New Heart Failure Guidelines Issued

New ACC/AHA/HFSA guideline redefines heart failure stages to focus on prevention, updates treatment options, and emphasizes care coordination with a heart failure specialty team.
Carrie Adkins-Ali
Executive Editor
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The American College of Cardiology, the American Heart Association, and the Heart Failure Society of America have issued a new guideline that increases the focus on preventing heart failure (HF) in people who are showing early signs of pre-heart failure. It also adds SGLT-2 inhibitor (SGLT2i) medicines to the list of treatment strategies for people with symptomatic heart failure. 

The guideline offers recommendations for managing:

  • advanced therapies for people with stage D heart failure
  • cardiac amyloidosis
  • comorbidities in the setting of heart failure
  • cardio-oncology complications
  • consideration of implantable devices

Stages of Heart Failure

The ACC/AHA stages of heart failure describe the development and progression of the disease. Advanced stages indicate more serious disease and reduced survival rate.

Stage A: At Risk for HF. At risk but without symptoms, structural heart disease or blood tests indicating heart muscle injury. This includes people with a hereditary risk for heart failur, high blood pressure, metabolic syndrome and obesity, diabetes, and exposure to medications or treatments that may damage the heart.

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Stage B: Pre-HF. No symptoms or signs of HF, but evidence of one of the following:

  • structural heart disease, such as reduced ejection fraction, enlargement of the heart muscle, abnormalities in heart muscle contraction, or valve disease
  • increased filling pressures as measured via ultrasound
  • risk factors from stage A plus increased levels of B-type natriuretic peptide or persistently elevated cardiac troponin, an indicator of heart muscle injury.

Stage C: Symptomatic HF. Structural heart disease with current or previous symptoms of heart failure. Symptoms include persistent cough, nausea, shortness of breath, swelling (in the legs, feet, abdomen), and fatigue.

Stage D: Advanced HF. Symptoms interfere with daily life, are difficult to control, and result in recurrent hospitalizations despite continued guideline-directed medical therapy.

New York Heart Association classification (Class I – IV) is used when people reach symptomatic (stage C) or advanced (stage D) HF, to describe their functional capacity and determine treatment strategies.

The new guideline revised these stages to identify HF risk factors early (stage A), and to provide treatment before structural changes or signs of decreased heart function occur (stage B).

Stage A Recommendations

A large number of Americans can be categorized as stage A. For people in this group, the guideline recommends:

  • Maintain blood pressure control according to the latest guidelines. A normal resting blood pressure should be below 120/80 mmHg.
  • People with Type 2 diabetes and either established cardiovascular disease or at high cardiovascular risk are recommended to consider SGLT2i medicines, which are shown to improve survival in these populations.
  • Follow healthy lifestyle habits such as physical activity, maintaining a healthy weight, healthful dietary patterns, and avoiding smoking.

Stage B Recommendations

  • For people with stage B HF with left ventricle ejection fraction (LVEF) ≤40%, ACE-inhibitors (angiotensin-converting-enzyme inhibitors, or ACEi) should be used to prevent HF symptoms from developing.
  • Angiotensin receptor blockers (ARBs) may be prescribed for individuals with an intolerance or contraindication to ACEi. Both medications help relax the blood vessels and reduce blood pressure.
  • Cholesterol-lowering statins are recommended for people with a history of heart attack or acute coronary syndrome.

Stage C Recommendations

People in stage C should receive care from multidisciplinary teams to facilitate guideline-directed medical therapy and self-care support for learning to manage symptoms. People in stage C should be fully vaccinated against respiratory illnesses including COVID-19

Self-care support includes maintaining healthy behaviors such as restricting sodium intake and staying physically active, understanding the importance of taking medicine as directed, understanding how to monitor for signs of worsening HF, and knowing what to do about these symptoms.

The guideline recommends screenings patients for potential medical or social barriers to effective self-care and providing education and support to reduce rehospitalization and improve survival.


Left ventricular ejection fraction (LVEF) informs prognosis and response treatments for people with HF. The percentage of blood that is pumped out of the left ventricle is measured as a percentage called ejection fraction. In general, LVEF of ≥50-55% is considered normal.

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For people with stage C HF, the new guideline refines the current four classifications of HF based on LVEF with new terminology:

  • HF with reduced ejection fraction (HFrEF) includes people with LVEF ≤40%.
  • HF with improved ejection fraction (HFimpEF) includes individuals with previous LVEF ≤40% and a follow-up measurement of LVEF >40%.
  • HF with mildly reduced ejection fraction (HFmrEF) includes people with LVEF 41-49% and evidence of increased LV filling pressures.
  • HF with preserved ejection fraction (HFpEF) includes individuals with LVEF ≥50% and evidence of increased LV filling pressures.


Guideline-directed medical therapy now includes four medication classes that include SGLT-2 inhibitors, noted said Biykem Bozkurt, MD, PhD, guideline writing committee vice-chair.

"Irrespective of diabetes status, the DAPA-HF and EMPEROR-HF trials have shown the benefit of treating patients with HFrEF with SGLT-2 inhibitors, showing a 30% reduction in heart failure rehospitalization."

Pharmacological treatment for people with HFrEF includes four classes of medications, in addition to diuretics, which are recommended for patients with fluid retention.

  • Use of angiotensin receptor-neprilysin inhibitors (ARNi) is recommended, and if not feasible, the use of ACEi is recommended.
  • ARBs are recommended for individuals with an intolerance or potential adverse reaction to ACEi medicines.
  • Mineralocorticoid receptor antagonists (MRA) or beta blockers are also recommended as in the prior guideline.
  • SGLT2i are now recommended for people with symptomatic chronic HFrEF regardless of the presence of Type 2 diabetes.

People with HFmrEF or those with LVEF 41-49% should be treated first with an SGLT2i along with diuretics as needed.

ARNi, ACEi, ARB, MRA and beta blockers are considered weaker recommendations. As LVEF may change over time, people with HFmrEF should have repeat evaluations of LVEF.

People with HFpEF and hypertension should aim for blood pressure targets in accordance with clinical guidelines. For people with HFpEF, SGLT2i may be beneficial in decreasing HF hospitalization and cardiovascular mortality.

Management of atrial fibrillation can also improve symptoms. In select individuals with HFpEF, MRAs, ARBs and ARNi may be considered, particularly among people with LVEF on the lower end of the spectrum of HFpEF.

The guideline also includes recommendations for implantable cardiac devices and cardiac revascularization therapy, diagnosis and treatment of cardiac amyloidosis, specialty referrals for individuals with stage D advanced HF, and recommendations for management of atrial fibrillation and valvular heart disease in HF and cardio-oncology.

This new heart failure guideline 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. The guideline is targeted to all clinicians who are involved in the care of people with cardiovascular disease with or without heart failure.

The “2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure” will publish simultaneously in the Journal of the American College of Cardiology, the American Heart Association’s flagship journal Circulation and the Journal of Cardiac Failure.