Top Things to Know: 2022 Guideline for the Management of Heart Failure

Published: April 01, 2022

  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).
  2. SGLT-2 inhibitors have a 2a recommendation in heart failure with mildly reduced ejection fraction (HFmrEF). Weaker recommendations (2b) are made for ARNI/ACEi/ARB and MRAs in this population.
  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 (2a) avoidance of routine use of nitrates or phosphodiesterase-5 inhibitors (3-no benefit).
  4. Improved LVEF is used to refer to those with prior HFrEF who now have an LVEF > 40%. These patients should continue their HFrEF treatment.
  5. Value statements were created for select recommendations where high-quality cost-effectiveness studies of the intervention have been published.
  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.
  7. Evidence supporting increased filling pressures is important for the diagnosis of heart failure 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).
  8. Patients with advanced HF who wish to prolong survival should be referred to a team specialized in HF. A HF 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.
  9. Primary prevention is important for those at risk for heart failure (Stage A) or pre-heart failure (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.
  10. Recommendations are provided for select patients with heart failure and iron deficiency, anemia, hypertension, sleep disorders, type 2 diabetes, atrial fibrillation, coronary artery disease and malignancy.


Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published online ahead of print April 1, 2022]. Circulation. doi: 10.1161/CIR.0000000000001063