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Changes in AHA/ACC/HFSA Guideline for Management for Heart Failure

Updated: 15 hours ago

By Jiya Thomas, PharmD and Adenike Atanda, PharmD, BCACP, CDCES, CTTS


The AHA/ACC/HFSA guideline for the management of heart failure (HF) was updated in April 2022. The recommendations are classified based on the strength and level of evidence. Key changes include redefined heart failure stages, addition of SGLT2 inhibitors to the guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), management for amyloid heart disease, and treatment recommendations for advanced HF.

The 2022 AHA/ACC/HFSA heart failure guideline is designed to assist clinicians who treat patients with cardiovascular disease states by providing evidence-based recommendations for the prevention, diagnosis, and management of heart failure.

Stages of Heart Failure

To facilitate early intervention, the heart failure stages have been updated to include more risk factors associated with heart failure. Changes to the classification of stage B heart failure (classified as pre-heart failure) include patients with increased filling pressures, structural heart disease, or risk factors in addition to increased natriuretic peptide levels or elevated cardiac troponin levels. The new guideline also classifies patients with Stage C heart failure whose left ventricular ejection fraction (LVEF) falls between 40% and 50% as heart failure mildly reduced EF (HFmrEF). Additional classifications can be found in Table 1.

Table 1. Classification of Stage C Heart Failure

Sodium-glucose Cotransporter-2 (SGLT-2) Inhibitors

The new guideline recommends the addition of SGLT2 inhibitors (SGLT2I) as the fourth class to GDMT. Recommended GDMT includes beta blockers, angiotensin receptor-neprilysin inhibitor (ARNI) or ACE inhibitors (ACEI) or angiotensin receptor blockers (ARB), mineralocorticoid receptor antagonists (MRA), and SGLT2I. ARNI is first line therapy in HFrEF to reduce morbidity and mortality (class 1a recommendation). The use of SGLT2I, specifically dapagliflozin or empagliflozin, in symptomatic HFrEF patients regardless of the presence of type 2 diabetes is recommended (class 2a recommendation).

SGLT2I therapy is also recommended for HFmrEF and HFpEF (class 2a recommendation). Other therapies including ARNI, ACEI, ARB, MRA, and beta blockers are recommended in HFmrEF (2b recommendation). Diuretics (class 1 recommendation), MRAs, ARBs and ARNIs are recommended for HFpEF (class 2b recommendation).

Amyloid Heart Disease

The 2022 guideline recommends screening for serum and urine monoclonal light chains to confirm the diagnosis of amyloidosis. In patients with high clinical suspicion for amyloid heart disease without evidence of serum or urine monoclonal light chains, bone scintigraphy should be conducted to confirm (class 1 recommendation). Tafamidis is recommended in select patients with wild or variant type transthyretin cardiac amyloid (class 1 recommendation). In patients with cardiac amyloid and atrial fibrillation, anticoagulation is recommended regardless of the CHA2DS2-VASc score (class 2a recommendation).

Advanced Heart Failure

For patients with advanced heart failure, the guideline recommends referral to a heart failure specialist (class 1 recommendation). The benefits of fluid restriction in patients with advanced HF are unclear. In patients receiving optimized GDMT and device therapy, continuous intravenous inotropes can be employed as either as “bridge therapy” for individuals awaiting mechanical circulatory support or cardiac transplant, or as palliative therapy for those who are ineligible for advanced therapies.


1. Heidenreich PA, Bozkurt B, Aguilar D, et al. 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. 2022;145(18):e876-e894. doi:10.1161/CIR.0000000000001062.

2. Bayés-Genís A, Aimo A, Metra M, et al. Head-to-head comparison between recommendations by the ESC and ACC/AHA/HFSA heart failure guidelines [published correction appears in Eur J Heart Fail. 2023 Mar;25(3):444]. Eur J Heart Fail. 2022;24(6):916-926. doi:10.1002/ejhf.2542.


Jiya Thomas, PharmD

Pharmacist - CVS


Adenike Atanda, PharmD, BCACP, CDCES, CTTS

Assistant Professor of Pharmacotherapy

University of North Texas

Health Science Center College of Pharmacy

Fort Worth, TX

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