Key result
2022 ACC/AHA/HFSA guidelines classify HF by EF and cement SGLT2i and ARNI as foundational therapies.
Why the study?
The 2022 ACC/AHA/HFSA guidelines update previous heart failure management recommendations by incorporating recent studies and providing novel patient-centric, evidence-based guidance across the HF spectrum.
The updated 2022 ACC/AHA/HFSA guidelines introduce a new 4-tier LVEF-based classification for heart failure and elevate SGLT2 inhibitors to foundational therapy across multiple HF stages.
May inform updated HF classification and therapy selection; leaves open real-world implementation studies.
The new 2022 guidelines on the management of heart failure (HF) have been recently published1 replacing those from 2013 and 2017. These guidelines reflect a collaboration between the American Heart Association (AHA), the American College of Cardiology (ACC), and the Heart Failure Society of America (HFSA), incorporating many recent studies, providing updated definitions and novel patient-centric and evidence-based recommendations on the management of HF. The new HF classification based on left ventricular ejection fraction (EF) identifies four classes of HF, namely HF with reduced EF (HFrEF), HF with improved EF (HFimpEF), HF with mildly reduced EF (HFmrEF), and HF with preserved EF (HFpEF), as shown in Figure 1. Importantly, the evidence of spontaneous or provokable increased left ventricular filling pressures is needed to confirm a diagnosis of HFmrEF and HFpEF. New HF classification. HFimpEF: HF with improved EF; HFmrEF: HF with mildly reduced EF; HFpEF: HF with preserved EF; LV: left ventricle; LVEF: left ventricular ejection fraction. *Evidence of spontaneous or provokable increased LV filling pressures includes elevated natriuretic peptide (BNP ≥35 pg/mL, NT-proBNP ≥125 pg/mL; higher cutoff values are recommended for the diagnosis of HF in older patients or patients with atrial fibrillation or chronic kidney disease), invasive haemodynamic parameters and/or non-invasive measurements including LV wall thickness ≥12 mm, left atrial volume index (LAVI) ≥29 mL/m2, left ventricular mass index (LVMI) >116/95 g/m2, relative wall thickness (RWT) >0.42, GLS, global longitudinal strain (GLS) <16%, average E/e' ≥15, Septal e' <7 cm/s, Lateral e' <10 cm/s, tricuspid regurgitation velocity >2.8 m/s, estimated pulmonary artery systolic pressure >35 mm Hg. According to the AHA, the 2021 prevalence of HF in the USA is ∼6 million, which is ∼1.8% of the total US population. HF is far more prevalent in older age groups, projected to increase through year 2030 when the prevalence of HF among persons aged 65 to 70 years old could reach 8.5%. The new guidelines emphasize an increasing incidence of HFpEF and a declining incidence of HFrEF. Intriguingly, a large proportion of US adults would be considered in Stage A HF, which applies to people at risk for HF who have not yet shown signs of structural heart disease or heart muscle injury, thereby including the >120 million people with hypertension, 100 million with obesity, and 28 million with diabetes. The new foundational standard for guideline-directed medical therapy is formed by angiotensin receptor neprilysin inhibitors (ARNI), β-blockers, mineralocorticoid receptor antagonists (MRA), and sodium glucose cotransporter-2 (SGLT2) inhibitors. ARNI are recommended (Class 1A) as the preferred renin–angiotensin modulator in HFrEF; SGLT2 inhibitors are recommended as Class 1A in HFrEF and Class 2A in HFmrEF and HFpEF (where ARNI and MRA have weaker recommendations, Class 2B). These recommendations are mainly based on the benefits of SGLT2 inhibitors in the DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure)2, the EMPEROR-HF (Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Preserved Ejection Fraction)3, and the EMPEROR-PRESERVED (Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Preserved Ejection Fraction)4 trials, independent of the glucose-lowering effects and irrespective of the diabetes status. Of note, we have also demonstrated5 that SGLT2-inhibition improves cognitive impairment in patients with diabetes and HFpEF. The Santulli's Research Laboratory is supported in part by the National Institutes of Health (NIH): National Heart, Lung, and Blood Institute (NHLBI: R01-HL159062, R01-HL146691, T32-HL144456), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK: R01-DK123259, R01-DK033823), to G.S., by the Diabetes Action Research and Education Foundation (to G.S.), and by the Monique Weill-Caulier and Irma T. Hirschl Trusts (to G.S.). Conflict of interest: none declared.
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Santulli et al. (2022) conducted a review in Heart failure. 2022 ACC/AHA/HFSA guidelines on heart failure was evaluated. The 2022 ACC/AHA/HFSA guidelines introduce a new heart failure classification based on ejection fraction and establish SGLT2 inhibitors and ARNIs as foundational medical therapies.
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