonstrated to date.
II. Heart Failure with
Preserved Ejection
Fraction (HFpEF)
≥50% Also referred to as diastolic HF. The diagnosis of HFpEF is
challenging because it is largely one of excluding other potential
noncardiac causes of symptoms suggestive of HF. To date,
efficacious therapies have not been identified.
a. HFpEF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their
characteristics, treatment patterns, and outcomes appear similar to
those of patient with HFpEF.
b. HFpEF, Improved >40% It has been recognized that a subset of patients with HFpEF
previously had HFrEF. These patients with improvement or recovery
in EF may be clinically distinct from those with persistently
preserved or reduced EF. Further research is needed to better
characterize these patients.

Outline
I. Initial and Serial Evaluation of the HF Patient
(including HFpEF)
II. Treatment of Stage A thru D Heart Failure
(including HFpEF)
III. The Hospitalized Patient
IV. Surgical/Percutaneous/Transcatheter Interventional Treatments
V. Coordinating Care for Patients With Chronic HF
VI. Quality Metrics/Performance Measures

Initial and Serial Evaluation of the HF
Patient
Clinical Evaluation

Guideline for HF
Initial and Serial Evaluation of
the HF Patient

Patient
History and Physical
Examination

History and Physical Examination
I IIa IIb III
A thorough history and physical examination should be
obtained/performed in patients presenting with HF to
identify cardiac and noncardiac disorders or behaviors
that might cause or accelerate the development or
progression of HF.
In patients with idiopathic DCM, a 3-generational family
history should be obtained to aid in establishing the
diagnosis of familial DCM.
Volume status and vital signs should be assessed at
each patient encounter. This includes serial assessment
of weight, as well as estimates of jugular venous
pressure and the presence of peripheral edema or
orthopnea.
I IIa IIb III
I IIa IIb III

Patient
Risk Scoring

Risk Scoring
Validated multivariable risk scores can be useful to
estimate subsequent risk of mortality in ambulatory
or hospitalized patients with HF.
I IIa IIb III

Risk Scores to Predict Outcomes in HF
Risk Score Reference (from full-text guideline)/Link
Chronic HF
All patients with chronic HF
Seattle Heart Failure Model (204) / http://SeattleHeartFailureModel.org
Heart Failure Survival Score (200) / http://handheld.softpedia.com/get/Health/Calculator/HFSS-Calc-
37354.shtml
CHARM Risk Score (207)
CORONA Risk Score (208)
Specific to chronic HFpEF
I-PRESERVE Score (202)
Acutely Decompensated HF
ADHERE Classification and Regression
(201)
Tree (CART) Model
American Heart Association Get With the
Guidelines Score
(206) /
http://www.heart.org/HEARTORG/HealthcareProfessional/GetWithTheGuidel
inesHFStroke/GetWithTheGuidelinesHeartFailureHomePage/Get-With-The-
Guidelines-Heart-Failure-Home- %20Page_UCM_306087_SubHomePage.jsp
EFFECT Risk Score (203) / http://www.ccort.ca/Research/CHFRiskModel.aspx
ESCAPE Risk Model and Discharge Score (215)
OPTIMIZE HF Risk-Prediction Nomogram (216)

Seattle Heart Failure Model
Levy WC et al. Circulation 2006;113:1424-1433 www.SeattleHeartFailureModel.org

Patient
Diagnostic Tests

Diagnostic Tests
Initial lab. evaluation of patients presenting with HF should
include CBC, urinalysis, electrolytes (including calcium and
magnesium), BUN, serum creatinine, glucose, fasting lipid
profile, LFTs, and thyroid-stimulating hormone.
Serial monitoring, when indicated, should include serum
electrolytes and renal function.
I IIa IIb III
I IIa IIb III

Diagnostic Tests (cont.)
A 12-lead ECG should be performed initially on all patients
presenting with HF.
Screening for hemochromatosis or HIV is reasonable in
selected patients who present with HF.
Diagnostic tests for rheumatologic diseases, amyloidosis, or
pheochromocytoma are reasonable in patients presenting with
HF in whom there is a clinical suspicion of these diseases.
I IIa IIb III
I IIa IIb III
I IIa IIb III

Patient
Biomarkers
Ambulatory/Outpatient

Ambulatory/Outpatient
In ambulatory patients with dyspnea, measurement of BNP or
NT-proBNP is useful to support clinical decision making
regarding the diagnosis of HF, especially in the setting of
clinical uncertainty.
Measurement of BNP or NT-proBNP is useful for establishing
prognosis or disease severity in chronic HF.
I IIa IIb III
I IIa IIb III

Ambulatory/Outpatient (cont.)
BNP- or NT-proBNP guided HF therapy can be useful to achieve
optimal dosing of GDMT in selected clinically euvolemic patients
followed in a well-structured HF disease management program.
The usefulness of serial measurement of BNP or NT-proBNP to
reduce hospitalization or mortality in patients with HF is not well
established.
Measurement of other clinically available tests such as
biomarkers of myocardial injury may be considered for additive
risk stratification in patients with chronic HF.
I IIa IIb III
I IIa IIb III
I IIa IIb III

Patient
Biomarkers
Hospitalized/Acute

Hospitalized/Acute
Measurement of BNP or NT-proBNP is useful to support clinical
judgment for the diagnosis of acutely decompensated HF,
especially in the setting of uncertainty for the diagnosis.
Measurement of BNP or NT-proBNP and/or cardiac troponin is
useful for establishing prognosis or disease severity in acutely
decompensated HF.
I IIa IIb III
I IIa IIb III

Hospitalized/Acute (cont.)
The usefulness of BNP- or NT-proBNP guided therapy for
acutely decompensated HF is not well-established.
Measurement of other clinically available tests such as
biomarkers of myocardial injury or fibrosis may be considered
for additive risk stratification in patients with acutely
decompensated HF.
I IIa IIb III
I IIa IIb III

Recommendations for Biomarkers in HF
Biomarker, Application Setting COR LOE
Natriuretic peptides
Diagnosis or exclusion of HF
Ambulatory,
Acute
I A
Prognosis of HF
Ambulatory,
Acute
I A
Achieve GDMT Ambulatory IIa B
Guidance of acutely decompensated
Acute IIb C
HF therapy
Biomarkers of myocardial injury
Additive risk stratification
Acute,
Ambulatory I A
Biomarkers of myocardial fibrosis
Additive risk stratification
Ambulatory
IIb B
Acute
IIb A

Causes for Elevated Natriuretic Peptide
Levels
Cardiac Noncardiac
 Heart failure
 Acute coronary syndrome
 Heart muscle disease, including
LVH
 Valvular heart disease
 Pericardial disease
 Atrial fibrillation
 Myocarditis
 Cardiac surgery
 Cardioversion
 Advancing age
 Anemia
 Renal failure
 Pulmonary causes: obstructive
sleep apnea, severe pneumonia,
pulmonary hypertension
 Critical illness
 Bacterial sepsis
 Severe burns
 Toxic-metabolic insults, including
cancer chemotherapy

Patient
Noninvasive Cardiac Imaging

Noninvasive Cardiac Imaging
Patients with suspected or new-onset HF, or presenting with acute decompensated
HF, should undergo a C x-ray to assess heart size and pulmonary congestion, and to
detect alternative cardiac, pulmonary, and other diseases that may cause or
contribute to the patients’ symptoms.
A 2-D echo with Doppler should be performed during initial evaluation of patients
presenting with HF to assess ventricular function, size, wall thickness, wall motion,
and valve function.
Repeat measurement of EF and severity of structural remodeling are useful to
provide information in patients with HF who have had a significant change in clinical
status.
I IIa IIb III
I IIa IIb III
I IIa IIb III

Noninvasive Cardiac Imaging (cont.)
Noninvasive imaging to detect myocardial ischemia and
viability is reasonable in patients presenting with de novo HF
who have known CAD and no angina unless the patient is not
eligible for revascularization of any kind.
Viability assessment is reasonable in select situations when
planning revascularization in HF patients with CAD.
Radionuclide ventriculography or MRI can be useful to assess
LVEF and volume when echocardiography is inadequate.
I IIa IIb III
I IIa IIb III
I IIa IIb III

Noninvasive Cardiac Imaging (cont.)
MRI is reasonable when assessing myocardial
infiltrative processes or scar burden.
Routine repeat measurement of LV function
assessment in the absence of clinical status change or
treatment interventions should not be performed.
I IIa IIb III
I IIa IIb III
No Benefit

Recommendations for Noninvasive Imaging
Recommendation COR LOE
Patients with suspected, acute, or new-onset HF should undergo a chest x-ray
I C
A 2-D echo with Doppler should be performed for initial evaluation of HF I C
Repeat measurement of EF is useful in patients with HF who have had a
significant change in clinical status or received treatment that might affect
cardiac function, or for consideration of device therapy
I C
Noninvasive imaging to detect myocardial ischemia and viability is
reasonable in HF and CAD
IIa C
Viability assessment is reasonable before revascularization in HF patients
with CAD
IIa B
Radionuclide ventriculography or MRI can be useful to assess LVEF and
volume
IIa C
MRI is reasonable when assessing myocardial infiltration or scar
IIa B
Routine repeat measurement of LV function assessment should not be
performed
III: No
Benefit
B

Patient
Invasive Evaluation

Invasive Evaluation
Invasive hemodynamic monitoring with a pulmonary artery catheter should be
performed to guide therapy in patients who have respiratory distress or clinical
evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling
pressures cannot be determined from clinical assessment.
Invasive hemodynamic monitoring can be useful for carefully selected patients with
acute HF who have persistent symptoms despite empiric adjustment of standard
therapies and
a. whose fluid status, perfusion, or systemic or pulmonary vascular resistance is
uncertain;
b. whose systolic pressure remains low, or is associated with symptoms, despite
initial therapy;
c. whose renal function is worsening with therapy;
d. who require parenteral vasoactive agents; or
e. who may need consideration for MCS or transplantation.
I IIa IIb III
I IIa IIb III

Invasive Evaluation (cont.)
When ischemia may be contributing to HF, coronary arteriography
is reasonable for patients eligible for revascularization.
Endomyocardial biopsy can be useful in patients presenting with
HF when a specific diagnosis is suspected that would influence
therapy.
I IIa IIb III
I IIa IIb III

Invasive Evaluation (cont.)
Routine use of invasive hemodynamic monitoring is not
recommended in normotensive patients with acute
decompensated HF and congestion with symptomatic response
to diuretics and vasodilators.
Endomyocardial biopsy should not be performed in the routine
evaluation of patients with HF.
I IIa IIb III
No Benefit
I IIa IIb III
Harm

Recommendations for Invasive Evaluation
Monitoring with a pulmonary artery catheter should be performed in patients
with respiratory distress or impaired systemic perfusion when clinical
assessment is inadequate
I C
Invasive hemodynamic monitoring can be useful for carefully selected
patients with acute HF with persistent symptoms and/or when hemodynamics
are uncertain
IIa C
When coronary ischemia may be contributing to HF, coronary arteriography
is reasonable
IIa C
Endomyocardial biopsy can be useful in patients with HF when a specific
diagnosis is suspected that would influence therapy
IIa C
Routine use of invasive hemodynamic monitoring is not recommended in
normotensive patients with acute HF
III: No
Benefit
B
Endomyocardial biopsy should not be performed in the routine evaluation of
HF
III: Harm C

Guideline for HF
Treatment of Stages A to D

Stages, Phenotypes and Treatment of HF
At Risk for Heart Failure Heart Failure
STAGE A
At high risk for HF but
without structural heart
disease or symptoms of HF
STAGE B
Structural heart disease
but without signs or
symptoms of HF
THERAPY
Structural heart disease
Goals
 Control symptoms
 Improve HRQOL
 Prevent hospitalization
 Prevent mortality
STAGE C
with prior or current
symptoms of HF
Strategies
 Identification of comorbidities
Treatment
 Diuresis to relieve symptoms
of congestion
 Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
 Revascularization or valvular
surgery as appropriate
THERAPY
Goals
 Patient education
 Prevent hospitalization
 Prevent mortality
Drugs for routine use
 Diuretics for fluid retention
 ACEI or ARB
 Beta blockers
 Aldosterone antagonists
Drugs for use in selected patients
 Hydralazine/isosorbide dinitrate
 ACEI and ARB
 Digoxin
In selected patients
 CRT
 ICD
 Revascularization or valvular
surgery as appropriate
STAGE D
Refractory HF
THERAPY
Goals
 Prevent HF symptoms
 Prevent further cardiac
remodeling
Drugs
 ACEI or ARB as
appropriate
 Beta blockers as
appropriate
In selected patients
 ICD
 Revascularization or
valvular surgery as
appropriate
e.g., Patients with:
 Known structural heart disease and
 HF signs and symptoms
HFpEF HFrEF
THERAPY
Goals
 Heart healthy lifestyle
 Prevent vascular,
coronary disease
 Prevent LV structural
abnormalities
Drugs
 ACEI or ARB in
appropriate patients for
vascular disease or DM
 Statins as appropriate
THERAPY
Goals
 Improve HRQOL
 Reduce hospital
readmissions
 Establish patient’s end-of-
life goals
Options
 Advanced care
measures
 Heart transplant
 Chronic inotropes
 Temporary or permanent
MCS
 Experimental surgery or
drugs
 Palliative care and
hospice
 ICD deactivation
Refractory
symptoms of HF
at rest, despite
GDMT
 Marked HF symptoms at
rest
 Recurrent hospitalizations
despite GDMT
 Previous MI
 LV remodeling including
LVH and low EF
 Asymptomatic valvular
disease
 HTN
 Atherosclerotic disease
 DM
 Obesity
 Metabolic syndrome
or
Patients
 Using cardiotoxins
 With family history of
cardiomyopathy
Development of
symptoms of HF
Structural heart
disease

Stage A

Stage A
Hypertension and lipid disorders should be controlled in
accordance with contemporary guidelines to lower the risk of
HF.
Other conditions that may lead to or contribute to HF, such as
obesity, diabetes mellitus, tobacco use, and known cardiotoxic
agents, should be controlled or avoided.
I IIa IIb III
I IIa IIb III

Stage B

Stage B
In all patients with a recent or remote history of MI or ACS and
reduced EF, ACE inhibitors should be used to prevent
symptomatic HF and reduce mortality. In patients intolerant of
ACE inhibitors, ARBs are appropriate unless contraindicated.
In all patients with a recent or remote history of MI or ACS and
reduced EF, evidence-based beta blockers should be used to
reduce mortality.
In all patients with a recent or remote history of MI or ACS,
statins should be used to prevent symptomatic HF and
cardiovascular events.
I IIa IIb III
I IIa IIb III
I IIa IIb III

Stage B (cont.)
In patients with structural cardiac abnormalities, including LV
hypertrophy, in the absence of a history of MI or ACS, blood
pressure should be controlled in accordance with clinical
practice guidelines for hypertension to prevent symptomatic
HF.
ACE inhibitors should be used in all patients with a reduced EF
to prevent symptomatic HF, even if they do not have a history
of MI.
Beta blockers should be used in all patients with a reduced EF
to prevent symptomatic HF, even if they do not have a history
of MI.
I IIa IIb III
I IIa IIb III
I IIa IIb III

Stage B (cont.)
To prevent SCD, placement of an ICD is reasonable in patients with
asymptomatic ischemic cardiomyopathy who are at least 40 days
post-MI, have an LVEF of 30% or less, are on appropriate medical
therapy and have reasonable expectation of survival with a good
functional status for more than 1 year.
Nondihydropyridine calcium channel blockers with negative
inotropic effects may be harmful in asymptomatic patients with
low LVEF and no symptoms of HF after MI.
I IIa IIb III
I IIa IIb III
Harm

Recommendations for Treatment of Stage B HF
Recommendations COR LOE
In patients with a history of MI and reduced EF, ACE inhibitors or
ARBs should be used to prevent HF
I A
In patients with MI and reduced EF, evidence-based beta blockers
should be used to prevent HF
I B
In patients with MI, statins should be used to prevent HF I A
Blood pressure should be controlled to prevent symptomatic HF I A
ACE inhibitors should be used in all patients with a reduced EF to
I A
prevent HF
Beta blockers should be used in all patients with a reduced EF to
prevent HF
I C
An ICD is reasonable in patients with asymptomatic ischemic
cardiomyopathy who are at least 40 d post-MI, have an LVEF
≤30%, and on GDMT
IIa B
Nondihydropyridine calcium channel blockers may be harmful in
patients with low LVEF
III: Harm C

Stage C

Nonpharmacological
Interventions

Stage C: Nonpharmacological
Interventions
Patients with HF should receive specific education to
facilitate HF self-care.
Exercise training (or regular physical activity) is
recommended as safe and effective for patients with HF who
are able to participate to improve functional status.
Sodium restriction is reasonable for patients with
symptomatic HF to reduce congestive symptoms.
I IIa IIb III
I IIa IIb III
I IIa IIb III

Stage C: Nonpharmacological
Interventions (cont.)
Continuous positive airway pressure (CPAP) can be beneficial
to increase LVEF and improve functional status in patients
with HF and sleep apnea.
Cardiac rehabilitation can be useful in clinically stable
patients with HF to improve functional capacity, exercise
duration, and mortality.
I IIa IIb III
I IIa IIb III

Pharmacological Treatment for
Stage C HFrEF

Pharmacological Treatment for Stage
C HFrEF
Measures listed as Class I recommendations for patients in
stages A and B are recommended where appropriate for
patients in stage C. (Levels of Evidence: A, B, and C as
appropriate)
GDMT as depicted in Figure 1 should be the mainstay of
pharmacological therapy for HFrEF.
I IIa IIb III
See
recommendations
for stages A, B,
and C LOE for
LOE
I IIa IIb III

Pharmacologic Treatment for Stage C HFrEF
HFrEF Stage C
NYHA Class I – IV
Treatment:
For NYHA class II-IV patients.
Provided estimated creatinine
>30 mL/min and K+ <5.0 mEq/dL
Class I, LOE A
ACEI or ARB AND
Beta Blocker
For persistently symptomatic
African Americans,
NYHA class III-IV
Add Add Add
Class I, LOE C
Loop Diuretics
Class I, LOE A
Hydral-Nitrates
Class I, LOE A
Aldosterone
Antagonist
For all volume overload,
NYHA class II-IV patients

Stage C HFrEF (cont.)
Diuretics are recommended in patients with HFrEF who have
evidence of fluid retention, unless contraindicated, to improve
symptoms.
ACE inhibitors are recommended in patients with HFrEF and current
or prior symptoms, unless contraindicated, to reduce morbidity and
mortality.
ARBs are recommended in patients with HFrEF with current or prior
symptoms who are ACE inhibitor-intolerant, unless contraindicated,
to reduce morbidity and mortality.
I IIa IIb III
I IIa IIb III
I IIa IIb III

Drugs Commonly Used for HFrEF
(Stage C HF)
Drug Initial Daily Dose(s) Maximum Doses(s)
Mean Doses Achieved in
Clinical Trials
ACE Inhibitors
Captopril 6.25 mg 3 times 50 mg 3 times 122.7 mg/d (421)
Enalapril 2.5 mg twice 10 to 20 mg twice 16.6 mg/d (412)
Fosinopril 5 to 10 mg once 40 mg once ---------
Lisinopril 2.5 to 5 mg once 20 to 40 mg once 32.5 to 35.0 mg/d (444)
Perindopril 2 mg once 8 to 16 mg once ---------
Quinapril 5 mg twice 20 mg twice ---------
Ramipril 1.25 to 2.5 mg once 10 mg once ---------
Trandolapril 1 mg once 4 mg once ---------
ARBs
Candesartan 4 to 8 mg once 32 mg once 24 mg/d (419)
Losartan 25 to 50 mg once 50 to 150 mg once 129 mg/d (420)
Valsartan 20 to 40 mg twice 160 mg twice 254 mg/d (109)
Aldosterone Antagonists
Spironolactone 12.5 to 25 mg once 25 mg once or twice 26 mg/d (424)
Eplerenone 25 mg once 50 mg once 42.6 mg/d (445)

Drugs Commonly Used for HFrEF
(Stage C HF) (cont.)
Drug Initial Daily Dose(s) Maximum Doses(s)
Mean Doses Achieved in
Clinical Trials
Beta Blockers
Bisoprolol 1.25 mg once 10 mg once 8.6 mg/d (118)
Carvedilol 3.125 mg twice 50 mg twice 37 mg/d (446)
Carvedilol CR 10 mg once 80 mg once ---------
Metoprolol succinate
extended release
(metoprolol CR/XL)
12.5 to 25 mg once 200 mg once 159 mg/d (447)
Hydralazine & Isosorbide Dinitrate
Fixed dose combination
(423)
37.5 mg hydralazine/
20 mg isosorbide
dinitrate 3 times daily
75 mg hydralazine/
40 mg isosorbide
dinitrate 3 times daily
~175 mg hydralazine/90 mg
isosorbide dinitrate daily
Hydralazine and
isosorbide dinitrate (448)
Hydralazine: 25 to 50
mg, 3 or 4 times daily
and isorsorbide
dinitrate:
20 to 30 mg
3 or 4 times daily
Hydralazine: 300 mg
daily in divided doses
and isosorbide dinitrate
120 mg daily in
divided doses
---------

ARBs are reasonable to reduce morbidity and mortality as
alternatives to ACE inhibitors as first-line therapy for patients with
HFrEF, especially for patients already taking ARBs for other
indications, unless contraindicated.
Addition of an ARB may be considered in persistently symptomatic
patients with HFrEF who are already being treated with an ACE
inhibitor and a beta blocker in whom an aldosterone antagonist is
not indicated or tolerated.
I IIa IIb III
I IIa IIb III

Routine combined use of an ACE inhibitor, ARB, and aldosterone
antagonist is potentially harmful for patients with HFrEF.
Use of 1 of the 3 beta blockers proven to reduce mortality (i.e.,
bisoprolol, carvedilol, and sustained-release metoprolol succinate)
is recommended for all patients with current or prior symptoms of
HFrEF, unless contraindicated, to reduce morbidity and mortality.
I IIa IIb III
Harm
I IIa IIb III

Aldosterone receptor antagonists are recommended in
patients with NYHA class II-IV and who have LVEF of 35% or
less, unless contraindicated, to reduce morbidity and mortality.
Patients with NYHA class II should have a history of prior
cardiovascular hospitalization or elevated plasma natriuretic
peptide levels to be considered for aldosterone receptor
antagonists.
Creatinine should be 2.5 mg/dL or less in men or 2.0 mg/dL
or less in women (or estimated glomerular filtration rate >30
mL/min/1.73m2) and potassium should be less than 5.0 mEq/L.
I IIa IIb III

Aldosterone receptor antagonists are recommended to reduce
morbidity and mortality following an acute MI in patients who
have LVEF of 40% or less who develop symptoms of HF or who
have a history of diabetes mellitus, unless contraindicated.
Inappropriate use of aldosterone receptor antagonists is
potentially harmful because of life-threatening hyperkalemia or
renal insufficiency when serum creatinine greater than 2.5
mg/dL in men or greater than 2.0 mg/dL in women (or
estimated glomerular filtration rate <30 mL/min/1.73m2),
and/or potassium above 5.0 mEq/L.
I IIa IIb III
I IIa IIb III
Harm

The combination of hydralazine and isosorbide dinitrate is
recommended to reduce morbidity and mortality for African
Americans patients with NYHA class III–IV HFrEF receiving
optimal therapy with ACE inhibitors and beta blockers, unless
contraindicated.
A combination of hydralazine and isosorbide dinitrate can be
useful to reduce morbidity or mortality in patients with current
or prior symptomatic HFrEF who cannot be given an ACE
inhibitor or ARB because of drug intolerance, hypotension, or
renal insufficiency, unless contraindicated.
I IIa IIb III
I IIa IIb III

Digoxin can be beneficial in patients with HFrEF, unless
contraindicated, to decrease hospitalizations for HF.
Patients with chronic HF with AF and an additional risk factor
for cardioembolic stroke (history of hypertension, diabetes
mellitus, previous stroke or transient ischemic attack, or ≥75
years of age) should receive chronic anticoagulant therapy (in
the absence of contraindications to anticoagulation).
I IIa IIb III
I IIa IIb III

The selection of an anticoagulant agent for AF should be
individualized on the basis of risk factors, cost, tolerability,
patient preference, potential for drug interactions, and other
clinical characteristics, including time in the international
normalized rate therapeutic ration if the patient has been
taking warfarin.
Chronic anticoagulation is reasonable for patients with chronic
HF who have AF but are without an additional risk factor for
cardioembolic stroke (in the absence of contraindications to
anticoagulation).
I IIa IIb III
I IIa IIb III

Anticoagulation is not recommended in patients with chronic
HFrEF without AF, a prior thromboembolic event, or a
cardioembolic source.
Statins are not beneficial as adjunctive therapy when
prescribed solely for the diagnosis of HF in the absence of other
indications for their use.
Omega-3 PUFA supplementation is reasonable to use as
adjunctive therapy in patients with NYHA class II-IV symptoms
and HFrEF or HFpEF, unless contraindicated, to reduce
mortality and cardiovascular hospitalizations.
I IIa IIb III
No Benefit
I IIa IIb III
No Benefit
I IIa IIb III

Nutritional supplements as treatment for HF are not
recommended in patients with current or prior symptoms of
HFrEF.
Hormonal therapies other than to correct deficiencies are not
recommended for patients with current or prior symptoms of
HFrEF.
Drugs known to adversely affect the clinical status of patients
with current or prior symptoms of HFrEF are potentially harmful
and should be avoided or withdrawn whenever possible (e.g.,
most antiarrhythmic drugs, most calcium channel blocking
drugs (except amlodipine), NSAIDs, or TZDs).
I IIa IIb III
No Benefit
I IIa IIb III
No Benefit
I IIa IIb III
Harm

Long-term use of infused positive inotropic drugs is potentially
harmful for patients with HFrEF, except as palliation for patients
with end-stage disease who cannot be stabilized with standard
medical treatment (see recommendations for stage D).
Calcium channel blocking drugs are not recommended as
routine treatment for patients with HFrEF.
I IIa IIb III
Harm
I IIa IIb III
No Benefit

Stage C HFpEF
Systolic and diastolic blood pressure should be controlled in
patients with HFpEF in accordance with published clinical
practice guidelines to prevent morbidity.
Diuretics should be used for relief of symptoms due to volume
overload in patients with HFpEF.
Coronary revascularization is reasonable in patients with CAD in
whom symptoms (angina) or demonstrable myocardial
ischemia is judged to be having an adverse effect on
symptomatic HFpEF despite GDMT.
I IIa IIb III
I IIa IIb III
I IIa IIb III

Stage C HFpEF (cont.)
Management of AF according to published clinical practice
guidelines in patients with HFpEF is reasonable to improve
symptomatic HF.
The use of beta-blocking agents, ACE inhibitors, and ARBs in
patients with hypertension is reasonable to control blood
pressure in patients with HFpEF.
I IIa IIb III
I IIa IIb III

Stage C HFpEF (cont.)
The use of ARBs might be considered to decrease
hospitalizations for patients with HFpEF.
Routine use of nutritional supplements is not recommended for
patients with HFpEF.
I IIa IIb III
I IIa IIb III
No Benefit

Pharmacological Therapy for
Management of Stage C HFrEF
Diuretics
Diuretics are recommended in patients with HFrEF with fluid
retention
I C
ACE Inhibitors
ACE inhibitors are recommended for all patients with HFrEF
I A
ARBs
ARBs are recommended in patients with HFrEF who are ACE
inhibitor intolerant
I A
ARBs are reasonable as alternatives to ACE inhibitor as first
line therapy in HFrEF
IIa A
The addition of an ARB may be considered in persistently
symptomatic patients with HFrEF on GDMT
IIb A
Routine combined use of an ACE inhibitor, ARB, and
aldosterone antagonist is potentially harmful
III: Harm C

Management of Stage C HFrEF (cont.)
Beta Blockers
Use of 1 of the 3 beta blockers proven to reduce mortality is
recommended for all stable patients
I A
Aldosterone Antagonists
Aldosterone receptor antagonists are recommended in
patients with NYHA class II-IV HF who have LVEF ≤35%
I A
Aldosterone receptor antagonists are recommended in
patients following an acute MI who have LVEF ≤40% with
symptoms of HF or DM
I B
Inappropriate use of aldosterone receptor antagonists may be
harmful
III:
Harm
B
Hydralazine and Isosorbide Dinitrate
The combination of hydralazine and isosorbide dinitrate is
recommended for African-Americans, with NYHA class III–
IV HFrEF on GDMT
I A
A combination of hydralazine and isosorbide dinitrate can be
useful in patients with HFrEF who cannot be given ACE
inhibitors or ARBs
IIa B

Pharmacologic Therapy for
Digoxin
Digoxin can be beneficial in patients with HFrEF IIa B
Anticoagulation
Patients with chronic HF with permanent/persistent/paroxysmal AF and an
additional risk factor for cardioembolic stroke should receive chronic
anticoagulant therapy*
I A
The selection of an anticoagulant agent should be individualized I C
Chronic anticoagulation is reasonable for patients with chronic HF who have
permanent/persistent/paroxysmal AF but without an additional risk factor for
IIa B
cardioembolic stroke*
Anticoagulation is not recommended in patients with chronic HFrEF without
AF, prior thromboembolic event, or a cardioembolic source
III: No
Benefit
B
Statins
Statins are not beneficial as adjunctive therapy when prescribed solely for HF III: No
Benefit
A
Omega-3 Fatty Acids
Omega-3 PUFA supplementation is reasonable to use as adjunctive therapy in
HFrEF or HFpEF patients
IIa B

Other Drugs
Nutritional supplements as treatment for HF are not recommended
in HFrEF
III: No
Benefit
B
Hormonal therapies other than to replete deficiencies are not
recommended in HFrEF
III: No
Benefit
C
Drugs known to adversely affect the clinical status of patients with
HFrEF are potentially harmful and should be avoided or
withdrawn
III: Harm B
Long-term use of an infusion of a positive inotropic drug is not
recommended and may be harmful except as palliation
III: Harm C
Calcium Channel Blockers
Calcium channel blocking drugs are not recommended as routine
in HFrEF
III: No
Benefit
A

Treatment for Stage C HFpEF

Treatment of HFpEF
Systolic and diastolic blood pressure should be controlled
according to published clinical practice guidelines I B
Diuretics should be used for relief of symptoms due to
I C
volume overload
Coronary revascularization for patients with CAD in
whom angina or demonstrable myocardial ischemia is
present despite GDMT
IIa
C
Management of AF according to published clinical
practice guidelines for HFpEF to improve symptomatic
HF
IIa C
Use of beta-blocking agents, ACE inhibitors, and ARBs
for hypertension in HFpEF IIa C
ARBs might be considered to decrease hospitalizations in
IIb B
HFpEF
Nutritional supplementation is not recommended in
HFpEF
III: No
Benefit
C

Device Treatment for Stage C
HFrEF

Device Therapy for Stage C HFrEF
ICD therapy is recommended for primary prevention of SCD to reduce
total mortality in selected patients with nonischemic DCM or ischemic
heart disease at least 40 days post-MI with LVEF of 35% or less, and
NYHA class II or III symptoms on chronic GDMT, who have reasonable
expectation of meaningful survival for more than 1 year.
CRT is indicated for patients who have LVEF of 35% or less, sinus
rhythm, left bundle-branch block (LBBB) with a QRS duration of 150 ms
or greater, and NYHA class II, III, or ambulatory IV symptoms on GDMT.
I IIa IIb III
I IIa IIb III
NYHA Class III/IV
I IIa IIb III
NYHA Class II

(cont.)
ICD therapy is recommended for primary prevention of SCD to
reduce total mortality in selected patients at least 40 days post-
MI with LVEF less than or equal to 30%, and NYHA class I
symptoms while receiving GDMT, who have reasonable
expectation of meaningful survival for more than 1 year.
CRT can be useful for patients who have LVEF of 35% or less,
sinus rhythm, a non-LBBB pattern with a QRS duration of 150
ms or greater, and NYHA class III/ambulatory class IV symptoms
on GDMT.
I IIa IIb III
I IIa IIb III

(cont.)
CRT can be useful for patients who have LVEF of 35% or less,
sinus rhythm, LBBB with a QRS duration of 120 to 149 ms, and
NYHA class II, III, or ambulatory IV symptoms on GDMT.
CRT can be useful in patients with AF and LVEF of 35% or less on
GDMT if a) the patient requires ventricular pacing or otherwise
meets CRT criteria and b) atrioventricular nodal ablation or
pharmacological rate control will allow near 100% ventricular
pacing with CRT.
I IIa IIb III
I IIa IIb III

(cont.)
CRT can be useful for patients on GDMT who have LVEF of 35%
or less, and are undergoing placement of a new or replacement
device placement with anticipated requirement for significant
(>40%) ventricular pacing.
The usefulness of implantation of an ICD is of uncertain benefit
to prolong meaningful survival in patients with a high risk of
nonsudden death as predicted by frequent hospitalizations,
advanced frailty, or comorbidities such as systemic malignancy
or severe renal dysfunction.
I IIa IIb III
I IIa IIb III

(cont.)
CRT may be considered for patients who have LVEF of 35% or
less , sinus rhythm, a non-LBBB pattern with a QRS duration of
150 ms or greater, and NYHA class II symptoms on GDMT.
CRT may be considered for patients who have LVEF of 30% or
less, ischemic etiology of HF, sinus rhythm, LBBB with a QRS
duration of 150 ms or greater, and NYHA class I symptoms on
GDMT.
I IIa IIb III
I IIa IIb III

(cont.)
CRT is not recommended for patients with NYHA class I or II
symptoms and non-LBBB pattern with a QRS duration of less
than 150 ms.
CRT is not indicated for patients whose comorbidities and/or
frailty limit survival with good functional capacity to less than 1
year.
I IIa IIb III
No Benefit
I IIa IIb III
No Benefit

Indications for CRT Therapy
Patient with cardiomyopathy on GDMT for >3 mo or on GDMT and >40 d after MI, or
with implantation of pacing or defibrillation device for special indications
LVEF <35%
Evaluate general health status
Comorbidities and/or frailty
limit survival with good
functional capacity to <1 y
Continue GDMT without
implanted device
Acceptable noncardiac health
Evaluate NYHA clinical status
NYHA class I
 LVEF ≤30%
 QRS ≥150 ms
 LBBB pattern
 Ischemic
cardiomyopathy
 QRS ≤150 ms
 Non-LBBB pattern
NYHA class II
 LVEF ≤35%
 QRS ≥150 ms
 LBBB pattern
 Sinus rhythm
 LVEF ≤35%
 QRS 120-149 ms
 LBBB pattern
 Sinus rhythm
 LVEF ≤35%
 QRS ≥150 ms
 Sinus rhythm
 QRS ≤150 ms
Colors correspond to the class of recommendations in the ACCF/AHA Table 1.
NYHA class III &
Ambulatory class IV
 LVEF ≤35%
 QRS ≥150 ms
 LBBB pattern
 Sinus rhythm
 LVEF ≤35%
 QRS 120-149 ms
 LBBB pattern
 Sinus rhythm
 LVEF≤35%
 QRS ≥150 ms
 Sinus rhythm
 LVEF ≤35%
 QRS 120-149 ms
 Sinus rhythm
Special CRT
Indications
 Anticipated to require
frequent ventricular
pacing (>40%)
 Atrial fibrillation, if
ventricular pacing is
required and rate
control will result in
near 100%
ventricular pacing
with CRT
Benefit for NYHA class I and II patients has only been shown in CRT-D trials, and while patients may not experience immediate symptomatic benefit, late remodeling may be avoided along
with long-term HF consequences. There are no trials that support CRT-pacing (without ICD) in NYHA class I and II patients. Thus, it is anticipated these patients would receive CRT-D
unless clinical reasons or personal wishes make CRT-pacing more appropriate. In patients who are NYHA class III and ambulatory class IV, CRT-D may be chosen but clinical reasons and
personal wishes may make CRT-pacing appropriate to improve symptoms and quality of life when an ICD is not expected to produce meaningful benefit in survival.

Device Therapy for Stage C HFrEF (cont.)
ICD therapy is recommended for primary prevention of SCD in selected
patients with HFrEF at least 40 days post-MI with LVEF ≤35%, and NYHA
I A
class II or III symptoms on chronic GDMT, who are expected to live ≥1 year*
CRT is indicated for patients who have LVEF ≤35%, sinus rhythm, LBBB with
a QRS ≥150 ms
I
A (NYHA
class III/IV)
B (NYHA
class II)
ICD therapy is recommended for primary prevention of SCD in selected
patients with HFrEF at least 40 days post-MI with LVEF ≤30%, and NYHA
class I symptoms while receiving GDMT, who are expected to live ≥1 year*
I B
CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, a non-
LBBB pattern with a QRS ≥150 ms, and NYHA class III/ambulatory class IV
symptoms on GDMT.
IIa A
CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, LBBB
with a QRS 120 to 149 ms, and NYHA class II, III or ambulatory IV symptoms
on GDMT
IIa
B
CRT can be useful in patients with AF and LVEF ≤35% on GDMT if a) the
patient requires ventricular pacing or otherwise meets CRT criteria and b) AV
nodal ablation or rate control allows near 100% ventricular pacing with CRT
IIa B

CRT can be useful for patients on GDMT who have LVEF ≤35%, and are
undergoing new or replacement device with anticipated (>40%) ventricular
pacing
IIa C
An ICD is of uncertain benefit to prolong meaningful survival in patients with
high risk of nonsudden death such as frequent hospitalizations, frailty, or severe
comorbidities*
IIb
B
CRT may be considered for patients who have LVEF ≤35%, sinus rhythm, a non-
LBBB pattern with QRS 120 to 149 ms, and NYHA class III/ambulatory class IV
on GDMT
IIb B
CRT may be considered for patients who have LVEF ≤35%, sinus rhythm, a non-
LBBB pattern with a QRS ≥150 ms, and NYHA class II symptoms on GDMT IIb B
CRT may be considered for patients who have LVEF ≤30%, ischemic etiology of
HF, sinus rhythm, LBBB with a QRS ≥150 ms, and NYHA class I symptoms on
GDMT
IIb C
CRT is not recommended for patients with NYHA class I or II symptoms and
non-LBBB pattern with QRS <150 ms
III: No
Benefit
B
CRT is not indicated for patients whose comorbidities and/or frailty limit
survival to <1 year
III: No
Benefit
C
Device Therapy for Stage C HFrEF (cont.)

Stage D

Clinical Events and Findings Useful for
Identifying Patients With Advanced HF
Repeated (≥2) hospitalizations or ED visits for HF in the past year
Progressive deterioration in renal function (e.g., rise in BUN and creatinine)
Weight loss without other cause (e.g., cardiac cachexia)
Intolerance to ACE inhibitors due to hypotension and/or worsening renal function
Intolerance to beta blockers due to worsening HF or hypotension
Frequent systolic blood pressure <90 mm Hg
Persistent dyspnea with dressing or bathing requiring rest
Inability to walk 1 block on the level ground due to dyspnea or fatigue
Recent need to escalate diuretics to maintain volume status, often reaching daily
furosemide equivalent dose >160 mg/d and/or use of supplemental metolazone therapy
Progressive decline in serum sodium, usually to <133 mEq/L
Frequent ICD shocks
Adapted from Russell et al. Congest Heart Fail. 2008;14:316-21.

Water Restriction

Water Restriction
Fluid restriction (1.5 to 2 L/d) is reasonable in stage
D, especially in patients with hyponatremia, to
reduce congestive symptoms.
I IIa IIb III

Inotropic Support

Inotropic Support
Until definitive therapy (e.g., coronary revascularization, MCS,
heart transplantation) or resolution of the acute precipitating
problem, patients with cardiogenic shock should receive
temporary intravenous inotropic support to maintain systemic
perfusion and preserve end-organ performance.
Continuous intravenous inotropic support is reasonable as
“bridge therapy” in patients with stage D refractory to GDMT
and device therapy who are eligible for and awaiting MCS or
cardiac transplantation.
I IIa IIb III
I IIa IIb III

Inotropic Support (cont.)
Short-term, continuous intravenous inotropic support may be
reasonable in those hospitalized patients presenting with
documented severe systolic dysfunction who present with low
blood pressure and significantly depressed cardiac output to
maintain systemic perfusion and preserve end-organ
performance.
Long-term, continuous intravenous inotropic support may be
considered as palliative therapy for symptom control in select
patients with stage D despite optimal GDMT and device therapy
who are not eligible for either MCS or cardiac transplantation.
I IIa IIb III
I IIa IIb III

Inotropic Support (cont.)
Long-term use of either continuous or intermittent, intravenous
parenteral positive inotropic agents, in the absence of specific
indications or for reasons other than palliative care, is
potentially harmful in the patient with HF.
Use of parenteral inotropic agents in hospitalized patients
without documented severe systolic dysfunction, low blood
pressure, or impaired perfusion, and evidence of significantly
depressed cardiac output, with or without congestion, is
potentially harmful.
I IIa IIb III
Harm
I IIa IIb III
Harm

Mechanical Circulatory
Support

Mechanical Circulatory Support
MCS use is beneficial in carefully selected* patients with stage D
HFrEF in whom definitive management (e.g., cardiac
transplantation) or cardiac recovery is anticipated or planned.
Nondurable MCS, including the use of percutaneous and
extracorporeal ventricular assist devices (VADs), is reasonable as
a “bridge to recovery” or a “bridge to decision” for carefully
selected patients with HFrEF with acute, profound
hemodynamic compromise.
Durable MCS is reasonable to prolong survival for carefully
selected patients with stage D HFrEF.
I IIa IIb III
I IIa IIb III
I IIa IIb III

Cardiac Transplantation

Cardiac Transplantation
Evaluation for cardiac transplantation is indicated for
carefully selected patients with stage D HF despite
GDMT, device, and surgical management.
I IIa IIb III

Guideline for HF
The Hospitalized Patient

Precipitating Causes of
Decompensated HF

Precipitating Causes of Decompensated
HF
ACS precipitating acute HF decompensation should be promptly
identified by ECG and serum biomarkers including cardiac
troponin testing, and treated optimally as appropriate to the
overall condition and prognosis of the patient.
Common precipitating factors for acute HF should be considered
during initial evaluation, as recognition of these conditions is
critical to guide appropriate therapy.
I IIa IIb III
I IIa IIb III

Maintenance of GDMT During
Hospitalization

Maintenance of GDMT During
Hospitalization
In patients with HFrEF experiencing a symptomatic exacerbation of
HF requiring hospitalization during chronic maintenance treatment
with GDMT, it is recommended that GDMT be continued in the
absence of hemodynamic instability or contraindications.
Initiation of beta-blocker therapy is recommended after
optimization of volume status and successful discontinuation of
intravenous diuretics, vasodilators, and inotropic agents. Beta-blocker
therapy should be initiated at a low dose and only in stable
patients. Caution should be used when initiating beta blockers in
patients who have required inotropes during their hospital course.
I IIa IIb III
I IIa IIb III

Diuretics in Hospitalized
Patients

Diuretics in Hospitalized Patients
Patients with HF admitted with evidence of significant fluid
overload should be promptly treated with intravenous loop
diuretics to reduce morbidity.
If patients are already receiving loop diuretic therapy, the initial
intravenous dose should equal or exceed their chronic oral daily
dose and should be given as either intermittent boluses or
continuous infusion. Urine output and signs and symptoms of
congestion should be serially assessed, and the diuretic dose
should be adjusted accordingly to relieve symptoms, reduce
volume excess, and avoid hypotension.
I IIa IIb III
I IIa IIb III

Diuretics in Hospitalized Patients (cont.)
The effect of HF treatment should be monitored with careful
measurement of fluid intake and output, vital signs, body weight
that is determined at the same time each day, and clinical signs and
symptoms of systemic perfusion and congestion. Daily serum
electrolytes, urea nitrogen, and creatinine concentrations should be
measured during the use of intravenous diuretics or active titration
of HF medications.
When diuresis is inadequate to relieve symptoms, it is reasonable to
intensify the diuretic regimen using either:
a. higher doses of intravenous loop diuretics.
b. addition of a second (e.g., thiazide) diuretic.
I IIa IIb III
I IIa IIb III

Diuretics in Hospitalized Patients (cont.)
Low-dose dopamine infusion may be considered in
addition to loop diuretic therapy to improve diuresis
and better preserve renal function and renal blood
flow.
I IIa IIb III

Parenteral Therapy in
Hospitalized HF

Parenteral Therapy in Hospitalized HF
If symptomatic hypotension is absent, intravenous
nitroglycerin, nitroprusside or nesiritide may be
considered an adjuvant to diuretic therapy for relief
of dyspnea in patients admitted with acutely
decompensated HF.
I IIa IIb III

Venous Thromboembolism
Prophylaxis in Hospitalized
Patients

Venous Thromboembolism Prophylaxis
in Hospitalized Patients
A patient admitted to the hospital with
decompensated HF should be treated for venous
thromboembolism prophylaxis with an anticoagulant
medication if the risk:benefit ratio is favorable.
I IIa IIb III

Inpatient and Transitions of
Care

Inpatient and Transitions of Care
The use of performance improvement systems and/or
evidence-based systems of care is recommended in
the hospital and early post-discharge outpatient
setting to identify appropriate HF patients for GDMT,
provide clinicians with useful reminders to advance
GDMT, and to assess the clinical response.
I IIa IIb III

Throughout the hospitalization as appropriate, before hospital discharge, at
the first postdischarge visit, and in subsequent follow-up visits, the
following should be addressed:
a. initiation of GDMT if not previously established and not contraindicated;
b. precipitant causes of HF, barriers to optimal care transitions, and limitations in
postdischarge support;
c. assessment of volume status and supine/upright hypotension with adjustment
of HF therapy, as appropriate;
d. titration and optimization of chronic oral HF therapy;
e. assessment of renal function and electrolytes, where appropriate;
f. assessment and management of comorbid conditions;
g. reinforcement of HF education, self-care, emergency plans, and need for
adherence; and
h. consideration for palliative care or hospice care in selected patients.
I IIa IIb III

Multidisciplinary HF disease-management programs are
recommended for patients at high risk for hospital readmission,
to facilitate the implementation of GDMT, to address different
barriers to behavioral change, and to reduce the risk of
subsequent rehospitalization for HF.
Scheduling an early follow-up visit (within 7 to 14 days) and
early telephone follow-up (within 3 days) of hospital discharge is
reasonable.
Use of clinical risk prediction tools and/or biomarkers to identify
patients at higher risk for postdischarge clinical events is
reasonable.
I IIa IIb III
I IIa IIb III
I IIa IIb III

Therapies in the Hospitalized HF Patient
HF patients hospitalized with fluid overload should be treated with
intravenous diuretics
I B
HF patients receiving loop diuretic therapy, should receive an initial
parenteral dose greater than or equal to their chronic oral daily dose, then
should be serially adjusted
I B
HFrEF patients requiring HF hospitalization on GDMT should continue
GDMT unless hemodynamic instability or contraindications
I B
Initiation of beta-blocker therapy at a low dose is recommended after
optimization of volume status and discontinuation of intravenous agents
I B
Thrombosis/thromboembolism prophylaxis is recommended for patients
hospitalized with HF
I B
Serum electrolytes, urea nitrogen, and creatinine should be measured
during the titration of HF medications, including diuretics
I C

Hospital Discharge
Recommendation or Indication COR LOE
Performance improvement systems in the hospital and early postdischarge outpatient setting
to identify HF for GDMT
I B
Before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits,
the following should be addressed:
a) initiation of GDMT if not done or contraindicated;
b) causes of HF, barriers to care, and limitations in support;
c) assessment of volume status and blood pressure with adjustment of HF therapy;
d) optimization of chronic oral HF therapy;
e) renal function and electrolytes;
f) management of comorbid conditions;
g) HF education, self-care, emergency plans, and adherence; and
h) palliative or hospice care.
I B
Multidisciplinary HF disease-management programs for patients at high risk for hospital
readmission are recommended
I B
A follow-up visit within 7 to 14 days and/or a telephone follow-up within 3 days of hospital
discharge is reasonable
IIa B
Use of clinical risk-prediction tools and/or biomarkers to identify higher-risk patients is
reasonable
IIa B

Guideline for HF
Surgical/Percutaneous/
Transcatheter Interventional
Treatments of HF

Surgical/Percutaneous/Transcatheter
Interventional Treatment of HF
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 disease
I C
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
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
Surgical aortic valve replacement is reasonable for patients with critical aortic
stenosis and a predicted surgical mortality of no greater than 10%
IIa B
Transcatheter aortic valve replacement is reasonable for patients with critical aortic
stenosis who are deemed inoperable
IIa B
CABG may be considered in patients with ischemic heart disease, severe LV systolic
dysfunction and suitable coronary anatomy whether or not viable myocardium is
present
IIb B
Transcatheter mitral valve repair or mitral valve surgery for functional mitral
insufficiency is of uncertain benefit
IIb B
Surgical reverse remodeling or LV aneurysmectomy may be considered in HFrEF for
specific indications including intractable HF and ventricular arrhythmias
IIb B

Guideline for HF
Coordinating Care for Patients
With Chronic HF

Coordinating Care for Patients With
Chronic HF
Effective systems of care coordination with special attention 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.
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 conditions, 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.
Palliative and supportive care is effective for patients with symptomatic
advanced HF to improve quality of life.
I IIa IIb III
I IIa IIb III
I IIa IIb III

Guideline for HF
Quality Metrics/Performance
Measures

Quality Metrics/Performance Measures
Performance measures based on professionally
developed clinical practice guidelines should be used
with the goal of improving quality of care for HF.
Participation in quality improvement programs and
patient registries based on nationally endorsed,
clinical practice guideline-based quality and
performance measures may be beneficial in
improving quality of HF care.
I IIa IIb III
I IIa IIb III

Conclusions
• Evidence-based guideline directed diagnosis, evaluation and
therapy should be the mainstay for all patients with HF.
• Effective implementation of guideline-directed best quality care
reduces mortality, improves QOL and preserves health care
resources.
• Ongoing research is needed to answer the remaining questions
including: prevention, nonpharmacological therapy of HF
including dietary adjustments, treatment of HFpEF,
management of hospitalized HF, effective reduction in HF
readmissions, more precise use of device-based therapy.

Common Factors That Precipitate Acute Decompensated HF
 Nonadherence with medication regimen,
sodium and/or
fluid restriction
 Acute myocardial ischemia
 Uncorrected high blood pressure
 AF and other arrhythmias
 Recent addition of negative inotropic drugs (e.g.,
verapamil, nifedipine, diltiazem, beta blockers)
 Pulmonary embolus
Initiation of drugs that increase salt retention (e.g.,
steroids, thiazolidinediones, NSAIDs)
 Excessive alcohol or illicit drug use
Endocrine abnormalities (e.g., diabetes mellitus,
hyperthyroidism, hypothyroidism)
 Concurrent infections (e.g., pneumonia, viral illnesses)
 Additional acute cardiovascular disorders (e.g., valve
disease endocarditis, myopericarditis, aortic dissection)

Although optimal patient selection for MCS remains an active area of
investigation, general indications for referral for MCS therapy include
patients with LVEF <25% and
NYHA class III–IV functional status despite GDMT, including,
when indicated, CRT, with either high predicted 1- to 2-year mortality
(e.g., as suggested by markedly reduced peak oxygen consumption
and clinical prognostic scores) or dependence on continuous
parenteral inotropic support.
Patient selection requires a multidisciplinary team of experienced
advanced HF and transplantation cardiologists, cardiothoracic
surgeons, nurses, and ideally, social workers and
palliative care clinicians.

ACCF/AHA/AMA-PCPI 2011 HF Performance
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 that was 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 those 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
Outpatien
t
Individual
practitioner
*Please refer to the complete measures for comprehensive information, including measure exception.
Adapted from Bonow et al. J Am Coll Cardiol. 2012;59:1812-32.

ACCF/AHA/AMA-PCPI 2011 HF Performance Measurement Set (cont.)
Measure Description* Care
Setting
Level of
Measurement
4. Symptom
management†
Percentage of patient visits for those 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
practitioner
5. Patient self-care
education†‡
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
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
†Test 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.
‡New measure.

ACCF/AHA/AMA-PCPI 2011 HF Performance Measurement Set (cont.)
Measure Description* Care Setting Level of
Measurement
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
regarding ICD
implantation for
patients with LVSD on
combination medical
therapy†‡
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 regarding ICD implantation as a
treatment option for the prophylaxis of sudden death
practitioner
9. Post-discharge
appointment for heart
failure 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
†Test 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.
‡New measure.

Mechanical Circulatory Support:
Ventricular Assist Devices: Bridge to Tx, Destination Therapy
• Volume Displacement
– Thoratec
– Novacor
– Heartmate LVAS
– Abiomed
• Axial Flow
– Heartmate II
– Jarvik
• Centrifugal
– CentriMag
– Heartware
Baughman KL, Jarcho JA. NEJM 2007;379(9):846-9.

Medical Therapy for Stage C HFrEF:
Magnitude of Benefit Demonstrated in RCTs
GDMT
RR Reduction
in Mortality
NNT for Mortality
Reduction
(Standardized to 36 mo)
RR Reduction
in HF
Hospitalizations
ACE inhibitor or
ARB
17% 26 31%
Beta blocker 34% 9 41%
Aldosterone
30% 6 35%
antagonist
Hydralazine/nitrate 43% 7 33%

Therapies in the Hospitalized HF Patient (cont.)
When diuresis is inadequate, it is reasonable to
a) Give higher doses of intravenous loop diuretics; or
b) add a second diuretic (e.g., thiazide)
IIa
B
B
Low-dose dopamine infusion may be considered with loop diuretics to
improve diuresis
IIb B
Ultrafiltration may be considered for patients with obvious volume
overload
IIb B
Ultrafiltration may be considered for patients with refractory congestion IIb C
Intravenous nitroglycerin, nitroprusside or nesiritide may be considered an
IIb B
adjuvant to diuretic therapy for stable patients with HF
In patients hospitalized with volume overload and severe hyponatremia,
vasopressin antagonists may be considered
IIb B

Framingham Criteria for Congestive Heart Failure
Diagnosis of CHF requires the simultaneous presence of at least 2 major criteria or 1
major criterion in conjunction with 2 minor criteria.
Major criteria:
· Paroxysmal nocturnal dyspnea
· Neck vein distention
· Rales
· Radiographic cardiomegaly (increasing heart size on chest radiography)
· Acute pulmonary edema
· S3 gallop
· Increased central venous pressure (>16 cm H2O at right atrium)
· Hepatojugular reflux
· Weight loss >4.5 kg in 5 days in response to treatment
Minor criteria:
· Bilateral ankle edema
· Nocturnal cough
· Dyspnea on ordinary exertion
· Hepatomegaly
· Pleural effusion
· Decrease in vital capacity by one third from maximum recorded
· Tachycardia (heart rate>120 beats/min.)
The Framingham Heart Study criteria are 100% sensitive and 78% specific for
identifying persons with definite congestive heart failure.

CHF guidelines 2013seminar

More Related Content

What's hot

Viewers also liked

Similar to CHF guidelines 2013seminar

Recently uploaded

CHF guidelines 2013seminar

Editor's Notes