Population: Adults with HF.

Organizations

ACC/AHA 2022, 2017, NICE 2018

Recommendations

Evaluation

–Obtain CXR, 12-lead ECG, blood tests (renal function, thyroid function, liver function, lipid profile, A1c, complete blood count, troponin I level), urine analysis, and peak flow or spirometry. Identify prior cardiac or noncardiac disease that may lead to HF. For patients at risk for developing HF, natriuretic peptide biomarker–based screening (BNP or NT-pro-BNP) and optimizing GDMT can help prevent the development of LV dysfunction (systolic or diastolic) or new-onset HF. B-type natriuretic peptide can help exclude HF in patients with dyspnea.

–Obtain history to include diet or medicine nonadherence; current or past use of alcohol, illicit drugs, and chemotherapy; or recent viral illness.

–If idiopathic dilated cardiomyopathy, obtain a three-generational family history to exclude familial disease.

–Obtain 2D echocardiogram to determine the systolic function, diastolic function, valvular function, and pulmonary artery pressure.

–In patients with angina or significant ischemia, perform coronary arteriography unless the patient is not eligible for surgery.

–Refer for genetic testing in patients whose first-degree relatives have genetic or inherited cardiomyopathies.

–Classify HF as reduced or preserved ejection fraction:

• Heart failure with reduced ejection fraction (HFrEF): left ventricular ejection fraction (LVEF) ≤ 40%.

• Heart failure with mildly reduced ejection fraction (HFmrEF): LVEF 41%–49%.

• Heart failure with preserved ejection fraction (HFpEF): LVEF > 50%.

Management

–Diuresis, if volume overloaded:

• Regardless of classification, initiate diuretic therapy and salt restriction.

• Diuretics do not improve long-term survival but improve symptoms and short-term survival.

• Prefer loop diuretic, but consider thiazide (eg, metolazone) if not responding.

• Once euvolemic and symptoms have resolved, carefully wean dosage as an outpatient to lowest dose possible to prevent electrolyte disorders and activation of the renin-angiotensin system.

–If HFrEF, initiate guideline-directed medical therapy (GDMT). GDMT includes 4 classes of medication:

• Angiotensin receptor-neprilysin inhibitors (ARNi), ACE inhibitor (ACEi), or angiotensin receptor blocker (ARB). Choose ARNi over ACEi or ARB if available, unless NYHA Class IV (sxs at rest). If on ACEi or ARB and ARNi is an option, switch to ARNi. Titrate dose every 2 wk to target doses as BP allows. Measure renal function and electrolytes 1–2 wk after every change.

• Beta-blocker (BB): Choose bisoprolol, carvedilol, or sustained-release metoprolol succinate. Start with low dose; titrate to heart rate 65–70 bpm.

• Mineralocorticoid receptor antagonist (MRA) such as spironolactone. Use if GFR is >30 mL/min/1.73 m² and K⁺< 5.0 mEq/L. Monitor renal function and potassium levels. Discontinue if K⁺ cannot be maintained <5.5 mEq/L.

• Sodium-glucose cotransporter-2 inhibitors (SGLT2i): Use regardless of the presence/absence of diabetes.

–If HFmrEF:

• Consider SGLT2i, as it may reduce hospitalizations and mortality, though data for this class is modest. (COR 2a)

• Consider ACEi/ARB/ARNi, MRA, though their benefit has not been well established in this class. (COR 2b)

–If HFpEF:

• Treat hypertension according to clinical practice guidelines.

• Consider SGLT2i, as it may reduce hospitalizations and mortality, though data for this class is modest. (COR 2a)

–If atrial fibrillation, manage to reduce symptoms.

–Alternative agents to consider in HFrEF:

• Use hydralazine plus isosorbide dinitrate to improve outcomes in Blacks with moderate-to-severe HFrEF, in addition to optimal therapy.¹ Consider using it in lieu of ACEi or ARB if they are contraindicated regardless of race/ethnicity.

• Consider ivabradine in select patients: symptomatic stable chronic HFrEF (EF < 35%) at least 4 wk removed from exacerbation on optimal medical therapy including optimal dosing of ACE inhibitor and beta-blocker at maximal tolerated dose in sinus rhythm with resting HR ≥70.

• Consider digoxin if persistent symptoms from HFrEF despite optimized GDMT.

• Consider vericiguat if LVEF < 45%, recent hospitalization, and elevated BNP.

• Consider omega-3 polyunsaturated fatty acid supplementation as adjunct once optimized GDMT.

• Consider potassium binders if hyperkalemia on MRA to preserve their ability to be used.

–Do not use statins as adjunctive therapy solely for the diagnosis of HF. In all patients with a recent or remote history of CAD, CVA, PAD, or hyperlipidemia, use statins according to guidelines.

–Discontinue anti-inflammatory agents, diltiazem, and verapamil.

–Nutritional supplements are not useful therapy for patients with current or prior symptoms of systolic dysfunction (HFrEF).

–Avoid calcium channel blockers in the routine treatment for patients with HFrEF.

–Do not administer long-term anticoagulation therapy in patients with chronic systolic function while in sinus rhythm unless AF, a prior thromboembolic event, or cardioembolic source.

–Maintain BP < 130/80 mmHg.

Additional Interventions

–Recommend exercise training, which is beneficial in HF patients with decreased ejection fraction (systolic dysfunction) or preserved ejection fraction (diastolic dysfunction) once therapy is optimized.

–Refer for intracardiac cardiac defibrillator in patients who survive cardiac arrest, ventricular fibrillation, or hemodynamically significant ventricular tachycardia.

–Refer for intracardiac cardiac defibrillator in patients with EF ≤ 35% with New York Heart Association (NYHA) class II or III. Before referring, ensure at least 40 d post-MI, optimize GDMT, and expect a life expectancy of at least 1 y.

–Refer for cardiac resynchronization therapy (CRT) with biventricular heart pacemaker when QRS duration ≥150 ms +/− LBBB and EF ≤ 35% with NYHA class II and III or ambulatory class IV on GDMT.

–Arrange postdischarge appointment with physician and health care team with attention to information on discharge medications.

–Ensure patients are up to date on influenza, COVID, and pneumococcal vaccinations.

Sources

–Circulation. 2022;145:e895-e1032. doi:10.1161/CIR.0000000000001063

–ACCF/AHA 2017 Guidelines. Circulation. 2017. doi: 10.1161/CIR.0000000000000509.

–N Engl J Med. 2012.

–J Am Coll Cardiol. 2012;59(20):1812-1832.

–Circulation. 2013;128:e240-e327.