Cardiac societies issue new joint guideline on management of heart failure

The updated guideline recommends sodium-glucose cotransporter-2 inhibitors for many heart failure patients, regardless of their diabetes status, among other changes.

A new guideline on management of heart failure (HF) was jointly released by the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Failure Society of America (HFSA).

Among other changes, the new guideline refines the classifications of heart failure based on left ventricular ejection fraction (LVEF) as follows:

  • HF with reduced ejection fraction (HFrEF): LVEF less than or equal to 40%;
  • HF with improved ejection fraction (HFimpEF): previous LVEF less than or equal to 40% and a follow-up measurement of LVEF over 40%;
  • HF with mildly reduced ejection fraction (HFmrEF): LVEF of 41% to 49% and evidence of increased LV filling pressures; and
  • HF with preserved ejection fraction (HFpEF): LVEF equal to or greater than 50% and evidence of increased LV filling pressures.

Another significant change is that the guideline now recommends sodium-glucose cotransporter-2 (SGLT-2) inhibitors for patients with symptomatic HFrEF regardless of diabetes status. Recommended pharmacological treatment for HFrEF includes four classes of medications, in addition to diuretics: angiotensin receptor-neprilysin inhibitors or, if not feasible, angiotensin-converting enzyme inhibitors; mineralocorticoid receptor antagonists or beta-blockers; and SGLT-2 inhibitors.

HFmrEF should be treated first with an SGLT-2 inhibitor along with diuretics as needed. Patients with HFpEF and hypertension should aim for blood pressure targets in accordance with other guidelines, and SGLT-2 inhibitors may be beneficial in decreasing their risk of HF hospitalization and cardiovascular mortality, the new guideline said.

It also includes recommendations on use of implantable cardiac devices and cardiac revascularization therapy, diagnosis and treatment of cardiac amyloidosis, referral of patients with advanced heart failure to subspecialty care, and management of atrial fibrillation and valvular heart disease in HF and cardio-oncology.

The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure replaces the 2013 ACCF/AHA Guideline for the Management of Heart Failure and the 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure and was published simultaneously on April 1 in the Journal of the American College of Cardiology, Circulation, and the Journal of Cardiac Failure.

Another recent study on heart failure looked at the association between depression and hospitalization risk. Researchers reviewed medical records from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study of 30,239 community-dwelling U.S. adults ages 45 years and older, classifying HF by the lowest documented LVEF during hospitalization. Depression symptoms were obtained at baseline examination using the four-item Center for Epidemiologic Studies Depression scale. Results were published March 24 by the Journal of the American Heart Association.

Over a median of 9.2 years of follow-up, there were 872 HF hospitalizations, 526 in patients without coronary heart disease (CHD) and 334 in those with CHD. Age-adjusted hospitalization rates per 1,000 person-years were 4.9 (95% CI, 4.0 to 5.9) for participants with depressive symptoms versus 3.2 (95% CI, 3.0 to 3.5) for those without (P<0.001). When HFpEF was assessed separately in an analysis that controlled for all covariates, depressive symptoms were associated with hospitalization in those without baseline CHD (hazard ratio [HR], 1.48; 95% CI, 1.00 to 2.18) but were not associated with HFrEF hospitalizations. Statistically significant associations between depression symptoms and HFpEF persisted after adjustment for demographics, physiological parameters, and health behaviors in the total sample (HR, 1.37; 95% CI, 1.01 to 1.85).

Routine depression screening and targeted treatment interventions for depression among individuals without established CHD may reduce the risk for HFpEF, the authors noted. “The primary prevention of HF and reducing the risk of hospitalization for HF are one of the major challenges in the modern medicine,” they wrote. “The possibility that depressive symptoms are an independent risk factor of incident HF hospitalization underscores the importance of screening and treatment of depressive symptoms. Our study results suggest an important opportunity for primary prevention of HFpEF by addressing depressive symptoms.”