Heart Failure Guidelines: 2022 Update

Thank you to Kathleen H. Byrne, MSN, CRNP, CCRN for this article on the 2022 Heart Failure Guidelines.

The American Heart Association (AHA), American College of Cardiology (ACC), and Heart Failure Society of America (HFSA) released the updated guideline for heart failure on April 1, 2022.[i] The 2022 Heart Failure Guidelines update included a number of changes that impact the care provided by nurses and other healthcare professionals who diagnose and manage patients with heart failure. Highlights of the latest guidelines-directed medical therapies are reviewed below.

For a quick pocket or online reference on these new guidelines, check out PCNA’s resource Heart Failure: A Guide to Prevention and Management, available digitally or to order.

Heart Failure Incidence

No matter your work setting, chances are a significant number of patients are either presenting with—or are at risk for—heart failure. Of all Americans ages 40 and older, one in five will develop heart failure in their lifetime. Today, more than 6 million Americans live with heart failure, and the number is expected to rise to an unprecedented 8 million individuals by 2030.

There are racial and ethnic disparities in heart failure morbidity and mortality; non-Hispanic Black patients have the highest death rate per capita. These disparities warrant further studies and health policy changes, and it is incumbent on each healthcare professional to be cognizant of the challenges these populations face.

Categories of Heart Failure

Heart failure comprises a broad range of left ventricular function. To describe the entire gamut of heart failure, the updated guideline expands to four categories:

  • HFrEF (heart failure with reduced ejection fraction)
    • Individuals with left ventricular ejection fraction (LVEF) ≤40%
  • HFimpEF (heart failure with improved ejection fraction)
    • Those with a previous LVEF ≤40% and follow-up measurement of LVEF >40%
  • HFmrEF (heart failure with mildly reduced ejection fraction)
    • Patients with LVEF of 41-49%
  • HFpEF (heart failure with preserved ejection fraction)
    • Those that have an LVEF ≥50%

Heart Failure Guideline-Directed Medical Therapy

All patients with heart failure, either current or prior, and irrespective of ejection fraction, should be considered for guideline-directed medical therapy (GDMT). The current GDMT now includes 4 classes—often referred to as the 4 pillars of care—of medical therapy.

  1. Beta-blockers
  2. Renin-angiotensin system inhibition (RASi) with angiotensin receptor-neprilysin inhibitors (ARNi), angiotensin-converting enzyme inhibitors (ACEi), or angiotensin receptor blocks (ARB)
  3. Mineralocorticoid receptor antagonists (MRA)
  4. Sodium-glucose cotransporter-2 inhibitors (SGLT2i)

ARNis are now recommended as the first-line renin-angiotensin system inhibitors (RASis) to reduce morbidity and mortality in HFrEF (Class 1a recommendation). An ACEi is recommended when ARNi is not feasible, and an ARB in those who are ACEi intolerant and when ARNi is not feasible. In symptomatic patients with HFrEF who are able to tolerate an ACEi or ARB, changing to an ARNi is recommended for further reduction in morbidity and mortality.

SGLT2is were initially approved in 2014 for the management of type 2 diabetes (T2D). However, approval has now been extended to patients with heart failure to improve cardiovascular outcomes. According to the updated guideline, those with symptomatic chronic HFrEF—regardless of the presence of T2D—should receive an SGLT2i as a Class 1a recommendation. In addition, patients with HFmrEF have a type 2a recommendation, and those who have HFpEF have a type 2b recommendation. 

Heart Failure Clinical Trials

These new recommendations are a result of the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF),[ii] Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Preserved Ejection Fraction (EMPEROR-Preserved),[iii] and Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure (EMPEROR-Reduced)[iv] trials.

The DAPA-HF trial had 4,744 participants with NYHA class II-IV heart failure with an ejection fraction of 40% or less. Of the total participants, 2373 received dapagliflozin and 2,371 received placebo once daily in a double-blinded fashion. Worsening heart failure or death from cardiovascular causes occurred in 502 participants in the placebo group, compared to 386 in the dapagliflozin group (95% CI:0.65-0.85, p<0.001).

The EMPEROR-Preserved trial enrolled 5,988 participants with NYHA class II-IV heart failure with an ejection fraction of >40%, in order to receive empagliflozin or placebo. Of the 2,991 who received placebo, 511 experienced death from a cardiovascular cause or hospitalization from heart failure, and of the 2,997 who received empagliflozin, 415 also experienced this primary composite outcome (05% CI:0.69-0.90, p<0.001).

Both trials demonstrated the cardiovascular benefits of SGLT2is in heart failure, regardless of diabetes as a comorbidity.

In the TRED-HF [v] study, a small, randomized trial of patients with HFimpEF demonstrated a 44% rate of relapse of dilated cardiomyopathy within 6 months of discontinuation of guideline-directed medical therapy. Thus, it is recommended that guideline-directed medical therapy be continued in patients with HFimpEF, including those who are asymptomatic, in order to prevent relapse of heart failure and left ventricular dysfunction.

A Final Note

Heart failure is a progressive disease, and this is highlighted by the ACC/AHA stages of heart failure A-D. The updated 2022 Heart Failure Guidelines include the terms, “at-risk” and “pre-heart failure.” For heart failure prevention in these individuals, lifestyle modification, screening, and management of risk factors and comorbid conditions are recommended.

[i] Heidenreich PA, Bozkurt B, Aguilar D, et al. 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. Circ. 2022;145:e895-e1032. https://doi.org/10.1161/CIR.0000000000001063

[ii] McMurray JJV, Solomon SD, Inzucchi SE, et al. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. NEJM. 2019;381:1995-2008. nejm.org/doi/full/10.1056/NEJMoa1911303

[iii] Wagdy K, Nagy S. EMPEROR-Preserved: SGLT2 inhibitors breakthrough in the management of heart failure with preserved ejection fraction. Glob Cardiol Sci Pract. 2021 Oct 30; 2021(3): e202117. doi: 10.21542/gcsp.2021.17.

[iv] Packer M, Anker SD, Butler J, et al. Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure. NEJM. 2020;383:1413-1424. doi: 10.1056/NEJMoa2022190

[v] Halliday BP, Wassall R, Lota AS, et al. Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy (TRED-HF): an open-label, pilot, randomised trial. Lancet. 2019;393(10166):61-73. doi: 10.1016/S0140-6736(18)32484-X.

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