2013ACCF/AHAGuidelinefortheManagementofHeartFailureDevelopedinCollaborationWiththeAmericanAcademyofFamilyPhysicians,AmericanCollegeofChestPhysicians,HeartRhythmSociety,andInternationalSocietyforHeartandLungTransplantationEndorsedbytheAmericanAssociationofCardiovascularandPulmonaryRehabilitation?AmericanCollegeofCardiologyFoundationandAmericanHeartAssociation,Inc.2013ACCF/AHAGuidelineforth1CitationThisslidesetisadaptedfromthe2013ACCF/AHAGuidelinefortheManagementofHeartFailure.E-PublishedonJune5,2013,availableat:[/article.aspx?doi=10.1016/j.jacc.2013.05.019and/lookup/doi/10.1161/CIR.0b013e31829e8776]Thefull-textguidelinesarealsoavailableonthefollowingWebsites:ACC()andAHA()CitationThisslidesetisadap2ClydeW.YancyandMariellJessupACCF/AHAHeartFailureGuidelineWritingCommitteeMembersClydeW.Yancy,MD,MSc,FACC,FAHA,Chair??MariellJessup,MD,FACC,FAHA,ViceChair*?SlideSetEditors

*Writingcommitteemembersarerequiredtorecusethemselvesfromvotingonsectionstowhichtheirspecificrelationshipswithindustryandotherentitiesmayapply;seeAppendix1forrecusalinformation.?ACCF/AHARepresentative.?ACCF/AHATaskForceonPracticeGuidelinesLiaison.§AmericanCollegeofPhysiciansRepresentative.║AmericanCollegeofChestPhysiciansRepresentative.?InternationalSocietyforHeartandLungTransplantationRepresentative.#ACCF/AHATaskForceonPerformanceMeasuresLiaison.**AmericanAcademyofFamilyPhysiciansRepresentative.??HeartRhythmSocietyRepresentative.ClydeW.YancyandMariellJes3ClassificationofRecommendationsandLevelsofEvidenceArecommendationwithLevelofEvidenceBorCdoesnotimplythattherecommendationisweak.Manyimportantclinicalquestionsaddressedintheguidelinesdonotlendthemselvestoclinicaltrials.Althoughrandomizedtrialsareunavailable,theremaybeaveryclearclinicalconsensusthataparticulartestortherapyisusefuloreffective.

*Dataavailablefromclinicaltrialsorregistriesabouttheusefulness/efficacyindifferentsubpopulations,suchassex,age,historyofdiabetes,historyofpriormyocardialinfarction,historyofheartfailure,andprioraspirinuse.?Forcomparativeeffectivenessrecommendations(ClassIandIIa;LevelofEvidenceAandBonly),studiesthatsupporttheuseofcomparatorverbsshouldinvolvedirectcomparisonsofthetreatmentsorstrategiesbeingevaluated.ClassificationofRecommendati4Stages,PhenotypesandTreatmentofHFStages,PhenotypesandTreatme5InitialandSerialEvaluationoftheHFPatient

(includingHFpEF)II.TreatmentofStageAthruDHeartFailure

(includingHFpEF)III.TheHospitalizedPatientIV.Surgical/Percutaneous/TranscatheterInterventionalTreatmentsV.CoordinatingCareforPatientsWithChronicHFVI.QualityMetrics/PerformanceMeasuresOutlineInitialandSerialEvaluation6ClinicalEvaluationInitialandSerialEvaluationoftheHFPatientClinicalEvaluationInitialand7DefinitionofHeartFailureDefinitionofHeartFailure8ClassificationofHeartFailureClassificationofHeartFailur9InitialandSerialEvaluationoftheHFPatientGuidelineforHFInitialandSerialEvaluation10HistoryandPhysicalExaminationInitialandSerialEvaluationoftheHFPatientHistoryandPhysicalExaminati11Athoroughhistoryandphysicalexaminationshouldbeobtained/performedinpatientspresentingwithHFtoidentifycardiacandnoncardiacdisordersorbehaviorsthatmightcauseoracceleratethedevelopmentorprogressionofHF.InpatientswithidiopathicDCM,a3-generationalfamilyhistoryshouldbeobtainedtoaidinestablishingthediagnosisoffamilialDCM.Volumestatusandvitalsignsshouldbeassessedateachpatientencounter.Thisincludesserialassessmentofweight,aswellasestimatesofjugularvenouspressureandthepresenceofperipheraledemaororthopnea.

HistoryandPhysicalExaminationIIIaIIbIIIIIIaIIbIIIIIIaIIbIIIBAthoroughhistoryandphysica12RiskScoringInitialandSerialEvaluationoftheHFPatientRiskScoringInitialandSerial13RiskScoringValidatedmultivariableriskscorescanbeusefultoestimatesubsequentriskofmortalityinambulatoryorhospitalizedpatientswithHF.IIIaIIbIIIBRiskScoringIIIaIIbIIIB14RiskScorestoPredictOutcomesinHFRiskScorestoPredictOutcome15DiagnosticTestsInitialandSerialEvaluationoftheHFPatientDiagnosticTestsInitialandSe16DiagnosticTestsInitiallaboratoryevaluationofpatientspresentingwithHFshouldincludecompletebloodcount,urinalysis,serumelectrolytes(includingcalciumandmagnesium),bloodureanitrogen,serumcreatinine,glucose,fastinglipidprofile,liverfunctiontests,andthyroid-stimulatinghormone.Serialmonitoring,whenindicated,shouldincludeserumelectrolytesandrenalfunction.IIIaIIbIIIIIIaIIbIIIDiagnosticTestsInitiallabora17DiagnosticTests(cont.)A12-leadECGshouldbeperformedinitiallyonallpatientspresentingwithHF.ScreeningforhemochromatosisorHIVisreasonableinselectedpatientswhopresentwithHF.Diagnostictestsforrheumatologicdiseases,amyloidosis,orpheochromocytomaarereasonableinpatientspresentingwithHFinwhomthereisaclinicalsuspicionofthesediseases.IIIaIIbIIIIIIaIIbIIIIIIaIIbIIIDiagnosticTests(cont.)A12-l18BiomarkersAmbulatory/OutpatientInitialandSerialEvaluationoftheHFPatientBiomarkersInitialandSerialE19Ambulatory/OutpatientInambulatorypatientswithdyspnea,measurementofBNPorN-terminalpro-B-typenatriureticpeptide(NT-proBNP)isusefultosupportclinicaldecisionmakingregardingthediagnosisofHF,especiallyinthesettingofclinicaluncertainty.MeasurementofBNPorNT-proBNPisusefulforestablishingprognosisordiseaseseverityinchronicHF.IIIaIIbIIIAIIIaIIbIIIAAmbulatory/OutpatientInambula20Ambulatory/Outpatient(cont.)BNP-orNT-proBNPguidedHFtherapycanbeusefultoachieveoptimaldosingofGDMTinselectclinicallyeuvolemicpatientsfollowedinawell-structuredHFdiseasemanagementprogram.TheusefulnessofserialmeasurementofBNPorNT-proBNPtoreducehospitalizationormortalityinpatientswithHFisnotwellestablished.MeasurementofotherclinicallyavailabletestssuchasbiomarkersofmyocardialinjuryorfibrosismaybeconsideredforadditiveriskstratificationinpatientswithchronicHF.IIIaIIbIIIBIIIaIIbIIIBIIIaIIbIIIBAmbulatory/Outpatient(cont.)B21Hospitalized/AcuteMeasurementofBNPorNT-proBNPisusefultosupportclinicaljudgmentforthediagnosisofacutelydecompensatedHF,especiallyinthesettingofuncertaintyforthediagnosis.MeasurementofBNPorNT-proBNPand/orcardiactroponinisusefulforestablishingprognosisordiseaseseverityinacutelydecompensatedHF.IIIaIIbIIIAIIIaIIbIIIAHospitalized/AcuteMeasurement22BiomarkersHospitalized/AcuteInitialandSerialEvaluationoftheHFPatientBiomarkersInitialandSerialE23Hospitalized/Acute(cont.)TheusefulnessofBNP-orNT-proBNPguidedtherapyforacutelydecompensatedHFisnotwell-established.MeasurementofotherclinicallyavailabletestssuchasbiomarkersofmyocardialinjuryorfibrosismaybeconsideredforadditiveriskstratificationinpatientswithacutelydecompensatedHF.IIIaIIbIIIIIIaIIbIIIAHospitalized/Acute(cont.)The24RecommendationsforBiomarkersinHFRecommendationsforBiomarkers25CausesforElevatedNatriureticPeptideLevelsCausesforElevatedNatriureti26NoninvasiveCardiacImagingInitialandSerialEvaluationoftheHFPatientNoninvasiveCardiacImagingIni27NoninvasiveCardiacImagingPatientswithsuspectedornew-onsetHF,orthosepresentingwithacutedecompensatedHF,shouldundergoachestx-raytoassessheartsizeandpulmonarycongestion,andtodetectalternativecardiac,pulmonary,andotherdiseasesthatmaycauseorcontributetothepatients’symptoms.A2-dimensionalechocardiogramwithDopplershouldbeperformedduringinitialevaluationofpatientspresentingwithHFtoassessventricularfunction,size,wallthickness,wallmotion,andvalvefunction.RepeatmeasurementofEFandmeasurementoftheseverityofstructuralremodelingareusefultoprovideinformationinpatientswithHFwhohavehadasignificantchangeinclinicalstatus;whohaveexperiencedorrecoveredfromaclinicalevent;orwhohavereceivedtreatment,includingGDMT,thatmighthavehadasignificanteffectoncardiacfunction;orwhomaybecandidatesfordevicetherapy.IIIaIIbIIIIIIaIIbIIIIIIaIIbIIINoninvasiveCardiacImagingPat28NoninvasiveCardiacImaging(cont.)NoninvasiveimagingtodetectmyocardialischemiaandviabilityisreasonableinpatientspresentingwithdenovoHFwhohaveknownCADandnoanginaunlessthepatientisnoteligibleforrevascularizationofanykind.ViabilityassessmentisreasonableinselectsituationswhenplanningrevascularizationinHFpatientswithCAD.RadionuclideventriculographyormagneticresonanceimagingcanbeusefultoassessLVEFandvolumewhenechocardiographyisinadequate.IIIaIIbIIIIIIaIIbIIIIIIaIIbIIIBNoninvasiveCardiacImaging(c29NoninvasiveCardiacImaging(cont.)Magneticresonanceimagingisreasonablewhenassessingmyocardialinfiltrativeprocessesorscarburden.RoutinerepeatmeasurementofLVfunctionassessmentintheabsenceofclinicalstatuschangeortreatmentinterventionsshouldnotbeperformed.IIIaIIbIIIBNoBenefitIIIaIIbIIIBNoninvasiveCardiacImaging(c30RecommendationsforNoninvasiveImagingRecommendationsforNoninvasiv31InvasiveEvaluationInitialandSerialEvaluationoftheHFPatientInvasiveEvaluationInitialand32InvasiveEvaluationInvasivehemodynamicmonitoringwithapulmonaryarterycathetershouldbeperformedtoguidetherapyinpatientswhohaverespiratorydistressorclinicalevidenceofimpairedperfusioninwhomtheadequacyorexcessofintracardiacfillingpressurescannotbedeterminedfromclinicalassessment.InvasivehemodynamicmonitoringcanbeusefulforcarefullyselectedpatientswithacuteHFwhohavepersistentsymptomsdespiteempiricadjustmentofstandardtherapiesanda.whosefluidstatus,perfusion,orsystemicorpulmonaryvascularresistanceisuncertain;b.whosesystolicpressureremainslow,orisassociatedwithsymptoms,despiteinitialtherapy;c.whoserenalfunctionisworseningwiththerapy;d.whorequireparenteralvasoactiveagents;ore.whomayneedconsiderationforMCSortransplantation.IIIaIIbIIIIIIaIIbIIIInvasiveEvaluationInvasivehe33InvasiveEvaluation(cont.)WhenischemiamaybecontributingtoHF,coronaryarteriographyisreasonableforpatientseligibleforrevascularization.EndomyocardialbiopsycanbeusefulinpatientspresentingwithHFwhenaspecificdiagnosisissuspectedthatwouldinfluencetherapy.IIIaIIbIIIIIIaIIbIIIInvasiveEvaluation(cont.)III34InvasiveEvaluation(cont.)Routineuseofinvasivehemodynamicmonitoringisnotrecommended

innormotensivepatientswithacutedecompensatedHFandcongestionwithsymptomaticresponsetodiureticsandvasodilators.EndomyocardialbiopsyshouldnotbeperformedintheroutineevaluationofpatientswithHF.IIIaIIbIIIBNoBenefitIIIaIIbIIIHarmInvasiveEvaluation(cont.)Rou35RecommendationsforInvasiveEvaluationRecommendationsforInvasiveE36TreatmentofStagesAtoDGuidelineforHFTreatmentofStagesAtoDGuid37StageATreatmentofStagesAtoDStageATreatmentofStagesAt38StageAHypertensionandlipiddisordersshouldbecontrolledinaccordancewithcontemporaryguidelinestolowertheriskofHF.OtherconditionsthatmayleadtoorcontributetoHF,suchasobesity,diabetesmellitus,tobaccouse,andknowncardiotoxicagents,shouldbecontrolledoravoided.IIIaIIbIIIIIIaIIbIIIAStageAHypertensionandlipid39StageBTreatmentofStagesAtoDStageBTreatmentofStagesAt40StageBInallpatientswitharecentorremotehistoryofMIorACSandreducedEF,ACEinhibitorsshouldbeusedtopreventsymptomaticHFandreducemortality.InpatientsintolerantofACEinhibitors,ARBsareappropriateunlesscontraindicated.InallpatientswitharecentorremotehistoryofMIorACSandreducedEF,evidence-basedbetablockersshouldbeusedtoreducemortality.InallpatientswitharecentorremotehistoryofMIorACS,statinsshouldbeusedtopreventsymptomaticHFandcardiovascularevents.IIIaIIbIIIAIIIaIIbIIIAIIIaIIbIIIBStageBInallpatientswitha41StageB(cont.)Inpatientswithstructuralcardiacabnormalities,includingLVhypertrophy,intheabsenceofahistoryofMIorACS,bloodpressureshouldbecontrolledinaccordancewithclinicalpracticeguidelinesforhypertensiontopreventsymptomaticHF.ACEinhibitorsshouldbeusedinallpatientswithareducedEFtopreventsymptomaticHF,eveniftheydonothaveahistoryofMI.BetablockersshouldbeusedinallpatientswithareducedEFtopreventsymptomaticHF,eveniftheydonothaveahistoryofMI.IIIaIIbIIIAIIIaIIbIIIAIIIaIIbIIIStageB(cont.)Inpatientswit42StageB(cont.)Topreventsuddendeath,placementofanICDisreasonableinpatientswithasymptomaticischemiccardiomyopathywhoareatleast40dayspost-MI,haveanLVEFof30%orless,areonappropriatemedicaltherapyandhavereasonableexpectationofsurvivalwithagoodfunctionalstatusformorethan1year.NondihydropyridinecalciumchannelblockerswithnegativeinotropiceffectsmaybeharmfulinasymptomaticpatientswithlowLVEFandnosymptomsofHFafterMI.IIIaIIbIIIBIIIaIIbIIIHarmStageB(cont.)Topreventsudd43RecommendationsforTreatmentofStageBHFRecommendationsforTreatment44StageCTreatmentofStagesAtoDStageCTreatmentofStagesAt45NonpharmacologicalInterventionsTreatmentofStagesAtoDNonpharmacologicalInterventio46StageC:NonpharmacologicalInterventionsPatientswithHFshouldreceivespecificeducationtofacilitateHFself-care.Exercisetraining(orregularphysicalactivity)isrecommendedassafeandeffectiveforpatientswithHFwhoareabletoparticipatetoimprovefunctionalstatus.SodiumrestrictionisreasonableforpatientswithsymptomaticHFtoreducecongestivesymptoms.IIIaIIbIIIBIIIaIIbIIIIIIaIIbIIIAStageC:NonpharmacologicalIn47StageC:NonpharmacologicalInterventions(cont.)Continuouspositiveairwaypressure(CPAP)canbebeneficialtoincreaseLVEFandimprovefunctionalstatusinpatientswithHFandsleepapnea.CardiacrehabilitationcanbeusefulinclinicallystablepatientswithHFtoimprovefunctionalcapacity,exerciseduration,HRQOL,andmortality.IIIaIIbIIIBIIIaIIbIIIBStageC:NonpharmacologicalIn48PharmacologicalTreatmentforStageCHFrEFTreatmentofStagesAtoDPharmacologicalTreatmentfor49PharmacologicalTreatmentforStageCHFrEFMeasureslistedasClassIrecommendationsforpatientsinstagesAandBarerecommendedwhereappropriateforpatientsinstageC.(LevelsofEvidence:A,B,andCasappropriate)GDMTasdepictedinFigure1shouldbethemainstayofpharmacologicaltherapyforHFrEF.IIIaIIbIIIAIIIaIIbIIISeerecommendationsforstagesA,B,andCLOEforLOEPharmacologicalTreatmentfor50PharmacologicTreatmentforStageCHFrEFPharmacologicTreatmentforSt51PharmacologicalTreatmentfor

StageCHFrEF(cont.)DiureticsarerecommendedinpatientswithHFrEFwhohaveevidenceoffluidretention,unlesscontraindicated,toimprovesymptoms.ACEinhibitorsarerecommendedinpatientswithHFrEFandcurrentorpriorsymptoms,unlesscontraindicated,toreducemorbidityandmortality.ARBsarerecommendedinpatientswithHFrEFwithcurrentorpriorsymptomswhoareACEinhibitor-intolerant,unlesscontraindicated,toreducemorbidityandmortality.IIIaIIbIIIIIIaIIbIIIAIIIaIIbIIIAPharmacologicalTreatmentfor52DrugsCommonlyUsedforHFrEF

(StageCHF)DrugsCommonlyUsedforHFrEF53DrugsCommonlyUsedforHFrEF(StageCHF)(cont.)DrugsCommonlyUsedforHFrEF54PharmacologicalTreatmentfor

StageCHFrEF(cont.)ARBsarereasonabletoreducemorbidityandmortalityasalternativestoACEinhibitorsasfirst-linetherapyforpatientswithHFrEF,especiallyforpatientsalreadytakingARBsforotherindications,unlesscontraindicated.AdditionofanARBmaybeconsideredinpersistentlysymptomaticpatientswithHFrEFwhoarealreadybeingtreatedwithanACEinhibitorandabetablockerinwhomanaldosteroneantagonistisnotindicatedortolerated.IIIaIIbIIIAIIIaIIbIIIAPharmacologicalTreatmentfor55PharmacologicalTreatmentfor

StageCHFrEF(cont.)RoutinecombineduseofanACEinhibitor,ARB,andaldosteroneantagonistispotentiallyharmfulforpatientswithHFrEF.Useof1ofthe3betablockersproventoreducemortality(i.e.,bisoprolol,carvedilol,andsustained-releasemetoprololsuccinate)isrecommendedforallpatientswithcurrentorpriorsymptomsofHFrEF,unlesscontraindicated,toreducemorbidityandmortality.IIIaIIbIIIAIIIaIIbIIIHarmPharmacologicalTreatmentfor56PharmacologicalTreatmentfor

StageCHFrEF(cont.)Aldosteronereceptorantagonists[ormineralocorticoidreceptorantagonists(MRA)]arerecommendedinpatientswithNYHAclassII-IVandwhohaveLVEFof35%orless,unlesscontraindicated,toreducemorbidityandmortality.PatientswithNYHAclassIIshouldhaveahistoryofpriorcardiovascularhospitalizationorelevatedplasmanatriureticpeptidelevelstobeconsideredforaldosteronereceptorantagonists.Creatinineshouldbe2.5mg/dLorlessinmenor2.0mg/dLorlessinwomen(orestimatedglomerularfiltrationrate>30mL/min/1.73m2)andpotassiumshouldbelessthan5.0mEq/L.Carefulmonitoringofpotassium,renalfunction,anddiureticdosingshouldbeperformedatinitiationandcloselyfollowedthereaftertominimizeriskofhyperkalemiaandrenalinsufficiency.IIIaIIbIIIAPharmacologicalTreatmentfor57PharmacologicalTreatmentfor

StageCHFrEF(cont.)AldosteronereceptorantagonistsarerecommendedtoreducemorbidityandmortalityfollowinganacuteMIinpatientswhohaveLVEFof40%orlesswhodevelopsymptomsofHForwhohaveahistoryofdiabetesmellitus,unlesscontraindicated.Inappropriateuseofaldosteronereceptorantagonistsispotentiallyharmfulbecauseoflife-threateninghyperkalemiaorrenalinsufficiencywhenserumcreatininegreaterthan2.5mg/dLinmenorgreaterthan2.0mg/dLinwomen(orestimatedglomerularfiltrationrate<30mL/min/1.73m2),and/orpotassiumabove5.0mEq/L.IIIaIIbIIIBIIIaIIbIIIBHarmPharmacologicalTreatmentfor58PharmacologicalTreatmentfor

StageCHFrEF(cont.)Thecombinationofhydralazineandisosorbidedinitrateisrecommendedtoreducemorbidityandmortalityforpatientsself-describedasAfricanAmericanswithNYHAclassIII–IVHFrEFreceivingoptimaltherapywithACEinhibitorsandbetablockers,unlesscontraindicated.AcombinationofhydralazineandisosorbidedinitratecanbeusefultoreducemorbidityormortalityinpatientswithcurrentorpriorsymptomaticHFrEFwhocannotbegivenanACEinhibitororARBbecauseofdrugintolerance,hypotension,orrenalinsufficiency,unlesscontraindicated.IIIaIIbIIIAIIIaIIbIIIBPharmacologicalTreatmentfor59PharmacologicalTreatmentfor

StageCHFrEF(cont.)DigoxincanbebeneficialinpatientswithHFrEF,unlesscontraindicated,todecreasehospitalizationsforHF.PatientswithchronicHFwithpermanent/persistent/paroxysmalAFandanadditionalriskfactorforcardioembolicstroke(historyofhypertension,diabetesmellitus,previousstrokeortransientischemicattack,or≥75yearsofage)shouldreceivechronicanticoagulanttherapy(intheabsenceofcontraindicationstoanticoagulation).IIIaIIbIIIBIIIaIIbIIIAPharmacologicalTreatmentfor60PharmacologicalTreatmentfor

StageCHFrEF(cont.)Theselectionofananticoagulantagent(warfarin,dabigatran,apixaban,orrivaroxaban)forpermanent/persistent/paroxysmalAFshouldbeindividualizedonthebasisofriskfactors,cost,tolerability,patientpreference,potentialfordruginteractions,andotherclinicalcharacteristics,includingtimeintheinternationalnormalizedratetherapeuticrationifthepatienthasbeentakingwarfarin.ChronicanticoagulationisreasonableforpatientswithchronicHFwhohavepermanent/persistent/paroxysmalAFbutarewithoutanadditionalriskfactorforcardioembolicstroke(intheabsenceofcontraindicationstoanticoagulation).IIIaIIbIIIIIIaIIbIIIBPharmacologicalTreatmentfor61PharmacologicalTreatmentfor

StageCHFrEF(cont.)AnticoagulationisnotrecommendedinpatientswithchronicHFrEFwithoutAF,apriorthromboembolicevent,oracardioembolicsource.StatinsarenotbeneficialasadjunctivetherapywhenprescribedsolelyforthediagnosisofHFintheabsenceofotherindicationsfortheiruse.Omega-3polyunsaturatedfattyacid(PUFA)supplementationisreasonabletouseasadjunctivetherapyinpatientswithNYHAclassII-IVsymptomsandHFrEForHFpEF,unlesscontraindicated,toreducemortalityandcardiovascularhospitalizations.IIIaIIbIIIBNoBenefitIIIaIIbIIIANoBenefitIIIaIIbIIIBPharmacologicalTreatmentfor62PharmacologicalTreatmentfor

StageCHFrEF(cont.)NutritionalsupplementsastreatmentforHFarenotrecommendedinpatientswithcurrentorpriorsymptomsofHFrEF.HormonaltherapiesotherthantocorrectdeficienciesarenotrecommendedforpatientswithcurrentorpriorsymptomsofHFrEF.DrugsknowntoadverselyaffecttheclinicalstatusofpatientswithcurrentorpriorsymptomsofHFrEFarepotentiallyharmfulandshouldbeavoidedorwithdrawnwheneverpossible(e.g.,mostantiarrhythmicdrugs,mostcalciumchannelblockingdrugs(exceptamlodipine),NSAIDs,orTZDs).NoBenefitIIIaIIbIIIBIIIaIIbIIIIIIaIIbIIIBNoBenefitHarmPharmacologicalTreatmentfor63PharmacologicalTreatmentfor

StageCHFrEF(cont.)Long-termuseofinfusedpositiveinotropicdrugsispotentiallyharmful

forpatientswithHFrEF,exceptaspalliationforpatientswithend-stagediseasewhocannotbestabilizedwithstandardmedicaltreatment(seerecommendationsforstageD).CalciumchannelblockingdrugsarenotrecommendedasroutinetreatmentforpatientswithHFrEF.HarmIIIaIIbIIIIIIaIIbIIIANoBenefitPharmacologicalTreatmentfor64PharmacologicalTreatmentfor

StageCHFpEFSystolicanddiastolicbloodpressureshouldbecontrolledinpatientswithHFpEFinaccordancewithpublishedclinicalpracticeguidelinestopreventmorbidity.DiureticsshouldbeusedforreliefofsymptomsduetovolumeoverloadinpatientswithHFpEF.CoronaryrevascularizationisreasonableinpatientswithCADinwhomsymptoms(angina)ordemonstrablemyocardialischemiaisjudgedtobehavinganadverseeffectonsymptomaticHFpEFdespiteGDMT.IIIaIIbIIIBIIIaIIbIIIIIIaIIbIIIPharmacologicalTreatmentfor65PharmacologicalTreatmentfor

StageCHFpEF(cont.)ManagementofAFaccordingtopublishedclinicalpracticeguidelinesinpatientswithHFpEFisreasonabletoimprovesymptomaticHF.Theuseofbeta-blockingagents,ACEinhibitors,andARBsinpatientswithhypertensionisreasonabletocontrolbloodpressureinpatientswithHFpEF.IIIaIIbIIIIIIaIIbIIIPharmacologicalTreatmentfor66PharmacologicalTreatmentfor

StageCHFpEF(cont.)TheuseofARBsmightbeconsideredtodecreasehospitalizationsforpatientswithHFpEF.RoutineuseofnutritionalsupplementsisnotrecommendedforpatientswithHFpEF.IIIaIIbIIINoBenefitIIIaIIbIIIBPharmacologicalTreatmentfor67PharmacologicalTherapyforManagementofStageCHFrEFPharmacologicalTherapyforMa68PharmacologicalTherapyforManagementofStageCHFrEF(cont.)PharmacologicalTherapyforMa69PharmacologicTherapyforManagementofStageCHFrEF(cont.)PharmacologicTherapyforMana70PharmacologicalTherapyforManagementofStageCHFrEF(cont.)PharmacologicalTherapyforMa71MedicalTherapyforStageCHFrEF:MagnitudeofBenefitDemonstratedinRCTsMedicalTherapyforStageCHF72TreatmentforStageCHFpEFTreatmentofStagesAtoDTreatmentforStageCHFpEFTre73TreatmentofHFpEFTreatmentofHFpEF74DeviceTreatmentforStageCHFrEFTreatmentofStagesAtoDDeviceTreatmentforStageCH75DeviceTherapyforStageCHFrEFICDtherapyisrecommendedforprimarypreventionofSCDtoreducetotalmortalityinselectedpatientswithnonischemicDCMorischemicheartdiseaseatleast40dayspost-MIwithLVEFof35%orless,andNYHAclassIIorIIIsymptomsonchronicGDMT,whohavereasonableexpectationofmeaningfulsurvivalformorethan1year.CRTisindicatedforpatientswhohaveLVEFof35%orless,sinusrhythm,leftbundle-branchblock(LBBB)withaQRSdurationof150msorgreater,andNYHAclassII,III,orambulatoryIVsymptomsonGDMT.IIIaIIbIIIAIIIaIIbIIIANYHAClassIII/IVIIIaIIbIIIBNYHAClassIIDeviceTherapyforStageCHFr76DeviceTherapyforStageCHFrEF(cont.)ICDtherapyisrecommendedforprimarypreventionofSCDtoreducetotalmortalityinselectedpatientsatleast40dayspost-MIwithLVEFlessthanorequalto30%,andNYHAclassIsymptomswhilereceivingGDMT,whohavereasonableexpectationofmeaningfulsurvivalformorethan1year.CRTcanbeusefulforpatientswhohaveLVEFof35%orless,sinusrhythm,anon-LBBBpatternwithaQRSdurationof150msorgreater,andNYHAclassIII/ambulatoryclassIVsymptomsonGDMT.IIIaIIbIIIBIIIaIIbIIIADeviceTherapyforStageCHFr77DeviceTherapyforStageCHFrEF(cont.)CRTcanbeusefulforpatientswhohaveLVEFof35%orless,sinusrhythm,LBBBwithaQRSdurationof120to149ms,andNYHAclassII,III,orambulatoryIVsymptomsonGDMT.CRTcanbeusefulinpatientswithAFandLVEFof35%orlessonGDMTifa)thepatientrequiresventricularpacingorotherwisemeetsCRTcriteriaandb)atrioventricularnodalablationorpharmacologicalratecontrolwillallownear100%ventri