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Guideline for the Management of Heart Failure PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled ""The AHA/ACC/HFSA Guideline for the Management of Heart Failure"".

The AHA/ACC/HFSA Guideline for the Management of Heart Failure was last updated in 2021. The guidelines are intended to provide a framework for the diagnosis and management of heart failure in adults.

Some of the key recommendations of the guideline include:

Diagnostic testing: The guideline recommends that patients suspected of having heart failure undergo a comprehensive diagnostic evaluation that includes a detailed history, physical examination, electrocardiogram (ECG), chest X-ray, and laboratory testing.

Treatment of heart failure with reduced ejection fraction (HFrEF): The guideline recommends the use of guideline-directed medical therapy (GDMT), which includes angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs) for patients with HFrEF.

Treatment of heart failure with preserved ejection fraction (HFpEF): The guideline recommends lifestyle modifications such as weight loss, physical activity, and salt restriction, as well as management of comorbidities, such as hypertension and diabetes. There is limited evidence to support the use of pharmacologic therapies for HFpEF, and the guideline recommends further research in this area.

Device therapy: The guideline recommends the use of implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) for selected patients with HFrEF who meet specific criteria.

Advanced therapies: For patients with refractory heart failure who remain symptomatic despite optimal medical therapy and device therapy, the guideline recommends considering advanced therapies such as left ventricular assist devices (LVADs) or heart transplantation.

Overall, the guideline emphasizes the importance of a multidisciplinary approach to the management of heart failure, with a focus on optimizing medical therapy, addressing comorbidities, and promoting patient self-care and education.

Tags : Guideline for the Management of Heart Failure, Heart Failure, diagnosis and management of heart failure, cardiology, cardiology PowerPoint presentation

Published on : Mar 19, 2023 | Views : 3239 | Downloads : 2

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Slide 1-

Developed in partnership with the Heart Failure Society of America 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure
Slide 2-

This slide set is adapted from the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Published online ahead of print April 1, 2022, available at: Circulation. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 And Journal of the American College of Cardiology published online ahead of print April 1, 2022. J Am Coll Cardiol. https://www.jacc.org/doi/10.1016/j.jacc.2021.12.012 Citation © 2022 the American Heart Association, Inc., the American College of Cardiology Foundation, and Heart Failure Society of America. All rights reserved. This article has been published in Circulation, the Journal of the American College of Cardiology, and the Journal of Cardiac Failure.
Slide 3-

Paul A. Heidenreich, MD, MS, FACC, FAHA, FHFSA, Chair† Biykem Bozkurt, MD, PhD, FACC, FAHA, FHFSA, Vice Chair† 2022 Writing Committee Members* David Aguilar, MD, MSc, FAHA† Larry A. Allen, MD, MHS, FACC, FAHA, FHFSA† Joni J. Byun† Monica M. Colvin, MD, MS, FAHA† Anita Deswal, MD, MPH, FACC, FAHA, FHFSA‡ Shannon M. Dunlay, MD, MS, FAHA, FHFSA† Linda R. Evers, JD† James C. Fang, MD, FACC, FAHA, FHFSA† Savitri E. Fedson, MD, MA† Gregg C. Fonarow, MD, FACC, FAHA, FHFSA§ Salim S. Hayek, MD, FACC† Adrian F. Hernandez, MD, MHS‡ Prateeti Khazanie, MD, MPH, FHFSA† Michelle M. Kittleson, MD, PhD† Christopher S. Lee, PhD, RN, FAHA, FHFSA† Mark S. Link, MD† Carmelo A. Milano, MD† Lorraine C. Nnacheta, DrPH, MPH† Alexander T. Sandhu, MD, MS† Lynne Warner Stevenson, MD, FACC, FAHA, FHFSA† Orly Vardeny, PharmD, MS, FAHA, FHFSA║ Amanda R. Vest, MBBS, MPH, FHFSA║ Clyde W. Yancy, MD, MSc, MACC, FAHA, FHFSA† *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. † ACC/AHA Representative. ‡ ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison. §Task Force Performance Measures. ║HFSA Representative. #Former Joint Committee member; current member during the writing effort.
Slide 4-

2022 Guideline for the Management of Heart Failure Top 10 Take-Home Messages
Slide 5-

1. Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) now includes 4 medication classes which include sodium-glucose cotransporter-2 inhibitors (SGLT2i). Top 10 Take Home Messages 5
Slide 6-

Top 10 Take Home Messages 6 2. SGLT2 inhibitors have a 2a recommendation in heart failure with mildly reduced ejection fraction (HFmrEF). Weaker recommendations (2b) are made for ARNi, ACEi, ARB, MRA and beta blockers in this population.
Slide 7-

3. New recommendations for HFpEF are made for SGLT2 inhibitors (2a) , MRAs (2b) and ARNi (2b). Several prior recommendations have been renewed including treatment of hypertension (1), treatment of atrial fibrillation (2a), use of ARBs (2b) avoidance of routine use of nitrates or phosphodiesterase-5 inhibitors (3-no Benefit). Top 10 Take Home Messages 7
Slide 8-

Top 10 Take Home Messages 8 4. Improved LVEF is used to refer to those patients with a previous HFrEF who now have an LVEF > 40%. These patients should continue their HFrEF treatment.
Slide 9-

5. Value statements were created for select recommendations where high-quality cost-effectiveness studies of the intervention have been published. Top 10 Take Home Messages 9
Slide 10-

Top 10 Take Home Messages 10 6. Amyloid heart disease has new recommendations for treatment including screening for serum and urine monoclonal light chains, bone scintigraphy, genetic sequencing, tetramer stabilizer therapy, and anticoagulation.
Slide 11-

7. Evidence supporting increased filling pressures is important for the diagnosis of HF if the LVEF is >40%. Evidence for increased filling pressures can be obtained from non-invasive (e.g., natriuretic peptide, diastolic function on imaging) or invasive testing (e.g., hemodynamic measurement). Top 10 Take Home Messages 11
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Top 10 Take Home Messages 12 8. Patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF. A heart failure specialty team reviews HF management, assesses suitability for advanced HF therapies and uses palliative care including palliative inotropes where consistent with the patient’s goals of care.
Slide 13-

9. Primary prevention is important for those at risk for HF (Stage A) or pre-HF (Stage B). Stages of HF were revised to emphasize the new terminologies of “at risk” for HF for Stage A and Pre-HF for Stage B. Top 10 Take Home Messages 13
Slide 14-

Top 10 Take Home Messages 14 10. Recommendations are provided for select patients with HF and iron deficiency, anemia, hypertension, sleep disorders, type 2 diabetes, atrial fibrillation, coronary artery disease and malignancy.
Slide 15-

Table 2. Applying American College of Cardiology/American Heart Association Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)* 15
Slide 16-

16 Definition of HF
Slide 17-

Table 3. Stages of HF 17
Slide 18-

Table 3. Stages of HF (con’t.) 18
Slide 19-

Table 3. Stages of HF (con’t.) 19 BNP indicates B-type natriuretic peptide; CKD, chronic kidney disease; GDMT, guideline-directed medical therapy; HF, heart failure; LV, left ventricular; and RV, right ventricular.
Slide 20-

Figure 1. ACC/AHA Stages of HF 20 The ACC/AHA stages of HF are shown. ACC indicates American College of Cardiology; AHA, American Heart Association; CVD, cardiovascular disease; GDMT, guideline-directed medical therapy; and HF, heart failure.
Slide 21-

Figure 2. Trajectory of Class C HF 21 The trajectory of stage C HF is displayed. Patients whose symptoms and signs of HF are resolved are still stage C and should be treated accordingly. If all HF symptoms, signs, and structural abnormalities resolve, the patient is considered to have HF in remission. *Full resolution of structural and functional cardiac abnormalities is uncommon. HF indicates heart failure; and LV, left ventricular.
Slide 22-

Table 4. Classification of HF by LVEF 22 HF indicates heart failure; LV, left ventricular; and LVEF, left ventricular ejection fraction.
Slide 23-

Figure 3. Classification and Trajectories of HF Based on LVEF 23
Slide 24-

Figure 4. Diagnostic Algorithm for HF and EF-Based Classification 24 The algorithm for a diagnosis of HF and EF-based classification is shown. BNP indicates B-type natriuretic peptide; ECG, electrocardiogram; EF, ejection fraction; HF, heart failure; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; LV, left ventricular; NP, natriuretic peptides; and NT-proBNP, N-terminal pro-B type natriuretic peptide.
Slide 25-

25 Initial and Serial Evaluation
Slide 26-

Clinical Assessment: History and Physical Examination 26
Slide 27-

27 Clinical Assessment: History and Physical Examination (con’t.)
Slide 28-

28 Table 5. Other Potential Nonischemic Causes of HF HF indicates heart failure; PVC, premature ventricular contraction; and RV, right ventricular.
Slide 29-

29 Initial Laboratory and Electrocardiographic Testing
Slide 30-

30 Use of Biomarkers for Prevention, Initial Diagnosis, and Risk Stratification
Slide 31-

31 Use of Biomarkers for Prevention, Initial Diagnosis, and Risk Stratification (con’t.)
Slide 32-

32 Table 6. Selected Potential Causes of Elevated Natriuretic Peptide Levels
Slide 33-

33 Table 6. Selected Potential Causes of Elevated Natriuretic Peptide Levels (50-53) (con’t.) ACS indicates acute coronary syndromes; AF, atrial fibrillation; HF, heart failure; LVH, left ventricular hypertrophy; RV, right ventricular; and VHD, valvular heart disease.
Slide 34-

34 Genetic Evaluation and Testing
Slide 35-

35 Table 7. Examples of Factors Implicating Possible Genetic Cardiomyopathy
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36 Table 7. Examples of Factors Implicating Possible Genetic Cardiomyopathy (con’t.) AF indicates atrial fibrillation; CAD, coronary artery disease; LV, left ventricular; NSVT, nonsustained ventricular tachycardia; PVC, premature ventricular contraction; and RV, right ventricular.
Slide 37-

37 Evaluation With Cardiac Imaging
Slide 38-

38 Evaluation With Cardiac Imaging (con’t.)
Slide 39-

39 Evaluation With Cardiac Imaging (con’t.)
Slide 40-

40 Invasive Evaluation
Slide 41-

41 Invasive Evaluation (con’t.)
Slide 42-

42 Wearables and Remote Monitoring (Including Telemonitoring and Device Monitoring)
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43 Exercise and Functional Capacity Testing
Slide 44-

44 Initial and Serial Evaluation: Clinical Assessment: HF Risk Scoring
Slide 45-

45 Table 8. Selected Multivariable Risk Scores to Predict Outcome in HF
Slide 46-

46 Table 8. Selected Multivariable Risk Scores to Predict Outcome in HF (con’t.) ADHERE indicates Acute Decompensated Heart Failure National Registry; AHA, indicates American Heart Association; ARIC, Atherosclerosis Risk in Communities; CHARM, Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity; CORONA, Controlled Rosuvastatin Multinational Trial in Heart Failure; EFFECT, Enhanced Feedback for Effective Cardiac Treatment; ESCAPE, Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness; GUIDE-ID, Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HF-ACTION, Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training MAGGIC Meta-analysis Global Group in Chronic Heart Failure; I-PRESERVE, Irbesartan in Heart Failure with Preserved Ejection Fraction Study; PCP-HF, Pooled Cohort Equations to Prevent HF; TOPCAT, Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial.
Slide 47-

47 Stage A (Patients at Risk for HF)
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48 Patients at Risk for HF (Stage A: Primary Prevention)
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49 Patients at Risk for HF (Stage A: Primary Prevention) (con’t.)
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50 Figure 5. Recommendations (Class 1 and 2a) for Patients at Risk of HF (Stage A) and Those With Pre-HF (Stage B) Colors correspond to COR in Table 2. Class 1 and Class 2a recommendations for patients at risk for HF (stage A) and those with pre-HF (stage B) are shown. Management strategies implemented in patients at risk for HF (stage A) should be continued though stage B. ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BP, blood pressure; CVD, cardiovascular disease; HF, heart failure; ICD, implantable cardioverter-deﬁbrillator; LVEF, left ventricular ejection fraction; MI, myocardial infarction; and SGLT2i, sodium glucose cotransporter 2 inhibitor.
Slide 51-

51 Table 9. Selected Multivariable Risk Scores to Predict Development of Incident HF HF indicates heart failure; and PCP-HF, Pooled Cohort Equations to Prevent HF.
Slide 52-

52 Stage B (Patients With Pre-HF)
Slide 53-

53 Management of Stage B: Preventing the Syndrome of Clinical HF in Patients With Pre-HF
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54 Management of Stage B: Preventing the Syndrome of Clinical HF in Patients With Pre-HF (con’t.)
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55 Table 10. Other ACC/AHA Clinical Practice Guidelines Addressing Patients With Stage B HF
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56 Table 10. Other ACC/AHA Clinical Practice Guidelines Addressing Patients With Stage B HF (con’t.) AATS indicates American Association for Thoracic Surgery; ACC, American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; GDMT, guideline-directed medical therapy; HF, heart failure; MI, myocardial infarction; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; and STS, The Society of Thoracic Surgeons.
Slide 57-

57 Stage “C” HF
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58 Nonpharmacological Interventions: Self-Care Support in HF
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59 Nonpharmacological Interventions: Self-Care Support in HF (con’t.)
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60 Table 11. Potential Barriers to Effective HF Self-Care and Example Interventions
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61 Table 11. Potential Barriers to Effective HF Self-Care and Example Interventions (con’t.)
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62 Table 11. Potential Barriers to Effective HF Self-Care and Example Interventions (con’t.)
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63 Table 11. Potential Barriers to Effective HF Self-Care and Example Interventions (con’t.)
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64 Table 11. Potential Barriers to Effective HF Self-Care and Example Interventions (con’t.)
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65 Table 11. Potential Barriers to Effective HF Self-Care and Example Interventions (con’t.) HF indicates heart failure.
Slide 66-

66 Dietary Sodium Restriction
Slide 67-

67 Management of Stage C HF: Activity, Exercise Prescription, and Cardiac Rehabilitation
Slide 68-

68 Diuretics and Decongestion Strategies in Patients With HF
Slide 69-

69 Table 12. Commonly Used Oral Diuretics in Treatment of Congestion for Chronic HF
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70 Table 12. Commonly Used Oral Diuretics in Treatment of Congestion for Chronic HF (con’t.) HF indicates heart failure.
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71 Renin-Angiotensin System Inhibition With ACEi or ARB or ARNi
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72 Renin-Angiotensin System Inhibition With ACEi or ARB or ARNi (con’t.)
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73 Renin-Angiotensin System Inhibition With ACEi or ARB or ARNi (con’t.)
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74 Beta Blockers
Slide 75-

75 Mineralocorticoid Receptor Antagonists (MRAs) 1
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76 Sodium-Glucose Cotransporter 2 Inhibitors
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77 Hydralazine and Isosorbide Dinitrate
Slide 78-

78 Hydralazine and Isosorbide Dinitrate (con’t.)
Slide 79-

79 Figure 6. Treatment of HFrEF Stages C and D Colors correspond to COR in Table 2. Treatment recommendations for patients with HFrEF are displayed. Step 1 medications may be started simultaneously at initial (low) doses recommended for HFrEF. Alternatively, these medications may be started sequentially, with sequence guided by clinical or other factors, without need to achieve target dosing before initiating next medication. Medication doses should be increased to target as tolerated.
Slide 80-

80 Other Drug Treatment
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81 Other Drug Treatment (con’t.)
Slide 82-

82 Drugs of Unproven Value or That May Worsen HF
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83 Drugs of Unproven Value or That May Worsen HF (con’t.)
Slide 84-

84 Table 13. Selected Prescription Medications That May Cause or Exacerbate HF
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85 Table 13. Selected Prescription Medications That May Cause or Exacerbate HF (con’t.) COX indicates cyclo-oxygenase; and HF, heart failure.
Slide 86-

86 GDMT Dosing: Sequencing and Uptitration
Slide 87-

87 Table 14. Drugs Commonly Used for HFrEF (Stage C HF)
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88 Table 14. Drugs Commonly Used for HFrEF (Stage C HF) (con’t.)
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89 Table 14. Drugs Commonly Used for HFrEF (Stage C HF) (con’t.)
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90 Table 14. Drugs Commonly Used for HFrEF (Stage C HF) (con’t.)
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91 Table 14. Drugs Commonly Used for HFrEF (Stage C HF) (con’t.) ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CR, controlled release; CR/XL, controlled release/extended release; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; NA, not applicable; NR, not reported; and SGLT2i, sodium glucose cotransporter 2 inhibitor.
Slide 92-

92 Table 15. Benefits of Evidence-Based Therapies for Patients With HFrEF ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor neprilysin inhibitor; CRT, cardiac resynchronization therapy; ICD, implantable cardioverter-defibrillator; SGLT2i, sodium-glucose cotransporter-2 inhibitor; and NNT, number needed to treat. *Median duration follow-up in the respective clinical trial. †Benefit of ARNi therapy incremental to that achieved with ACEi therapy. For the other medications shown, the benefits are based on comparisons to placebo control. ‡Benefit of hydralazine-nitrate therapy was limited to African American patients in this trial.
Slide 93-

93 Management of Stage C HF: Ivabradine
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94 Pharmacological Treatment for Stage C HFrEF (Digoxin)
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95 Pharmacological Treatment for Stage C HFrEF: Soluble Guanylyl Cyclase Stimulators
Slide 96-

96 Figure 7. Additional Medical Therapies for Patients With HFrEF Colors correspond to COR in Table 2 Recommendations for additional medical therapies that may be considered for patients with HF are shown. GDMT indicates guideline-directed medical therapy; HF, heart failure; HFH, heart failure hospitalization; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; LVEF, left ventricular ejection fraction; LVESD, left ventricular end systolic dimension; MV, mitral valve; MR, mitral regurgitation; NP, natriuretic peptide; NSR, normal sinus rhythm; and NYHA, New York Heart Association; RAASi, renin-angiotensin-aldosterone system inhibitors.
Slide 97-

97 ICDs and CRTs
Slide 98-

98 ICDs and CRTs (con’t.)
Slide 99-

99 ICDs and CRTs (con’t.)
Slide 100-

100 ICDs and CRTs (con’t.)
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101 ICDs and CRTs (con’t.)
Slide 102-

102 ICDs and CRTs (con’t.)
Slide 103-

103 Figure 8. Algorithm for CRT Indications in Patients With Cardiomyopathy or HFrEF Colors correspond to COR in Table 2. Recommendations for cardiac resynchronization therapy (CRT) are displayed. AF indicates atrial fibrillation; Amb, ambulatory; CM, cardiomyopathy; GDMT, guideline-directed medical therapy; HB, heart block; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LBBB, left bundle branch block; LV, left ventricular; LVEF, left ventricular ejection fraction; NSR, normal sinus rhythm; NYHA, New York Heart Association; and RV, right ventricular.
Slide 104-

104 Revascularization for CAD
Slide 105-

105 Figure 9. Additional Device Therapies Colors correspond to COR in Table 2. Recommendations for additional nonpharmaceutical interventions that may be considered for patients with HF are shown. GDMT indicates guideline-directed medical therapy; HF, heart failure; HFH, heart failure hospitalization; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; LVEF, left ventricular ejection fraction; LVESD, left ventricular end systolic dimension; MV, mitral valve; MR, mitral regurgitation; NP, natriuretic peptide; NSR, normal sinus rhythm; NYHA, New York Heart Association; and PASP, pulmonary artery systolic pressure.
Slide 106-

106 Valvular Heart Disease
Slide 107-

107 Figure 10. Treatment Approach in Secondary Mitral Regurgitation Colors correspond to Table 2
Slide 108-

108 HF With Mildly Reduced Ejection Fraction
Slide 109-

109 Figure 11. Recommendations for Patients With Mildly Reduced LVEF (41%–49%) Medication recommendations for HFmrEF are displayed. ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HRmrEF, heart failure with mildly reduced ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; and SGLT2i, sodium- glucose cotransporter 2 inhibitor. Colors correspond to COR in Table 2.
Slide 110-

110 HF With Improved Ejection Fraction
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111 HF With Preserved Ejection Fraction
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112 HF With Preserved Ejection Fraction (con’t.)
Slide 113-

113 Figure 12. Recommendations for Patients With Preserved LVEF (≥50%) Colors correspond to COR in Table 2. Medication recommendations for HFpEF are displayed. *Greater benefit in patients with LVEF closer to 50%. ARB indicates angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; and SGLT2i, sodium-glucose cotransporter 2 inhibitor.
Slide 114-

114 Diagnosis of 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 ECG, and in the context of aortic stenosis, HFpEF, carpal tunnel syndrome, spinal stenosis, and autonomic or sensory polyneuropathy.
Slide 115-

115 Treatment of Cardiac Amyloidosis
Slide 116-

116 Figure 13. Diagnostic and Treatment of Transthyretin Cardiac Amyloidosis Algorithm Colors correspond to COR in Table 2. AF indicates atrial fibrillation; AL-CM, AL amyloid cardiomyopathy; ATTR-CM, transthyretin amyloid cardiomyopathy; ATTRv, variant transthyretin amyloidosis; ATTRwt, wild-type transthyretin amyloidosis; CHA2DS2-VASc, congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category; ECG, electrocardiogram; H/CL, heart to contralateral chest; HFrEF, heart failure with reduced ejection fraction; IFE, immunofixation electrophoresis; MRI, magnetic resonance imaging; NYHA, New York Heart Association; PYP, pyrophosphate; Tc, technetium; and TTR, transthyretin.
Slide 117-

117 Stage D (Advanced) HF
Slide 118-

118 Specialty Referral for Advanced HF
Slide 119-

119 Table 16. ESC Definition of Advanced HF
Slide 120-

120 Table 16. ESC Definition of Advanced HF (con’t.) EF indicates ejection fraction; ESC, European Society of Cardiology; HF, heart failure; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; RV, right ventricular; and VO2, oxygen consumption/oxygen uptake. Adapted from Crespo-Leiro et al.
Slide 121-

121 Table 17. INTERMACS Profiles
Slide 122-

122 Table 17. INTERMACS Profiles (con’t.)
Slide 123-

123 Table 17. INTERMACS Profiles (con’t.)
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124 Table 17. INTERMACS Profiles (con’t.) ICD indicates implantable cardioverter-defibrillator; INTERMACS, Interagency Registry for Mechanically Assisted Circulatory Support; and NYHA, New York Heart Association.
Slide 125-

125 Table 18. Clinical Indicators of Advanced HF
Slide 126-

126 Table 18. Clinical Indicators of Advanced HF (con’t.) HF indicates heart failure; ICD, implantable cardioverter-defibrillator; MAGGIC, Meta-analysis Global Group in Chronic Heart Failure; NYHA, New York Heart Association; RAAS, renin-angiotensin-aldosterone system; SBP, systolic blood pressure; SHFM, Seattle Heart Failure model; and VO2, oxygen consumption/oxygen uptake.
Slide 127-

127 Table 19. Indications and Contraindications to Durable Mechanical Support
Slide 128-

128 Table 19. Indications and Contraindications to Durable Mechanical Support (con’t.)
Slide 129-

129 Table 19. Indications and Contraindications to Durable Mechanical Support (con’t.) CRT indicates cardiac resynchronization therapy; HF, heart failure; NYHA, New York Heart Association; VO2, oxygen consumption; and PVD, peripheral vascular disease.
Slide 130-

130 Nonpharmacological Management: Advanced HF
Slide 131-

131 Inotropic Support
Slide 132-

132 Table 20. Intravenous Inotropic Agents Used in the Management of HF
Slide 133-

133 Table 20. Intravenous Inotropic Agents Used in the Management of HF (con’t.)
Slide 134-

134 Table 20. Intravenous Inotropic Agents Used in the Management of HF (con’t.) BP indicates blood pressure; CI, contraindication; CO, cardiac output; F, fever; H, hepatic; HA, headache; HF, heart failure; HR, heart rate; LFT, liver function test; MAO-I, monoamine oxidase inhibitor; N, nausea; NA, not applicable; NR, not recommended; P, plasma; PDE, phosphodiesterase; PVR, pulmonary vascular resistance; R, renal; SVR, systemic vascular resistance; T, tachyarrhythmias; and t1/2, elimination half-life. Up arrow means increase. Side arrow means no change. Down arrow means decrease. Up/down arrow means either increase or decrease.
Slide 135-

135 Mechanical Circulatory Support
Slide 136-

136 Mechanical Circulatory Support
Slide 137-

137 Cardiac Transplantation
Slide 138-

138 Patients Hospitalized With Acute Decompensated HF
Slide 139-

139 Assessment of Patients Hospitalized With Decompensated HF
Slide 140-

140 Table 21. Common Factors Precipitating HF Hospitalization With Acute Decompensated HF ACS indicates acute coronary syndrome; AF, atrial fibrillation; and NSAID, nonsteroidal anti-inflammatory drug.
Slide 141-

141 Maintenance or Optimization of GDMT During Hospitalization
Slide 142-

142 Diuretics in Hospitalized Patients: Decongestion Strategy
Slide 143-

143 Diuretics in Hospitalized Patients: Decongestion Strategy (con’t.)
Slide 144-

144 Parenteral Vasodilation Therapy in Patients Hospitalized With HF
Slide 145-

145 VTE Prophylaxis in Hospitalized Patients
Slide 146-

146 Evaluation and Management of Cardiogenic Shock
Slide 147-

147 Evaluation and Management of Cardiogenic Shock (con’t.)
Slide 148-

148 Table 22. Suggested Shock Clinical Criteria* BP indicates blood pressure; and SBP, systolic blood pressure. *Systolic BP and hypoperfusion criteria need to be met for the shock diagnosis.
Slide 149-

149 Table 23. Suggested Shock Hemodynamic Criteria* BP indicates blood pressure; CO, cardiac output; CVP, central venous pressure; HR, heart rate; MAP, mean arterial pressure; PADP, pulmonary artery diastolic pressure; PASP, pulmonary artery systolic pressure; PCW, pulmonary capillary wedge; RV, right ventricular; and SBP, systolic blood pressure. *Diagnosis of shock requires ≥1 criteria to be present along with cardiac index <2.0 L/min/m2 and SBP <90 mm Hg.
Slide 150-

150 Table 24. Society for Cardiovascular Angiography and Interventions (SCAI) Cardiogenic Shock Criteria
Slide 151-

151 Table 24. Society for Cardiovascular Angiography and Interventions (SCAI) Cardiogenic Shock Criteria (con’t.)
Slide 152-

152 Table 24. Society for Cardiovascular Angiography and Interventions (SCAI) Cardiogenic Shock Criteria (con’t.)
Slide 153-

153 Table 24. Society for Cardiovascular Angiography and Interventions (SCAI) Cardiogenic Shock Criteria (con’t.) BNP indicates brain natriuretic peptide; CI, cardiac index; CPO, cardiac power output; CPR, cardiopulmonary resuscitation; CVP, central venous pressure; HR, heart rate; LFT, liver function test; MAP, mean arterial blood pressure; MCS, mechanical circulatory support; PAPi, pulmonary artery pulsatility index; PCW, pulmonary capillary wedge pressures; PEA, pulseless electrical activity; SBP, systolic blood pressure; VF, ventricular fibrillation; and VT, ventricular tachycardia.
Slide 154-

154 Integration of Care: Transitions and Team-Based Approaches
Slide 155-

155 Integration of Care: Transitions and Team-Based Approaches (con’t.)
Slide 156-

156 Table 25. Important Components of a Transitional Care Plan GDMT indicates guideline-directed medical therapy; and HF, heart failure.
Slide 157-

157 Comorbidities in Patients With HF
Slide 158-

158 Management of Comorbidities in Patients With HF
Slide 159-

159 Management of Comorbidities in Patients With HF (con’t.)
Slide 160-

160 Management of Comorbidities in Patients With HF (con’t.)
Slide 161-

161 Figure 14. Recommendations for Treatment of Patients With HF and Selected Comorbidities Colors correspond to COR in Table 2. Recommendations for treatment of patients with HF and select comorbidities are displayed. *Patients with chronic HF with permanent-persistent-paroxysmal AF and a CHA2DS2-VASc score of ≥2 (for men) and ≥3 (for women). ACEi indicates angiotensin-converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin receptor blocker; AV, atrioventricular; CHA2DS2-VASc, congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack [TIA], vascular disease, age 65 to 74 years, sex category; CPAP, continuous positive airway pressure; CRT, cardiac resynchronization therapy; EF, ejection fraction; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; SGLT2i, sodium-glucose cotransporter 2 inhibitor; and VHD, valvular heart disease.
Slide 162-

162 Table 26. Most Common Co-Occurring Chronic Conditions Among Medicare Beneficiaries With HF (N=4,947,918), 2011
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163 Table 26. Most Common Co-Occurring Chronic Conditions Among Medicare Beneficiaries With HF (N=4,947,918), 2011 (con’t.) AF indicates atrial fibrillation; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; and HF, heart failure. ∗Mean No. of conditions is 6.1; median is 6. †Mean No. of conditions is 5.5; median is 5.
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164 Management of AF in HF
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165 Management of AF in HF (con’t.)
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166 Special Populations
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167 Disparities and Vulnerable Populations*
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168 Table 27. Risk of HF and Outcomes in Special Populations
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169 Table 27. Risk of HF and Outcomes in Special Populations (con’t.)
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170 Table 27. Risk of HF and Outcomes in Special Populations (con’t.)
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171 Table 27. Risk of HF and Outcomes in Special Populations (con’t.)
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172 Table 27. Risk of HF and Outcomes in Special Populations (con’t.) CDC indicates Centers for Disease Control and Prevention; CVD, cardiovascular disease; FHS, Framingham Heart Study; GDMT, guideline-directed medical therapy; GWTG, Get With The Guidelines registry; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HR, hazard ratio; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MESA, Multi-Ethnic Study of Atherosclerosis; OPTMIZE-HF, Organized Program To Initiate Lifesaving Treatment In Hospitalized Patients With Heart Failure; and OR, odds ratio.
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173 Cardio-Oncology
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174 Cardio-Oncology (con’t.)
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175 Cardio-Oncology (con’t.)
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176 Table 28. Cancer Therapies Known to Be Associated With Cardiomyopathy
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177 Table 28. Cancer Therapies Known to Be Associated With Cardiomyopathy (con’t.)
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178 Table 29. Risk Factors for Cancer Therapy–Related Cardiomyopathy CAD indicates coronary artery disease.
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179 HF and Pregnancy
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180 Table 30. HF Management Strategies Across the Pregnancy Continuum
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181 Table 30. HF Management Strategies Across the Pregnancy Continuum (con’t.)
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182 Table 30. HF Management Strategies Across the Pregnancy Continuum (con’t.) ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; BNP, B-natriuretic peptide; GDMT, guideline-directed medical therapy; HF, heart failure; LVEF, left ventricular ejection fraction; MCS, mechanical circulatory support; MRA, mineralocorticoid receptor antagonist; NT-proBNP, N-terminal prohormone of brain natriuretic peptide; PPCM, peripartum cardiomyopathy; RCT, randomized controlled trial; RV, right ventricular; and SGLT2i, sodium-glucose cotransporter-2 inhibitor.
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183 Quality Metrics and Reporting
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184 Quality Metrics and Reporting
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185 Table 31. ACC/AHA 2020 HF Clinical Performance, Quality, and Structural Measures
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186 Table 31. ACC/AHA 2020 HF Clinical Performance, Quality, and Structural Measures (con’t.)
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187 Table 31. ACC/AHA 2020 HF Clinical Performance, Quality, and Structural Measures (con’t.)
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188 Table 31. ACC/AHA 2020 HF Clinical Performance, Quality, and Structural Measures (con’t.) ACEi indicates angiotensin-converting enzyme inhibitor; ACC, American College of Cardiology; AHA, American Heart Association; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter-defibrillator; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; PM, performance measure; QM, quality measure; and SM, structural measure.
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189 Goals of Care
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190 Palliative and Supportive Care, Shared Decision-Making, and End-of-Life
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191 Palliative and Supportive Care, Shared Decision-Making, and End-of-Life (con’t.)
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192 Table 32. Palliative and Supportive Care Domains to Improve Processes of Care and Patient Outcomes
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193 Table 32. Palliative and Supportive Care Domains to Improve Processes of Care and Patient Outcomes GDMT indicates guideline-directed medical therapy; HF, heart failure; and ICD, implantable cardioverter-defibrillator.
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194 Figure 15. A Depiction of the Clinical Course of HF With Associated Types and Intensities of Available Therapies Over Time CHF indicates congestive heart failure; HF, heart failure; and MCS, mechanical circulatory support.
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195 Recommendation for Patient-Reported Outcomes and Evidence Gaps and Future Research Directions
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196 Patient-Reported Outcomes
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197 Table 33. Evidence Gaps and Future Research Directions
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198 Table 33. Evidence Gaps and Future Research Directions (con’t.)
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199 Table 33. Evidence Gaps and Future Research Directions (con’t.)
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200 Table 33. Evidence Gaps and Future Research Directions (con’t.)
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201 Table 33. Evidence Gaps and Future Research Directions (con’t.)
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202 Table 33. Evidence Gaps and Future Research Directions (con’t.)
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203 Table 33. Evidence Gaps and Future Research Directions (con’t.)
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204 Table 33. Evidence Gaps and Future Research Directions (con’t.)
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205 Table 33. Evidence Gaps and Future Research Directions (con’t.) AF indicates atrial fibrillation; ARNi, angiotensin receptor-neprilysin inhibitor; ATTR, transthyretin amyloidosis; BP, blood pressure; CKD, chronic kidney disease; COVID-19, coronavirus disease 2019; eGFR, estimated glomerular filtration rate; GDMT, guideline-directed medical therapy; HF, heart failure; HFimpEF, heart failure with improved ejection fraction; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LV, left ventricular; MCS, mechanical circulatory support; MRA, mineralocorticoid receptor antagonist; PUFA, polyunsaturated fatty acid; QOL, quality of life; RV, right ventricular; SGLT1i, sodium-glucose cotransporter-1 inhibitors; SGLT2i, sodium-glucose cotransporter-2 inhibitors; TAVI, transcatheter aortic valve implantation; and VHD, valvular heart disease.
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206 Abbreviations
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207 Abbreviations
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208 Abbreviations
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209 Abbreviations
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210 Abbreviations
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211 Abbreviations