2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

Authors, Journal, Affiliations, Type, DOI

• Authors: Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, et al. (26 writing committee members)
• Journal: Circulation (2022;145:e895–e1032)
• Affiliations: ACC/AHA Joint Committee on Clinical Practice Guidelines; Heart Failure Society of America (HFSA) representatives
• Type: Clinical Practice Guideline — replaces 2013 ACCF/AHA HF Guideline and 2017 focused update
• DOI: https://doi.org/10.1161/CIR.0000000000001063

Overview

The 2022 AHA/ACC/HFSA HF Guideline is the comprehensive North American standard for HF management, replacing the 2013 guideline. Its headline addition is the formal incorporation of SGLT2 inhibitors as the fourth pillar of HFrEF GDMT (COR 1). The guideline introduces the HFimpEF subgroup, refines ACC/AHA staging with "at risk" and "pre-HF" terminology, provides new recommendations for cardiac amyloidosis, and offers updated guidance on genetic testing, SGLT2i use in HFmrEF/HFpEF (COR 2a), and management of HF + atrial fibrillation. Importantly, this guideline was completed before the DELIVER trial, so HFpEF/HFmrEF SGLT2i recommendations are COR 2a — lower than the subsequent 2023 ESC Class I upgrade.

Keywords

Heart failure; heart failure with reduced ejection fraction; heart failure with preserved ejection fraction; heart failure with mildly reduced ejection fraction; systolic heart failure; heart failure rehabilitation; acute decompensated heart failure; cardiogenic shock; beta blockers; mineralocorticoid receptor antagonists; ACE inhibitors; angiotensin and neprilysin receptor antagonist; sacubitril valsartan; SGLT2 inhibitors; cardiac amyloidosis; atrial fibrillation; guideline-directed medical therapy; reduced ejection fraction

Key Takeaways

Staging of Heart Failure (ACC/AHA 4-Stage Framework)

• Stage A — "At Risk for HF": No symptoms, no structural disease, no biomarker elevation. Includes patients with hypertension, atherosclerotic CVD, diabetes, metabolic syndrome/obesity, cardiotoxin exposure, genetic variants for cardiomyopathy, or positive family history.
• Stage B — "Pre-HF": No symptoms or signs of HF, but one of: structural heart disease, elevated filling pressures (invasive or noninvasive), or risk factors + elevated BNP/troponin.
• Stage C — Symptomatic HF: Structural heart disease with current or previous symptoms of HF.
• Stage D — Advanced HF: Marked HF symptoms interfering with daily life with recurrent hospitalizations despite optimized GDMT.
• NYHA functional class (I–IV) is used to characterize symptom burden within stage C (and D) and guides treatment eligibility.

Classification by LVEF

• HFrEF: LVEF ≤40%
• HFmrEF: LVEF 41–49% + evidence of elevated LV filling pressures (elevated natriuretic peptide, noninvasive/invasive hemodynamics)
• HFpEF: LVEF ≥50% + evidence of elevated LV filling pressures
• HFimpEF: Previous LVEF ≤40% with follow-up LVEF >40%. A new subgroup — distinct from "recovered" EF — acknowledging that structural abnormalities and risk of relapse persist.
• H2FPEF score integrates: obesity, AF, age >60, ≥2 antihypertensives, E/e' >9, PA systolic pressure >35 mmHg. Score 0–9; each 1-unit increase doubles odds of HFpEF (OR 1.98; c-stat 0.841). Scores <2 = low likelihood; ≥6 = high likelihood.

Biomarkers

• BNP or NT-proBNP (COR 1A): useful to support/exclude HF diagnosis in dyspnea; recommended for risk stratification in chronic HF; measure at admission for prognosis in hospitalized patients.
• Predischarge BNP/NT-proBNP (COR 2a): informs trajectory and postdischarge prognosis.
• BNP-based screening in at-risk patients (COR 2a): followed by team-based care including cardiovascular specialist can prevent LV dysfunction or new-onset HF.
• Obesity: associated with lower BNP/NT-proBNP, reducing diagnostic sensitivity.

Genetic Evaluation and Testing

• COR 1, LOE B-NR: Genetic screening and counseling for first-degree relatives of patients with confirmed genetic/inherited cardiomyopathy.
• COR 2a, LOE B-NR: Referral for genetic counseling and testing in select patients with nonischemic cardiomyopathy.
• Genetic variants implicated in 25–40% of DCM with positive family history; 10–30% without recognized family history.
• Key gene classes: TTN (most common DCM gene), LMNA (conduction disease + AF + malignant VT), desmosomal proteins (arrhythmogenic cardiomyopathy, including LV involvement), FLNC (VA risk).
• LMNA/C and desmosomal variant carriers: consideration of ICD even with LVEF >35% or <3 months of GDMT.
• Desmosomal disease: advise avoidance of strenuous exercise.

HFrEF Pharmacotherapy — Four Pillars (AHA/ACC COR 1)

• ARNi (sacubitril-valsartan): COR 1A for NYHA II–III HFrEF — reduces CV death or HF hospitalization by 20% vs. enalapril (PARADIGM-HF). Preferred over ACEi when feasible.
• ACEi: COR 1A for HFrEF if ARNi not feasible — reduces morbidity and mortality (multiple RCTs).
• ARB: COR 1A for HFrEF if intolerant to ACEi — use if ARNi also not feasible.
• Beta-blocker: COR 1A — bisoprolol, carvedilol, or metoprolol succinate. 34% relative risk reduction in all-cause mortality.
• MRA (mineralocorticoid receptor antagonist): COR 1A — spironolactone or eplerenone. 30% relative RRR in all-cause mortality.
• SGLT2 inhibitor (dapagliflozin or empagliflozin): COR 1A — reduces CV death and worsening HF regardless of diabetes status. 17% relative RRR in all-cause mortality. NNT at 36 months = 22.
• Hydralazine + isosorbide dinitrate: COR 1A for self-identified African-American patients with NYHA III–IV already on ACEi/ARB (A-HeFT); COR 2a if unable to tolerate renin-angiotensin agents.
• Use all 4 drug classes concurrently; titrate to target doses as shown in RCTs (Table 14). Estimated 73% reduction in all-cause mortality vs. no treatment with all 4 classes.

GDMT Dosing — Key Target Doses

• ARNi: sacubitril/valsartan 97/103 mg twice daily (initiate at 24/26 mg twice daily)
• ACEi examples: enalapril 10–20 mg twice daily; lisinopril 20–40 mg once daily
• Beta-blocker: bisoprolol 10 mg once daily; carvedilol 25–50 mg twice daily; metoprolol succinate 200 mg once daily
• MRA: spironolactone 25–50 mg once daily; eplerenone 50 mg once daily
• SGLT2i: dapagliflozin 10 mg once daily; empagliflozin 10 mg once daily

Drugs Harmful or Without Benefit in HFrEF

• COR 3 Harm: Non-dihydropyridine calcium channel blockers (diltiazem, verapamil); Class IC antiarrhythmics and dronedarone (mortality increase); thiazolidinediones; DPP-4 inhibitors saxagliptin and alogliptin; NSAIDs.
• COR 3 No Benefit: Dihydropyridine CCBs; anticoagulation in HFrEF without AF/VTE/cardioembolic source.

HFmrEF (LVEF 41–49%)

• SGLT2i (COR 2a, LOE B-R): Can be beneficial in decreasing HF hospitalizations and CV mortality (EMPEROR-Preserved subgroup).
• ACEi/ARB/ARNi, beta-blockers, MRAs (COR 2b): May be considered, particularly at lower end of LVEF spectrum — based on post hoc HFrEF trial subgroup analyses.
• Trajectory of LVEF must be serially evaluated — HFmrEF is often transitional.

HFpEF (LVEF ≥50%)

• Blood pressure control (COR 1, LOE C-LD): Titrate to published BP targets to prevent morbidity.
• SGLT2i (COR 2a, LOE B-R): Can be beneficial in decreasing HF hospitalizations and CV mortality. Based on EMPEROR-Preserved (empagliflozin, LVEF >40%): 21% RRR in composite endpoint; driven by 29% reduction in HF hospitalization; no significant reduction in CV death. Benefit consistent regardless of diabetes status. Signal for lower benefit at very high LVEF (>62.5%).
• AF management (COR 2a, C-EO): Can be useful to improve symptoms.
• MRA (COR 2b, B-R): May be considered, especially at lower LVEF spectrum. TOPCAT: borderline significant HF hospitalization reduction with spironolactone; post hoc analysis suggests benefit in Americas sub-population.
• ARB (COR 2b, B-R): May be considered, especially at lower LVEF spectrum. CHARM-Preserved: borderline HF hospitalization reduction.
• ARNi (COR 2b, B-R): May be considered, especially at lower LVEF spectrum. PARAGON-HF: primary endpoint missed (rate ratio 0.87, P=0.06); prespecified subgroup benefit at LVEF <57% and in women.
• Nitrates and phosphodiesterase-5 inhibitors (COR 3: No Benefit, B-R): Routine use to increase activity or QOL is ineffective. (NEAT-HFpEF: no benefit from isosorbide mononitrate; RELAX: no benefit from sildenafil.)

HFimpEF (Previous HFrEF with LVEF >40% on GDMT)

• COR 1, LOE B-R: Continue all GDMT to prevent relapse of HF and LV dysfunction, even if asymptomatic.
• Key RCT: Withdrawal of HF medications in patients with normalized LVEF (≥50%) → 40% relapsed within 6 months. Only 50% successfully withdrew. Consistent with TRED-HF concept.

Device Therapy

• ICD primary prevention (COR 1): LVEF ≤35%, NYHA II–III, ≥3 months of GDMT for ischaemic cardiomyopathy; COR 1 for NYHA II with non-ischaemic + LVEF ≤35%.
• ICD for specific genetic variants (COR 2a): LMNA/C, desmosomal proteins, phospholamban, FLNC — consideration for ICD even with LVEF >35% or <3 months GDMT. LMNA cardiomyopathy frequently progresses to transplant due to refractory arrhythmias rather than pump failure.
• CRT (COR 1, LOE A): LVEF ≤35%, LBBB morphology, QRS ≥150 ms, NYHA II–IV on GDMT.
• CRT (COR 2a): LVEF ≤35%, LBBB, QRS 120–149 ms.
• Benefit greatest with wider QRS + LBBB; no CRT benefit in QRS ≤120 ms.

Cardiac Amyloidosis — New Recommendations

• Clinical suspicion triggers: LV wall thickness ≥14 mm + fatigue/dyspnoea/oedema, especially with ECG-echo voltage discordance, aortic stenosis, HFpEF, carpal tunnel syndrome, spinal stenosis, or polyneuropathy.
• COR 1 B-NR: Screen for serum/urine monoclonal light chains with immunofixation electrophoresis and serum free light chains.
• COR 1 B-NR: If no monoclonal proteins found, perform bone scintigraphy (99mTc-PYP) to confirm transthyretin cardiac amyloidosis (ATTR-CM).
• COR 1 B-NR: If ATTR-CM confirmed, TTR gene sequencing to distinguish hereditary variant (ATTRv) from wild-type (ATTRwt).
• Tetramer stabilizer therapy (tafamidis) and anticoagulation are specific treatments noted in the guideline.

Comorbidities — Atrial Fibrillation in HF

• Section 10.2 provides HF-specific AF recommendations (not fully reproduced here).
• AF management in HFpEF: COR 2a — individualise rate/rhythm control (extrapolated from AF guidelines).
• RATE-AF trial: In elderly HFpEF + AF, digoxin vs bisoprolol — similar primary QOL endpoint at 6 months; several secondary QOL endpoints and functional capacity favoured digoxin at 12 months. More adverse events (dizziness, lethargy, hypotension) with bisoprolol.
• Dronedarone: COR 3 Harm in HFrEF patients — increased mortality in ANDROMEDA.
• Amiodarone and dofetilide: neutral mortality effect — the only antiarrhythmics safe in HFrEF.

Acute Decompensated HF

• Assessment at each encounter: vital signs, clinical congestion (JVD, orthopnoea, leg oedema, Valsalva response).
• Diuretics (COR 1): relieve congestion and symptoms; DOSE trial supports high-dose loop diuretics over thiazide addition when possible.
• Parenteral vasodilation (COR 2b): IV nitroglycerin or nitroprusside as adjunct to diuretics if no hypotension; tachyphylaxis limits nitroglycerin utility >24h.
• VTE prophylaxis (COR 1): in all hospitalized HF patients.

Cardiogenic Shock

• SCAI staging framework (A–E): Used to classify shock severity.
• COR 1 B-NR: IV inotropic support for cardiogenic shock to maintain systemic perfusion.
• COR 2a: Temporary MCS when end-organ function cannot be maintained pharmacologically.
• COR 2a: Multidisciplinary shock team management.

Advanced HF (Stage D)

• Specialty referral to HF team for: patients who wish to prolong survival; assessment for LVAD, cardiac transplantation, palliative inotropes.
• Cardiac transplantation and long-term LVAD for advanced HF refractory to medical/device therapy.
• Palliative inotropes where consistent with patient's goals of care.

Prevention (Stage A and B)

• Healthy lifestyle, BP control, diabetes management, avoidance of cardiotoxins.
• BNP screening + team-based care in at-risk patients (COR 2a) to prevent LV dysfunction.
• GDMT for pre-HF (Stage B) with structural disease or elevated biomarkers.

Limitations of the Document

• Literature search completed May–December 2020; additional studies through September 2021. Published May 2022 — predates the DELIVER trial (dapagliflozin in HFpEF, published August 2022), so HFpEF/HFmrEF SGLT2i recommendations (COR 2a) are lower than the 2023 ESC update (Class I) that incorporated DELIVER data.
• Focus is on medical practice in the United States; some recommendations (e.g., hydralazine/isosorbide dinitrate in African-American patients) are partly framed around US practice context.
• Many HFmrEF treatment recommendations derive from post hoc analyses of HFrEF trials — no dedicated prospective RCT for HFmrEF at time of publication.
• PARAGON-HF (ARNi in HFpEF) missed its primary endpoint; COR 2b recommendation for ARNi in HFpEF is based on exploratory subgroup analyses only.
• CHAMPION trial (PA pressure sensor) had methodological concerns (non-blinded, differential contact); GUIDE-HF negative trial not incorporated into final COR.

Key Concepts Mentioned

• concepts/HFpEF — pharmacotherapy, SGLT2i evidence, H2FPEF diagnostic score
• concepts/Genetic-Testing-in-AF — context for genetic testing in inherited cardiomyopathy
• concepts/Late-Gadolinium-Enhancement — CMR role in HF characterization
• concepts/Cascade-Family-Screening — 3-generation family history, first-degree relative screening

Key Entities Mentioned

• entities/Heart-Failure — classification, staging, management across all EF phenotypes
• entities/DCM — genetic testing COR 2a, GDMT continuation in HFimpEF
• entities/LMNA — ICD consideration at LVEF >35% in genetic cardiomyopathy
• entities/PKP2 — desmosomal variants, exercise restriction, ICD consideration
• entities/TTN — most common DCM gene mentioned in genetic context
• entities/ATTR-Amyloidosis — new cardiac amyloidosis diagnosis and treatment pathway

Wiki Pages Updated

• wiki/sources/HF-AHA-2022.md (created)
• wiki/entities/Heart-Failure.md (updated: ACC/AHA staging, HFimpEF, cardiac amyloidosis, comparison to ESC guidelines)
• wiki/concepts/HFpEF.md (updated: AHA 2022 COR 2a vs ESC Class I, H2FPEF score, nitrates/PDE5i COR 3)
• wiki/entities/DCM.md (updated: AHA genetic testing COR 2a; HFimpEF relapse data)
• wiki/entities/LMNA.md (updated: AHA 2022 ICD COR note for genetic variants at LVEF >35%)
• wiki/wikiindex.md (updated)
• log.md (updated)