Board-level quick read · Cardiology
Heart Failure
AHA/ACC/HFSA 2022 (JACC; DOI 10.1016/j.jacc.2021.12.012) · reviewed 2026-07-20
Personal study digest, pitched for IM boards / a rising subspecialty fellow. Recommendations (COR/LOE) are the 2022 guideline’s. The “What’s changed since 2022” section is reviewer synthesis of newer evidence, each claim cited — not guideline text. Not a substitute for the full document.
In one line
Classify HF by ejection fraction because EF dictates therapy. HFrEF earns four Class-1 pillars (ARNi/ACEi/ARB + evidence-based beta blocker + MRA + SGLT2i). The 2022 headline: SGLT2i are now core, and — per evidence since — they benefit patients across the entire EF spectrum.
Stage & classify (this drives everything)
Stages (A→D are one-directional):
- A — At risk: HTN, diabetes, ASCVD, obesity, cardiotoxin/genetic exposure. No structural disease, no symptoms.
- B — Pre-HF: structural disease, reduced EF/strain, chamber enlargement, OR elevated filling pressures / persistently ↑ natriuretic peptide or troponin — but no symptoms.
- C — Symptomatic: structural disease with current or prior HF symptoms. (Once C, always C — even if symptoms resolve.)
- D — Advanced: refractory symptoms despite optimized GDMT; recurrent hospitalizations.
EF classes:
| Class | LVEF | Caveat |
|---|---|---|
| HFrEF | ≤ 40% | The trial-proven target for mortality benefit. |
| HFmrEF | 41–49% | ALSO needs evidence of raised filling pressures (↑ NP or hemodynamics). |
| HFpEF | ≥ 50% | Same filling-pressure requirement; ≥50% of all HF and rising. |
| HFimpEF | prior ≤40%, now >40% | A subgroup of HFrEF — continue the HFrEF regimen. |
HFrEF: the four pillars (all Class 1) + doses
Start all four early; each independently cuts mortality. Together they are estimated to lower all-cause mortality ~73% vs none.
| Pillar | Agent · start → target | COR / key rule |
|---|---|---|
| ARNi (preferred RAS inhibitor) | Sacubitril-valsartan 49/51 mg BID (or 24/26) → 97/103 mg BID | 1 (A) NYHA II–III. Switch ACEi/ARB→ARNi (COR 1). No ARNi within 36 h of an ACEi; never with prior angioedema. |
| ACEi / ARB (if ARNi not feasible) | e.g. lisinopril → 20–40 mg; valsartan → 160 mg BID | 1 (A) ARB if ACEi cough/angioedema. |
| Beta blocker (only 3 proven) | Carvedilol 3.125 BID→25–50 BID · metoprolol succinate 12.5–25→200 · bisoprolol 1.25→10 | 1 (A) Class effect NOT assumed — use one of these three. |
| MRA | Spironolactone 12.5–25→25–50 · eplerenone 25→50 | 1 (A) Start only if eGFR >30 & K⁺ <5.0. Stop if K⁺ can’t stay <5.5. |
| SGLT2i | Dapagliflozin 10 mg · empagliflozin 10 mg | 1 (A) Benefit irrespective of diabetes. |
Add-ons by scenario
- Loop diuretic for congestion (Class 1); add thiazide/metolazone only for diuretic resistance.
- Hydralazine + isosorbide dinitrate — self-identified African-American, NYHA III–IV on optimal GDMT (Class 1, A).
- Ivabradine — LVEF ≤35%, NYHA II–III, sinus rhythm HR ≥70 on max-tolerated beta blocker (2a).
- Vericiguat — high-risk, recently worsening HFrEF on GDMT (2b; VICTORIA).
- Digoxin — symptom/hospitalization reduction only; target level 0.5–<0.9 ng/mL.
Devices (get the EF and QRS right)
- ICD, primary prevention (Class 1): LVEF ≤35%, NYHA II–III, on chronic GDMT — nonischemic DCM OR ischemic ≥40 days post-MI; expected survival >1 yr. Also LVEF ≤30%, NYHA I, ≥40 days post-MI (Class 1).
- CRT, strongest indication (Class 1): LVEF ≤35% + sinus rhythm + LBBB + QRS ≥150 ms + NYHA II–ambulatory IV on GDMT. Non-LBBB or QRS 120–149 ms → weaker. QRS <120 ms → not recommended.
HFmrEF, HFpEF & HFimpEF
- HFmrEF (41–49%): SGLT2i 2a; beta blocker, ARNi/ACEi/ARB, MRA all 2b — favor them at the lower end of the range.
- HFpEF (≥50%): control BP (Class 1) and manage AF (2a). SGLT2i 2a. MRA / ARB / ARNi 2b (lower-EF end). Nitrates and PDE5i give no benefit (Class 3).
- HFimpEF: continue GDMT even if EF normalizes and symptoms resolve (Class 1) — withdrawal relapses HF (TRED-HF).
Decisions a fellow owns
- Get all four HFrEF pillars started, then up-titrate — don’t withhold one drug to maximize another. (See STRONG-HF below.)
- Check K⁺ and renal function ~1 wk, 4 wk, then periodically after starting/intensifying an MRA.
- Enforce the 36-hour ACEi↔ARNi washout; screen for angioedema history before either.
- Refer Stage D (refractory symptoms, recurrent admissions, escalating diuretics, low output) to advanced-HF/transplant early.
What’s changed since 2022
Reviewer synthesis of evidence published after the guideline — each claim cited. The 2022 AHA/ACC/HFSA document remains the current U.S. guideline (no full replacement as of 2026).
- SGLT2i went from “2a” to the anchor drug across the whole EF spectrum. DELIVER (dapagliflozin, LVEF >40%, n=6263): worsening-HF/CV-death HR 0.82 (95% CI 0.73–0.92) NEJM 2022; 10.1056/NEJMoa2206286. Confirming EMPEROR-Preserved, the 2023 ESC focused update upgraded dapa/empagliflozin to Class I in HFpEF — stronger than the 2022 ACC/AHA 2a. escardio.org 2023 focused update
- Finerenone — a new nonsteroidal MRA for HFmrEF/HFpEF. FINEARTS-HF (LVEF ≥40%, n=6001): CV death + total worsening-HF events, rate ratio 0.84 (0.74–0.95) NEJM 2024; 10.1056/NEJMoa2407107. The 2022 guideline lists only steroidal MRAs (spironolactone/eplerenone, 2b in HFpEF).
- Incretins now treat the obesity-HFpEF phenotype. STEP-HFpEF (semaglutide 2.4 mg): KCCQ +7.8 vs placebo, weight −10.7 pp NEJM 2023; 10.1056/NEJMoa2306963. SUMMIT (tirzepatide, EF ≥50% + BMI ≥30): CV death/worsening-HF HR 0.62 (0.41–0.95) NEJM 2024; 10.1056/NEJMoa2410027. The 2022 guideline has no incretin recommendation.
- “Start low, go slow” is out for post-discharge titration. STRONG-HF: rapid up-titration to full-dose GDMT within ~2 weeks + close follow-up cut 180-day death/HF readmission, RR 0.66 (0.50–0.86); stopped early Lancet 2022; 10.1016/S0140-6736(22)02076-1.
- Still current: the four-pillar HFrEF regimen is unchanged and strongly reaffirmed. Open: IV iron for HFrEF + iron deficiency helps symptoms/function (2a) but a hard-outcome benefit remains debated after mixed RCTs.
Recency-sensitive — confirm before quoting as current
- Finerenone (Kerendia) FDA-approved for HF with LVEF ≥40% on 14 Jul 2025 (post my training cutoff; web-verified). Bayer / HFSA press, 2025
- Sotagliflozin (INPEFA) FDA-approved 26 May 2023 for HF across the full EF spectrum — the 2022 text said it was “not FDA-approved as of 2021.” ACC / FDA, 2023
Anki cards minted this run (4)
- LVEF classification cutoffs — HFrEF ≤40 / HFmrEF 41–49 / HFpEF ≥50 / HFimpEF prior ≤40, now >40.
- Normalized EF after HFrEF → continue GDMT (HFimpEF; TRED-HF relapse ~40%).
- STRONG-HF — rapid up-titration post-acute HF cut 180-day death/readmission (RR 0.66).
- STEP-HFpEF — semaglutide improved symptoms/weight in obesity-HFpEF.
Held (already in deck): finerenone/FINEARTS-HF, tirzepatide/SUMMIT, EMPEROR-Preserved, SGLT2i-Class-I-in-HFpEF, the four-pillar mortality list, and ICD primary-prevention — deduped, not re-carded.
Sources: 2022 AHA/ACC/HFSA HF Guideline (JACC; DOI 10.1016/j.jacc.2021.12.012) — local verbatim capture · DELIVER (NEJM 2022; 10.1056/NEJMoa2206286) · FINEARTS-HF (NEJM 2024; 10.1056/NEJMoa2407107) · STEP-HFpEF (NEJM 2023; 10.1056/NEJMoa2306963) · SUMMIT (NEJM 2024; 10.1056/NEJMoa2410027) · STRONG-HF (Lancet 2022; 10.1016/S0140-6736(22)02076-1) · TRED-HF (Lancet 2019; PMID 30429050) · 2023 ESC HF focused update (escardio.org) · FDA approvals: finerenone (Jul 2025), sotagliflozin (May 2023).