>Section (Yancy et al., 2013); including COR and LOE
ACCF/AHA/HFSA Focused Update of the 2013 HF Guidelines (Yancy et al., 2017)
COR LOE
Biomarkers—
screening
N/A
New: natriuretic peptide biomarker screening and early intervention may prevent HF
IIA B
Biomarkers—
diagnosis
Separate sections for ambulatory/outpatient and hospitalized/acute (recommendation for each: class I, level A)
Update: acute and chronic recommendations combined in the diagnosis section
I A
Biomarkers—
prognosis or added risk stratification
Levels of natriuretic peptide biomarkers are prognostic in ambulatory care and in acute
decompensated HF (both recommendations: class I, level A). Note: acute decompensated biomarkers include troponins
Update: emphasizes admission levels of natriuretic peptide biomarkers is recommended in establishing prognosis
I A
N/A New: predischarge natriuretic peptide level is reasonable
for determining postdischarge prognosis
IIa B-NR
Biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in ambulatory care (recommendation class IIb, level B) or hospitalized/acute care (recommendation class IIb, level A)
Update: combined biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in the prognosis section
IIb B-NR
Stage C HFrEF N/A
New: in patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACE inhibitor or an ARB, replacement by an ARNi is recommended to further reduce morbidity and mortality
I B-R
N/A
New: ARNi should not be administered concomitantly with ACE inhibitors or ARB therapy or within 36 hours of the last dose of an ACE inhibitor
III B-R
N/A
New: ARNi should not be administered to patients with a history of angioedema
III (harm)
C-EO
N/A
New: ivabradine is reasonable to reduce HF
hospitalization for patients with symptomatic (NYHA class II-III) stable chronic HFrEF (LVEF ≤ 35%) who are receiving maximum tolerated beta-blocker dose, in sinus rhythm with a HR of ≥70 beats/minute at rest
IIa B-R
Stage C HFpEF N/A
New: in appropriately selected patients with HFpEF (EF
≥45%), aldosterone receptor antagonist might be considered to decrease hospitalization
IIb B-R
N/A
New: use of nitrates or phosphodiesterase-5 inhibitors to increase activity or quality of life is not effective and is not recommended
III no benefit
B-R
Use of nutritional supplements is not recommended; class III, level C
Use of nutritional supplements is not recommended III no benefit
C-EO
Comorbidities N/A New: in NYHA class II and III HF and iron deficiency, IIb B-R
anemia
IV iron replacement might be considered to improve functional status and quality of life
N/A
New: erythropoietin-stimulating agents should not be used to improve morbidity and mortality
III no benefit
B-R
Comorbidities hypertension
N/A
New: stage A HF patients with increased risk should target blood pressure less than 130/80 mmHg
I B
N/A
New: stage C HFrEF should be prescribed GDMT titrated to attain systolic blood pressure less than 130 mmHg
I C-EO
N/A
New: stage C HFpEF and persistent hypertension after volume overload management should be prescribed GDMT titrated to attain systolic blood pressure less than 130 mmHg
I C-LD
Comorbidities N/A New: a formal sleep assessment is reasonable for IIa C-LD
sleep-disordered breathing
NYHA class II-IV HF and suspicion of sleep-disordered breathing or excessive daytime sleepiness
N/A
New: CPAP may be considered for improvement in sleep quality and daytime sleepiness in patients with CVD and OSA
IIb B-R
N/A New: adaptive servoventilation causes harm in patients
with NYHA class II-IV HFrEF and CSA
III harm B-R
Note: Legend for strength and quality of data used as evidence, from (Yancy et al., 2017). COR: I, is recommended (strong); IIa, is reasonable (moderate); IIb, may be considered (weak); III, no benefit or harm. LOE: A, more than one randomized controlled trial; B-R, one or more randomized controlled trials; B-NR, one or more well- designed and executed non-randomized trials; C-LD, observational or registry studies have limitations related to design or execution; C-EO, expert opinion. Note, in the 2013 guidelines (Yancy et al., 2013), Level C reflects no benefit (expert opinion) or harm.
ACC = American College of Cardiology; ACE = angiotensin-converting enzyme; AHA = American Heart Association; ARB = angiotensin II receptor blocker; ARNi = angiotensin receptor-neprilysin inhibitor; COR = class (strength) of recommendation; CPAP
= continuous positive airway pressure; CSA = central sleep apnea; CVD = cardiovascular disease; EF = ejection fraction; GDMT = guideline-directed management and therapy; HF = heart failure; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; HFSA = Heart Failure Society of America; HR = heart rate; IV = intravenous; LOE = level (quality) of evidence; LVEF = left ventricular ejection fraction; NYHA = New York Heart Association; OSA = obstructive sleep apnea.