Congestive heart failure clinical assessment

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History and Symptoms

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Electrocardiogram

Chest X Ray

Cardiac MRI

Echocardiography

Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

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Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
Positive Inotropics
Anticoagulants
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

Congestive heart failure clinical assessment On the Web

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Risk calculators and risk factors for Congestive heart failure clinical assessment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Edzel Lorraine Co, D.M.D., M.D. [2].

Overview

Clinical assessment of a patient based on a thorough history taking and physical examination is still the cornerstone in diagnosing heart failure. Based on the gathered data, patients can be assessed if he has an underlying heart condition which necessitates a disease-specific therapy such as amyloid heart disease, a cardiomyopathy, or a developing decompensated heart failure. It is important to investigate for presence of heart congestion so as to treat it the at the earliest stage to avoid deterioration in the quality of life and prognosis.

Diagnostic algorithm for heart failure

 
 
 
 
 
 
 
 
Suspected heart failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NT-proBNP ≥ 125 pg/mL or BNP ≥ 35 pg/mL

or if HF strongly suspected

or if NT-proBNP/BNP unavailable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Echocardiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abnormal findings
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hear failure unlikely, other dignosis shoulb be considered
 
NO
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Heart failure confirmed based on LVEF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
LVEF≤ 40%
 
 
 
 
LVEF=41-49%
 
 
 
 
LVEF≥50%
The above table adopted from 2021 ESC Guideline

[1]

Diagnostic of HF and EF-Based Classification.

Diagnostic Algorithm for HF and EF-Based Classification

[2] [3]

Criteria for definition of advanced heart failure

1. Severe and persistent symptoms of heart failure NYHA class III-IV
2. Severe cardiac dysfunction is defined by at least one of the following:

3. Episodes of pulmonary or systemic congestion requiring high-dose i.v. diuretics (or diuretic combinations) or episodes of low output requiring inotropes or vasoactive drugs or malignant arrhythmias causing >1 unplanned visit or hospitalization in the last 12 months
4. Severe impairment of exercise capacity with inability to exercise or low 6MWT distance (<300 m) or pVO2 <12 mL/kg/min or <50% predicted value, estimated to be of cardiac origin[1]

Clinical Assessment

Framingham Criteria

Major Criteria

Minor Criteria

Boston Criteria of Congestive Heart Failure

Category I: History

Category II: Physical Examination

HFpEF

The [H2FPEF https://www.mdcalc.com/calc/10105/h2fpef-score-for-heart-failure-with-preserved-ejection-fraction] can help diagnose[3].

Category III: Chest Radiography

No more than 4 points are allowed from each of three categories; hence the composite score (the sum of the subtotal from each category) has a possible maximum of 12 points.

The diagnosis of heart failure is classified as "definite" at a score of 8 to 12 points, "possible" at a score of 5 to 7 points, and "unlikely" at a score of 4 points or less.

2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

INITIAL AND SERIAL EVALUATION (DO NOT EDIT) [2]

Clinical Assessment: History and Physical Examination (DO NOT EDIT) [2]

Class I
"1. In patients with HF, vital signs and evidence of clinical congestion should be assessed at each encounter to guide overall management, including adjustment of diuretics and other medications.[4][5][6][7][8][9] (Level of Evidence: B-NR) "
"2. In patients with symptomatic HF, clinical factors indicating the presence of advanced HF should be sought via the history and physical examination. [10][11][12][13][14][15] (Level of Evidence: B-NR) "
"3. In patients with cardiomyopathy, a 3-generation family history should be obtained or updated when assessing the cause of the cardiomyopathy to identify possible inherited disease. [16][17] (Level of Evidence: B-NR) "
"4. In patients presenting with HF, a thorough history and physical examination should direct diagnostic strategies to uncover specific causes that may warrant disease-specific management. [18][19] (Level of Evidence: B-NR) "
"4. In patients presenting with HF, a thorough history and physical examination should be obtained and performed to identify cardiac and noncardiac disorders, lifestyle and behavioral factors, and social determinants of health that might cause or accelerate the development or progression of HF. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]) "

Initial Laboratory and Electrocardiographic Testing (DO NOT EDIT) [2]

Class I
"1. For patients presenting with HF, the specific cause of HF should be explored using additional laboratory testing for appropriate management. [20][21][22][23][24][25][26][27] (Level of Evidence: B-NR) "
"2. For patients who are diagnosed with HF, laboratory evaluation should include complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, glucose, lipid profile, liver function tests, iron studies, and thyroid-stimulating hormone to optimize management. (Level of Evidence: C-EO) "
"3. For all patients presenting with HF, a 12-lead ECG should be performed at the initial encounter to optimize management. (Level of Evidence: C-EO) "

Use of Biomarkers for Prevention, Initial Diagnosis, and Risk Stratification (DO NOT EDIT) [2]

Class I
"1. In patients presenting with dyspnea, measurement of B-type natriuretic peptide (BNP) or N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) is useful to support a diagnosis or exclusion of HF. [28][29][30][31][32][33][34][35][36][37][38][39] (Level of Evidence: A) "
"2.In patients with chronic HF, measurements of BNP or NT-proBNP levels are recommended for risk stratification. [38][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56] (Level of Evidence: A) "
"3. In patients hospitalized for HF, measurement of BNP or NT-proBNP levels at admission is recommended to establish prognosis. [38][40][41][42][43][44][45][46] (Level of Evidence: A) "
Class IIa
"4. In patients at risk of developing HF, BNP or NT-proBNP-based screening followed by team-based care, including a cardiovascular specialist, can be useful to prevent the development of LV dysfunction or new-onset HF. [57][58] (Level of Evidence: B-R) "
"5.In patients hospitalized for HF, a predischarge BNP or NT-proBNP level can be useful to inform the trajectory of the patient and establish a postdischarge prognosis. [41][44][47][48][49][50][51][52][53][54][55][56] (Level of Evidence: B-NR) "

Genetic Evaluation and Testing 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

Class I
"1. In first-degree relatives of selected patients with genetic or inherited cardiomyopathies, genetic screening and counseling are recommended to detect cardiac disease and prompt consideration of treatments to decrease HF progression and sudden death. [16][17] (Level of Evidence: B-NR) "
Class IIa
"1. In select patients with nonischemic cardiomyopathy, referral for genetic counseling and testing is reasonable to identify conditions that could guide treatment for patients and family members.[59][60] (Level of Evidence: B-NR) "

Evaluation With Cardiac Imaging 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

Class I
"1. In patients with suspected or new-onset HF, or those presenting with acute decompensated HF, a chest X-ray should be performed to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient's symptoms. [61][62](Level of Evidence: C-LD) "
"2. In patients with suspected or newly diagnosed HF, transthoracic echocardiography (TTE) should be performed during initial evaluation to assess cardiac structure and function. [63] (Level of Evidence: C-LD) "
"3. In patients with HF who have had a significant clinical change, or who have received GDMT and are being considered for invasive procedures or device therapy, repeat measurement of EF, degree of structural remodeling, and valvular function are useful to inform therapeutic interventions.[64][65][66][67] (Level of Evidence: C-LD) "
"4. In patients for whom echocardiography is inadequate, alternative imaging (eg, cardiac magnetic resonance [CMR], cardiac computed tomography [CT], radionuclide imaging) is recommended for assessment of LVEF.[68][69][70][71][72][73][74][75](Level of Evidence: C-LD) "
Class IIa
"5. In patients with HF or cardiomyopathy, CMR can be useful for diagnosis or management. [76][77][78][79][80][81][82][83] (Level of Evidence:B-NR) "
"6. In patients with HF, an evaluation for possible ischemic heart disease can be useful to identify the cause and guide management. [84][85][86][87] (Level of Evidence:B-NR) "
Class IIb
"7. In patients with HF and coronary artery disease (CAD) who are candidates for coronary revascularization, noninvasive stress imaging (stress echocardiography, single-photon emission CT [SPECT], CMR, or positron emission tomography [PET] may be considered for detection of myocardial ischemia to help guide coronary revascularization. [88][89][90][91][92] (Level of Evidence:B-NR) "
Class III (No Benefit)
"8. In patients with HF in the absence of 1) clinical status change, 2) treatment interventions that might have had a significant effect on cardiac function, or 3) candidacy for invasive procedures or device therapy, routine repeat assessment of LV function is not indicated. (Level of Evidence:C-EO) "

Invasive Evaluation 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

Class IIa
"1. In patients with HF, endomyocardial biopsy may be useful when a specific diagnosis is suspected that would influence therapy. [93][94] (Level of Evidence:B-NR) "
"2. In selected patients with HF with persistent or worsening symptoms, signs, diagnostic parameters, and in whom hemodynamics are uncertain, invasive hemodynamic monitoring can be useful to guide management. (Level of Evidence:C-EO) "
Class III (No Benefit)
"3. In patients with HF, routine use of invasive hemodynamic monitoring is not recommended. [95][96] (Level of Evidence:B-R) "
Class III (Harm)
"2. For patients undergoing routine evaluation of HF, endomyocardial biopsy should not be performed because of the risk of complications. [97][98](Level of Evidence:C-LD) "

Wearables and Remote Monitoring (Including Telemonitoring and Device Monitoring) 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

Class IIb
"1. In selected adult patients with NYHA class III HF and history of a HF hospitalization in the past year or elevated natriuretic peptide levels, on maximally tolerated stable doses of GDMT with optimal device therapy, the usefulness of wireless monitoring of PA pressure by an implanted hemodynamic monitor to reduce the risk of subsequent HF hospitalization is uncertain. [99][100][101][102] (Level of Evidence:B-R) "
Value Statement: Uncertain Value
"2. In patients with NYHA class III HF with a HF hospitalization within the previous year, wireless monitoring of the PA pressure by an implanted hemodynamic monitor provides uncertain value. [102][103][104][105] (Level of Evidence:B-NR) "

Exercise and Functional Capacity Testing 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

Class I
"1. In patients with HF, assessment and documentation of NYHA functional classification are recommended to determine eligibility for treatments. [106][107] (Level of Evidence: C-LD) "
"2. In selected ambulatory patients with HF, cardiopulmonary exercise testing (CPET) is recommended to determine appropriateness of advanced treatments (eg, LVAD, heart transplant). [108][109][110][111][112](Level of Evidence: C-LD) "
Class IIa
"3. In ambulatory patients with HF, performing a CPET or 6-minute walk test is reasonable to assess functional capacity. [108][109][113][114][115][116][117][118][119][120] (Level of Evidence: C-LD) "
"4. In ambulatory patients with unexplained dyspnea, CPET is reasonable to evaluate the cause of dyspnea. [121][122](Level of Evidence: C-LD) "

Initial and Serial Evaluation: Clinical Assessment: HF Risk Scoring 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

Class IIa
"1. In ambulatory or hospitalized patients with HF, validated multivariable risk scores can be useful to estimate subsequent risk of mortality. [123][124][125][126][127][128][129][130][131][132][133][134][135][48] (Level of Evidence: B-NR) "

Patients at risk for HF, Stage A.

Primary prevention recommendations for patients at risk for HF. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT)

Class I
"1. In patients with hypertension, blood pressure should be controlled in accordance with GDMT for hypertension to prevent symptomatic HF (Level of Evidence A).
"2. In patients with type 2 diabetes and either established CVD or at high cardiovascular risk, SGLT2i should be used to prevent hospitalization for HF (Level of Evidence A).
"3. In the general population, healthy lifestyle habits such as regular physical activity, maintaining normal weight, healthy dietary patterns, and avoiding smoking are helpful to reduce future risk of HF (Level of Evidence B-NR).
Class IIa
"1. For patients at risk of developing HF, natriuretic peptide biomarker-based screening followed by team-based care, including a cardiovascular specialist optimizing GDMT, can be useful to prevent the development of LV dysfunction (systolic or diastolic) or new-onset HF (Level of Evidence: B-R).
"2. In the general population, validated multivariable risk scores can be useful to estimate subsequent risk of incident HF (Level of Evidence: B-NR).

[2]

Stage B: Patients with PRE- HF

Management of patients in stage B. Preventing heart failure in pre-HF patients. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT)

Class I
"1. In patients with LVEF ≤40%, ACEi should be used to prevent symptomatic HF and reduce mortality (Level of Evidence: A) "
"2.   In patients with a recent or remote history of MI or ACS, statins should be used to prevent symptomatic HF and adverse cardiovascular events. (Level of Evidence: A) "
"3. In patients with a recent MI and LVEF ≤40% who are intolerant to ACEi, ARB should be used to prevent symptomatic HF and reduce mortality (Level of Evidence: B-R) "
"4. In patients with a recent or remote history of MI or acute coronary syndrome (ACS) and LVEF ≤40%, evidence-based beta blockers should be used to reduce mortality (Level of Evidence: B-R) "
"5. In patients who are at least 40 days post-MI with LVEF ≤30% and NYHA class I symptoms while obtaining GDMT and have a reasonable expectation of noteworthy survival for >1 year, an ICD is suggested for primary prevention of sudden cardiac death (SCD) to reduce total mortality (Level of Evidence: B-R) "
"6. In patients with LVEF ≤40%, beta blockers should be used to prevent symptomatic HF. (Level of Evidence: C-LD) "
Class III (Harm)
"1. In patients with LVEF <50%, thiazolidinediones should not be used because they raise the risk of HF, including hospitalizations(Level of Evidence: B-R) "
"2. In patients with LVEF <50%, nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful.(Level of Evidence: C- LD) "

[2]

Stage C

Non-pharmacological Therapy

Self-Care Support in HF. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT)

Class I
"1. Patients with HF should receive care from multidisciplinary units to facilitate the performance of GDMT, address possible barriers to self-care, decrease the risk of succeeding rehospitalization for HF, and enhance survival (Level of Evidence A)"
"2. Patients with HF should receive specific education and support to facilitate HF self-care in a multidisciplinary manner (Level of Evidence B-R)".
Class IIa
"1. In patients with HF, vaccinating against respiratory illnesses is reasonable to reduce mortality (Level of Evidence B-R)".
"2. In adults with HF, screening for depression, social isolation, frailty, and low health literacy as risk factors for poor self-care is reasonable to improve management (Level of Evidence B-R)".

[2]

Dietary Sodium Restriction in patients on Stage C. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT)

Class IIa
"1. For patients with stage C HF, avoiding excessive sodium intake is reasonable to reduce congestive symptoms. (Level of Evidence C-LD)".

[2]

The AHA currently advises cutting sodium intake to under 2300 mg per day to promote overall cardiovascular health, yet there are no studies that back up this amount of limitation. When combined with dietary counseling, the DASH diet can achieve salt restriction without sacrificing nutritional adequacy and may be linked to fewer hospitalizations for HF. Also, it is high in antioxidants and potassium. [2]

Activity, Exercise Prescription, and Cardiac Rehabilitation. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT)

Class I
"1. For patients with HF who are competent of participating, exercise training (or regular physical activity) is advised to enhance the functional status, exercise routine, and QOL (Level of Evidence A)"
Class IIa
"1. In patients with HF, a cardiac rehabilitation program can be helpful to improve functional capacity, exercise tolerance, and health-related quality of life (Level of Evidence B-NR)".

[2]

Diuretics and Decongestion Strategies in Patients With HF. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT)

Class I
"1. In patients with HF who have fluid retention, diuretics are recommended to relieve conges-tion, improve symptoms, and prevent worsening HF (Level of Evidence B -NR)"
"2. For patients with HF and congestive symptoms, the addition of a thiazide (eg, metolazone) to therapy with a loop diuretic should be dedicated for patients who do not react to moderate- or high-dose loop diuretics to minimize electrolyte anomalies (Level of Evidence B-NR)".

[2]

The majority of HF patients utilize loop diuretics as their first diuretic choice. Patients with hypertension, HF, and modest fluid retention may be candidates for thiazide diuretics such as chlorthalidone or hydrochlorothiazide. In patients with persistent edema that does not respond to loop diuretics alone, metolazone or chlorothiazide may be given in addition to loop diuretics. Diuretics should never be administered alone; instead, they should be used in conjunction with other GDMT for HF to lower hospitalization rates and increase survival[2].

Pharmacological Treatment for HFrEF. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT)

Renin-Angiotensin System Inhibition With ACEi or ARB or ARNi

Class I
"1. In patients with HFrEF and NYHA class II to III symptoms, the use of ARNi is recommended to reduce morbidity and mortality (Level of Evidence: A) "
"2.  In patients with previous or current symptoms of chronic HFrEF, the use of ACEi is beneficial to reduce morbidity and mortality when the use of ARNi is not feasible (Level of Evidence: A) "
"3. In patients with previous or current symptoms of chronic HFrEF who are intolerant to ACEi because of cough or angioedema and when the use of ARNi is not feasible, the use of ARB is recommended to reduce morbidity and mortality(Level of Evidence: A) "
Value Statement: High Value (A): "4. In patients with previous or current symptoms of chronic HFrEF, in whom ARNi is not feasible, treatment with an ACEi or ARB provides high economic value
"5. In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEi or ARB, replacement by an ARNi is recommended to further reduce morbidity and mortality(Level of Evidence: B-R) "
Value Statement: High Value (A): In patients with chronic symptomatic HFrEF, treatment with an ARNi instead of an ACEi provides high economic value.
Class III (Harm)
"1. ARNi should not be administered concomitantly with ACEi or within 36 hours of the last dose of an ACEi(Level of Evidence: B-R) "
"2. ARNi should not be administered to patients with any history of angioedema.(Level of Evidence: C- LD) "
"3. ACEi should not be administered to patients with any history of angioedema.(Level of Evidence: C- LD) "

[2]

Beta Blockers

Class I
"1. In patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta blockers proven to reduce mortality (eg, bisoprolol, carvedilol, sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalization (Level of Evidence A)"
Value Statement: High Value (A): In patients with HFrEF, with current or previous symptoms, beta-blocker therapy provides high economic value

[2]

Mineralocorticoid Receptor Antagonists

Class I
"1. In patients with HFrEF and NYHA class II to IV symptoms, an MRA (spironolactone or eplerenone) is recommended to reduce morbidity and mortality, if eGFR is >30 mL/min/1.73 m2 and serum potassium is <5.0 mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely monitored thereafter to minimize risk of hyperkalemia and renal insufficiency(Level of Evidence A)"
Value Statement: High Value (A): In patients with HFrEF and NYHA class II to IV symptoms, MRA therapy provides high economic value.

[2]

Class III (Harm)
"1. ARNi should not be administered concomi-tantly with ACEi or within 36 hours of the last dose of an ACEi(Level of Evidence: B-R) "

[2]

Sodium-Glucose Cotransporter 2 Inhibitors

Class I
"1. In patients with symptomatic chronic HFrEF, SGLT2i are advised to decrease hospitalization for HF and cardiovascular mortality, irrespective of the existence of type 2 diabetes(Level of Evidence A)"
Value Statement: High Value (A): In patients with symptomatic chronic HFrEF, SGLT2i medicine supplies medium economic value

[2]

Hydralazine and Isosorbide Dinitrate

Class I
"1. In patients with HFrEF and NYHA class II to IV symptoms, an MRA (spironolactone or eplerenone) is recommended to reduce morbidity and mortality, if eGFR is >30 mL/min/1.73 m2 and serum potassium is <5.0 mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely monitored thereafter to minimize risk of hyperkalemia and renal insufficiency(Level of Evidence A)"
Value Statement: High Value (B-NR): For patients self-identified as African American with NYHA class III to IV HFrEF who are receiving optimal medical therapy with ACEi or ARB, beta-blockers, and MRA, the combination of hydralazine and isosorbide dinitrate provides high economic value

[2]

Class IIb
"1. In patients with existing or prior symptomatic HFrEF who cannot be given first-line agents, such as ARNi, ACEi, or ARB, because of drug intolerance or renal insufficiency, a mixture of hydralazine and isosorbide dinitrate might be considered to reduce morbidity and mortality (Level of Evidence C-LD)".

[2]

Other drugs to consider

Class IIb
"1. In patients with HF class II to IV symptoms, omega-3 polyunsaturated fatty acid (PUFA) supplementation may be suitable to use as adjunctive therapy to decrease mortality and cardiovascular hospitalization (Level of Evidence B-R)".
''2. In patients with HF who experience hyperkalemia (serum potassium level ≥5.5 mEq/L) while taking a renin-angiotensin-aldosterone system inhibitor (RAASi), the effectiveness of potassium binders (patiromer, sodium zirconium cyclosilicate) to improve outcomes by facilitating the continuation of RAASi therapy is uncertain (Level of Evidence B-R)"

[2]

Class III (No Benefit)
"1. In patients with chronic HFrEF without a precise indication (eg, venous thromboembolism [VTE], AF, a prior thromboembolic event, or a cardioembolic source), anticoagulation is not suggested(Level of Evidence: B-R) "

[2]

Drugs of Unproven Value or That May Worsen HF

Class III (No Benefit)
"1. In patients with HFrEF, dihydropyridine calcium channel-blocking drugs are not recommended therapy for HF(Level of Evidence: B-R) "
"2. In patients with HFrEF, vitamins, nutritional supplements, and hormonal therapy are not guided other than to rectify specific deficiencies (Level of Evidence: B-R) "

[2]

Class III (Harm)
"3. In patients with HFrEF, nondihydropyridine calcium channel-blocking drugs are not recommended(Level of Evidence: A) "
"4. In patients with HFrEF, class IC antiarrhythmic medications and dronedarone may increase the risk of mortality .(Level of Evidence: A) "
"5.In patients with HFrEF, thiazolidinediones increase the risk of worsening HF symptoms and hospitalization .(Level of Evidence: C- A) "
"6. In patients with type 2 diabetes and high cardiovascular risk, the dipeptidyl pepti-dase-4 (DPP-4) inhibitors saxagliptin and alogliptin increase the risk of HF hospitaliza-tion and should be avoided in patients with H F (Level of Evidence: B-R)''
"7.In patients with HFrEF, NSAIDs worsen HF symptoms and should be avoided or withdrawn whenever possible (Level of Evidence: B-NR)''

[2]

Guideline directed medical therapy: Sequencing and Uptitration

Class I
"1. In patients with HFrEF, titration of guideline-directed medication dosing to reach target doses demonstrated to be efficacious in RCTs is required, to diminish cardiovascular mortality and HF hospitalizations, unless not sufficiently accepted Level of Evidence A)"

[2]

Class IIa
" 2. In patients with HFrEF, titration, and optimization of guideline-directed medications as frequently as every 1 to 2 weeks relying on the patient’s symptoms, vital signs, and laboratory results can be helpful to optimize management (Level of Evidence C-LD)".

[2]

Additional Medical Therapies. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT)

Management of Stage C: Ivabradine

Class IIa
" 1. For patients with symptomatic (NYHA class II to III) stable chronic HFrEF (LVEF ≤35%) who are obtaining GDMT, including a beta blocker at the maximum accepted dose, and who are in sinus rhythm with a heart rate of ≥70 bpm at rest, ivabradine can be advantageous to decrease HF hospitalizations and cardiovascular death(Level of Evidence B-R)".

[2]

Management of Stage C: Digoxin

Class IIb
" 1. In patients with symptomatic HFrEF despite GDMT (or who are unable to tolerate GDMT), digoxin might be considered to decrease hospitalizations for HF (Level of Evidence B-R)".

[2]

Management of Stage C: Soluble Guanylyl Cyclase Stimulators

Class IIb
" 1. In selected high-risk patients with HFrEF and recent worsening of HF already on GDMT, an oral soluble guanylate cyclase stimulator (vericiguat) may be considered to reduce HF hospitalization and cardiovascular death(Level of Evidence B-R)".

[2]

Device and Interventional Therapies for HFrEF

ICDs and CRTs

Class I
"1. In patients with nonischemic DCM or ischemic heart disease at least 40 days post-MI with LVEF ≤35% and NYHA class II or III symptoms on chronic GDMT, who keep a reasonable expectation of noteworthy survival for >1 year, ICD therapy is guided for primary prevention of SCD to decrease total mortality (Level of Evidence: A) "
"2. Value Statement: High Value (A):   A transvenous ICD delivers high financial value in the primary prevention of SCD particularly when the patient’s risk of death provoked by ventricular arrhythmia is deemed high and the risk of non arrhythmic death (either cardiac or noncardiac) is deemed low founded on the patient’s burden of comorbidities and functional status
"3.  In patients at least 40 days post-MI with LVEF ≤30% and NYHA class I symptoms while obtaining GDMT, who maintain a reasonable expectation of noteworthy survival for >1 year, ICD therapy is guided for primary prevention of SCD to reduce total mortality (Level of Evidence: B-R) "
"4. For patients who have LVEF ≤35%, sinus rhythm, left bundle branch block (LBBB) with a QRS duration ≥150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT, CRT is demonstrated to decrease total mortality, decrease hospitalizations, and enhance symptoms and QOL(Level of Evidence: B-R) "
5. Value Statement: High Value (B-NR): "4. In patients with previous or current symptoms of chronic HFrEF, in whom ARNi is not feasible, treatment with an ACEi or ARB provides high economic value

[2]

Class IIa
" 6.   For patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with a QRS duration ≥150 ms, and NYHA class II, III, or ambulatory class IV symptoms on GDMT, CRT can be useful to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL (Level of Evidence B-R)".
'' 7. In patients with high-degree or complete heart block and LVEF of 36% to 50%, CRT is reasonable to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL (Level of Evidence B-R)''
 ''8. For patients who have LVEF ≤35%, 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 to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL (Level of Evidence B- NR)''
''9. In patients with AF and LVEF ≤35% on GDMT, CRT can be useful to reduce total mortality, improve symptoms and QOL, and increase LVEF, if: a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) atrioventricular nodal ablation or pharmacologic rate control will allow near 100% ventricular pacing with CRT. (Level of Evidence B- NR)''
'' 10. For patients on GDMT who have LVEF ≤35% and are undergoing placement of a new or replacement device implantation with anticipated requirement for significant (>40%) ventricular pacing, CRT can be useful to reduce total mortality, reduce hospitalizations and improve symptoms and QOL (Level of Evidence B- NR)''
11. ''In patients with genetic arrhythmogenic cardiomyopathy with high-risk features of sudden death, with EF ≤45%, implantation of ICD is reasonable to decrease sudden death (Level of evidence B- NR)''

[2]

Class IIb
"12. For patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with QRS duration of 120 to 149 ms, and NYHA class III or ambulatory class IV on GDMT, CRT may be considered to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL (Level of Evidence:B-NR) "
''13. For patients who have LVEF ≤30%, ischemic cause of HF, sinus rhythm, LBBB with a QRS duration ≥150 ms, and NYHA class I symptoms on GDMT, CRT may be considered to reduce hospitalizations and improve symptoms and QOL (Level of Evidence:B-NR)''

[2]

Class III (No Benefit)
"14. In patients with QRS duration <120 ms, CRT is not recommended(Level of Evidence: B-R) "
"15. For patients with NYHA class I or II symptoms and non-LBBB pattern with QRS duration <150 ms, CRT is not recommended.(Level of Evidence: B-NR) "
"16. For patients whose comorbidities or frailty limit survival with a good functional capacity to <1 year, ICD and cardiac resynchronization therapy with defibrillation (CRT-D) are not indicated.(Level of Evidence: C- LD) "

[2]

Revascularization for CAD

Class I
"1. In selected patients with HF, reduced EF (EF ≤35%), and suitable coronary anatomy, surgical revascularization plus GDMT is worthwhile to improve symptoms, cardiovascular hospitalizations, and long-term all-cause mortality(Level of Evidence: B-R) "

[2]

Valvular Heart Diseases

Class I
"1. In patients with HF, VHD should be managed in a multidisciplinary manner in accordance with clinical practice guidelines for VHD to prevent worsening of HF and adverse clinical outcomes (Level of Evidence: B-R) "
''2. In patients with chronic severe secondary MR and HFrEF, optimization of GDMT is recommended before any intervention for secondary MR related to LV dysfunction (Level of Evidence: C-LD) "

[2]

HF With Mildly Reduced Ejection Fraction. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT)

Class IIa
" 1.  In patients with HFmrEF, SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular (Level of Evidence B-R)".

[2]

Class IIb
"2. Among patients with current or previous symptomatic HFmrEF (LVEF, 41%–49%), use of evidence-based beta blockers for HFrEF, ARNi, ACEi, or ARB, and MRAs may be considered to reduce the risk of HF hospitalization and cardiovascular mortality, particularly among patients with LVEF on the lower end of this spectrum (Level of Evidence:B-NR) "

[2]

HF With Improved Ejection Fraction. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT)

Class I
"1. In patients with HFimpEF after treatment, GDMT should be continued to prevent relapse of HF and LV dysfunction, even in patients who may become asymptomatic.(Level of Evidence: B-R) "

[2]

HF With Preserved Ejection Fraction. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT)

Class I
"1. Patients with HFpEF and hypertension should have medication titrated to attain blood pressure targets in accordance with published clinical practice guidelines to prevent morbidity(Level of Evidence: C-LD) "

[2]

Class IIa
" 2. In patients with HFpEF, SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular mortality (Level of Evidence B-R)".
'' 3. In patients with HFpEF, management of AF can be useful to improve symptoms (Level of Evidence C-EO)''

[2]

Class IIb
" 4.   I selected patients with HFpEF, MRAs may be considered to decrease hospitalizations, par-icularly among patients with LVEF on the lower end of this spectrrum Level of Evidence B-R)".
'' 5. n selected patients with HFpEF, the use of ARB may be considered to decrease hospital-zations, particularly among patients with LVEF on the lower end of this spectru(m Level of Evidence B-R)''
 ''6. In selected patients with HFpEF, ARNi may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum (Level of Evidence B- NR)''

[2]

Class III (No Benefit)
"7. In patients with HFpEF, routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or QOL is ineffective (Level of Evidence: B-R) "

[2]

Treatment for Heart Failure with Preserved Ejection Failure (LVEF ≥50%) [2]

Class I
Diuretics as needed
Class IIa
Sodium-glucose cotransporter-2 inhibitor.
Class IIb
Aangiotensin receptor-neprilysin inhibitor
Mineralocorticoid receptor antagonist
Angiotensin receptor blocker

Cardiac Amyloidosis. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT)

Diagnosis

Class I
"1.   Patients for whom there is a clinical suspicion for cardiac amyloidosis should have screening for serum and urine monoclonal light chains with serum and urine immunofixation electrophoresis and serum free light chains(Level of Evidence: B-NR) "
"2.  In patients with high clinical suspicion for cardiac amyloidosis, without evidence of serum or urine monoclonal light chains, bone scintigraphy should be performed to confirm the presence of transthyretin cardiac amyloidosis (Level of Evidence: B-NR) "
"3. In patients for whom a diagnosis of transthyretin cardiac amyloidosis is made, genetic testing with TTR gene sequencing is recommended to differentiate hereditary variant from wild-type transthyretin cardiac amyloidosis(Level of Evidence: B-NR) "

[2]

Clinical suspicion for cardiac amyloidosis: LV  wall  thickness  ≥14  mm in conjunction  with  fatigue, dyspnea, or edema, especially in the context of discordance between wall thickness on echocardiogram and QRS voltage on an ECG, and in the context of aortic stenosis,  HFpEF,  carpal  tunnel  syndrome, spinal stenosis, and autonomic or sensory polyneuropathy [2]

Treatment

Class I
"1. In select patients with wild-type or variant transthyretin cardiac amyloidosis and NYHA class I to III HF symptoms, transthyretin tetramer stabilizer therapy (tafamidis) is indicated to reduce cardiovascular morbidity and mortality(Level of Evidence: B-R) "
"2. Value Statement: High Value (B- NR):  At 2020 list prices, tafamidis provides low economic value (>$180 000 per QALY gained) in patients with HF with wild-type or variant transthyretin cardiac amyloidosis

[2]

Class IIa
''3. In patients with cardiac amyloidosis and AF, anticoagulation is reasonable to reduce the risk of stroke regardless of the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category (Level of Evidence: C-LD)''

[2]






Source

References

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  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 2.29 2.30 2.31 2.32 2.33 2.34 2.35 2.36 2.37 2.38 2.39 2.40 2.41 2.42 2.43 2.44 2.45 2.46 2.47 2.48 2.49 2.50 2.51 2.52 2.53 Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check |pmid= value (help).
  3. ↑ 3.0 3.1 Reddy YNV, Kaye DM, Handoko ML, van de Bovenkamp AA, Tedford RJ, Keck C; et al. (2022). "Diagnosis of Heart Failure With Preserved Ejection Fraction Among Patients With Unexplained Dyspnea". JAMA Cardiol. 7 (9): 891–899. doi:10.1001/jamacardio.2022.1916. PMC 9280610 Check |pmc= value (help). PMID 35830183 Check |pmid= value (help).
  4. ↑ Ambrosy AP, Pang PS, Khan S, Konstam MA, Fonarow GC, Traver B; et al. (2013). "Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction: findings from the EVEREST trial". Eur Heart J. 34 (11): 835–43. doi:10.1093/eurheartj/ehs444. PMID 23293303.
  5. ↑ Selvaraj S, Claggett B, Pozzi A, McMurray JJV, Jhund PS, Packer M; et al. (2019). "Prognostic Implications of Congestion on Physical Examination Among Contemporary Patients With Heart Failure and Reduced Ejection Fraction: PARADIGM-HF". Circulation. 140 (17): 1369–1379. doi:10.1161/CIRCULATIONAHA.119.039920. PMID 31510768.
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  9. ↑ Fudim M, Parikh KS, Dunning A, DeVore AD, Mentz RJ, Schulte PJ; et al. (2018). "Relation of Volume Overload to Clinical Outcomes in Acute Heart Failure (From ASCEND-HF)". Am J Cardiol. 122 (9): 1506–1512. doi:10.1016/j.amjcard.2018.07.023. PMC 6924269 Check |pmc= value (help). PMID 30172362.
  10. ↑ Anker SD, Negassa A, Coats AJ, Afzal R, Poole-Wilson PA, Cohn JN; et al. (2003). "Prognostic importance of weight loss in chronic heart failure and the effect of treatment with angiotensin-converting-enzyme inhibitors: an observational study". Lancet. 361 (9363): 1077–83. doi:10.1016/S0140-6736(03)12892-9. PMID 12672310.
  11. ↑ Eshaghian S, Horwich TB, Fonarow GC (2006). "Relation of loop diuretic dose to mortality in advanced heart failure". Am J Cardiol. 97 (12): 1759–64. doi:10.1016/j.amjcard.2005.12.072. PMID 16765130.
  12. ↑ Gorodeski EZ, Chu EC, Reese JR, Shishehbor MH, Hsich E, Starling RC (2009). "Prognosis on chronic dobutamine or milrinone infusions for stage D heart failure". Circ Heart Fail. 2 (4): 320–4. doi:10.1161/CIRCHEARTFAILURE.108.839076. PMID 19808355.
  13. ↑ Kittleson M, Hurwitz S, Shah MR, Nohria A, Lewis E, Givertz M; et al. (2003). "Development of circulatory-renal limitations to angiotensin-converting enzyme inhibitors identifies patients with severe heart failure and early mortality". J Am Coll Cardiol. 41 (11): 2029–35. doi:10.1016/s0735-1097(03)00417-0. PMID 12798577.
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  17. ↑ 17.0 17.1 Waddell-Smith KE, Donoghue T, Oates S, Graham A, Crawford J, Stiles MK; et al. (2016). "Inpatient detection of cardiac-inherited disease: the impact of improving family history taking". Open Heart. 3 (1): e000329. doi:10.1136/openhrt-2015-000329. PMC 4762189. PMID 26925241.
  18. ↑ González-López E, Gagliardi C, Dominguez F, Quarta CC, de Haro-Del Moral FJ, Milandri A; et al. (2017). "Clinical characteristics of wild-type transthyretin cardiac amyloidosis: disproving myths". Eur Heart J. 38 (24): 1895–1904. doi:10.1093/eurheartj/ehx043. PMID 28329248.
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  25. ↑ Brown EE, Lee YZJ, Halushka MK, Steenbergen C, Johnson NM, Almansa J; et al. (2017). "Genetic testing improves identification of transthyretin amyloid (ATTR) subtype in cardiac amyloidosis". Amyloid. 24 (2): 92–95. doi:10.1080/13506129.2017.1324418. PMID 28494620.
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  33. ↑ Booth RA, Hill SA, Don-Wauchope A, Santaguida PL, Oremus M, McKelvie R; et al. (2014). "Performance of BNP and NT-proBNP for diagnosis of heart failure in primary care patients: a systematic review". Heart Fail Rev. 19 (4): 439–51. doi:10.1007/s10741-014-9445-8. PMID 24969534.
  34. ↑ Dao Q, Krishnaswamy P, Kazanegra R, Harrison A, Amirnovin R, Lenert L; et al. (2001). "Utility of B-type natriuretic peptide in the diagnosis of congestive heart failure in an urgent-care setting". J Am Coll Cardiol. 37 (2): 379–85. doi:10.1016/s0735-1097(00)01156-6. PMID 11216950.
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  38. ↑ 38.0 38.1 38.2 Santaguida PL, Don-Wauchope AC, Ali U, Oremus M, Brown JA, Bustamam A; et al. (2014). "Incremental value of natriuretic peptide measurement in acute decompensated heart failure (ADHF): a systematic review". Heart Fail Rev. 19 (4): 507–19. doi:10.1007/s10741-014-9444-9. PMID 25052418.
  39. ↑ Hill SA, Booth RA, Santaguida PL, Don-Wauchope A, Brown JA, Oremus M; et al. (2014). "Use of BNP and NT-proBNP for the diagnosis of heart failure in the emergency department: a systematic review of the evidence". Heart Fail Rev. 19 (4): 421–38. doi:10.1007/s10741-014-9447-6. PMID 24957908.
  40. ↑ 40.0 40.1 van Kimmenade RR, Januzzi JL, Ellinor PT, Sharma UC, Bakker JA, Low AF; et al. (2006). "Utility of amino-terminal pro-brain natriuretic peptide, galectin-3, and apelin for the evaluation of patients with acute heart failure". J Am Coll Cardiol. 48 (6): 1217–24. doi:10.1016/j.jacc.2006.03.061. PMID 16979009.
  41. ↑ 41.0 41.1 41.2 Bettencourt P, Azevedo A, Pimenta J, Friões F, Ferreira S, Ferreira A (2004). "N-terminal-pro-brain natriuretic peptide predicts outcome after hospital discharge in heart failure patients". Circulation. 110 (15): 2168–74. doi:10.1161/01.CIR.0000144310.04433.BE. PMID 15451800.
  42. ↑ 42.0 42.1 Cheng V, Kazanagra R, Garcia A, Lenert L, Krishnaswamy P, Gardetto N; et al. (2001). "A rapid bedside test for B-type peptide predicts treatment outcomes in patients admitted for decompensated heart failure: a pilot study". J Am Coll Cardiol. 37 (2): 386–91. doi:10.1016/s0735-1097(00)01157-8. PMID 11216951.
  43. ↑ 43.0 43.1 Fonarow GC, Peacock WF, Phillips CO, Givertz MM, Lopatin M, ADHERE Scientific Advisory Committee and Investigators (2007). "Admission B-type natriuretic peptide levels and in-hospital mortality in acute decompensated heart failure". J Am Coll Cardiol. 49 (19): 1943–50. doi:10.1016/j.jacc.2007.02.037. PMID 17498579.
  44. ↑ 44.0 44.1 44.2 Logeart D, Thabut G, Jourdain P, Chavelas C, Beyne P, Beauvais F; et al. (2004). "Predischarge B-type natriuretic peptide assay for identifying patients at high risk of re-admission after decompensated heart failure". J Am Coll Cardiol. 43 (4): 635–41. doi:10.1016/j.jacc.2003.09.044. PMID 14975475.
  45. ↑ 45.0 45.1 Maisel A, Hollander JE, Guss D, McCullough P, Nowak R, Green G; et al. (2004). "Primary results of the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT). A multicenter study of B-type natriuretic peptide levels, emergency department decision making, and outcomes in patients presenting with shortness of breath". J Am Coll Cardiol. 44 (6): 1328–33. doi:10.1016/j.jacc.2004.06.015. PMID 15364340.
  46. ↑ 46.0 46.1 Zairis MN, Tsiaousis GZ, Georgilas AT, Makrygiannis SS, Adamopoulou EN, Handanis SM; et al. (2010). "Multimarker strategy for the prediction of 31 days cardiac death in patients with acutely decompensated chronic heart failure". Int J Cardiol. 141 (3): 284–90. doi:10.1016/j.ijcard.2008.12.017. PMID 19157603.
  47. ↑ 47.0 47.1 Dhaliwal AS, Deswal A, Pritchett A, Aguilar D, Kar B, Souchek J; et al. (2009). "Reduction in BNP levels with treatment of decompensated heart failure and future clinical events". J Card Fail. 15 (4): 293–9. doi:10.1016/j.cardfail.2008.11.007. PMID 19398076.
  48. ↑ 48.0 48.1 48.2 O'Connor CM, Hasselblad V, Mehta RH, Tasissa G, Califf RM, Fiuzat M; et al. (2010). "Triage after hospitalization with advanced heart failure: the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score". J Am Coll Cardiol. 55 (9): 872–8. doi:10.1016/j.jacc.2009.08.083. PMC 3835158. PMID 20185037.
  49. ↑ 49.0 49.1 O'Brien RJ, Squire IB, Demme B, Davies JE, Ng LL (2003). "Pre-discharge, but not admission, levels of NT-proBNP predict adverse prognosis following acute LVF". Eur J Heart Fail. 5 (4): 499–506. doi:10.1016/s1388-9842(03)00098-9. PMID 12921811.
  50. ↑ 50.0 50.1 Cohen-Solal A, Logeart D, Huang B, Cai D, Nieminen MS, Mebazaa A (2009). "Lowered B-type natriuretic peptide in response to levosimendan or dobutamine treatment is associated with improved survival in patients with severe acutely decompensated heart failure". J Am Coll Cardiol. 53 (25): 2343–8. doi:10.1016/j.jacc.2009.02.058. PMID 19539144.
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