Ejection fraction normal range american heart association

Abstract

ACC/AHA Joint Committee Members

Joshua A. Beckman, MD, MS, FAHA, FACC, Chair

Patrick T. O’Gara, MD, MACC, FAHA, Immediate Past Chair¶

Sana M. Al-Khatib, MD, MHS, FACC, FAHA¶

Anastasia L. Armbruster, PharmD, FACC

Kim K. Birtcher, PharmD, MS, AACC¶

Joaquin E. Cigarroa, MD, FACC¶

Lisa de las Fuentes, MD, MS, FAHA

Anita Deswal, MD, MPH, FACC, FAHA

Dave L. Dixon, PharmD, FACC¶

Lee A. Fleisher, MD, FACC, FAHA¶

Federico Gentile, MD, FACC¶

Zachary D. Goldberger, MD, FACC, FAHA¶

Bulent Gorenek, MD, FACC

Norrisa Haynes, MD, MPH

Adrian F. Hernandez, MD, MHS

Mark A. Hlatky, MD, FACC, FAHA¶

José A. Joglar, MD, FACC, FAHA

W. Schuyler Jones, MD, FACC

Joseph E. Marine, MD, FACC¶

Daniel B. Mark, MD, MPH, FACC, FAHA

Debabrata Mukherjee, MD, FACC, FAHA

Latha P. Palaniappan, MD, MS, FACC, FAHA

Mariann R. Piano, RN, PhD, FAHA

Tanveer Rab, MD, FACC

Erica S. Spatz, MD, MS, FACC

Jacqueline E. Tamis-Holland, MD, FAHA, FACC

Duminda N. Wijeysundera, MD, PhD¶

Y. Joseph Woo, MD, FACC, FAHA

Former Joint Committee member; current member during the writing effort.

Top 10 Take-Home Messages

Purpose of the Executive Summary

The purpose of the “2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure” (2022 HF guideline) is to provide an update and to consolidate the “2013 ACCF/AHA Guideline for the Management of Heart Failure” (1) for adults and the “2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure” (2) into a new document. Related ACC/AHA guidelines include recommendations relevant to HF and, in such cases, the HF guideline refers to these documents. For example, the 2019 primary prevention of cardiovascular disease guideline (3) includes recommendations that will be useful in preventing HF, and the 2021 valvular heart disease guideline (4) provides recommendations for mitral valve (MV) clipping in mitral regurgitation (MR).

Areas of focus include:

The intended primary target audience consists of clinicians who are involved in the care of patients with HF. The focus of the full clinical practice guideline (5) is to provide the most up-to-date evidence to direct the clinician in patient decision-making. This executive summary provides readers with the Top 10 items that they should know about the 2022 HF guideline (5) and incorporates material from the full guideline along with each statement.

Document Review and Approval

The full clinical practice guideline was reviewed by 2 official reviewers nominated by the AHA; 1 official reviewer nominated by the ACC; 2 official reviewers from the Heart Failure Society of America; 1 official Joint Committee on Clinical Practice Guidelines reviewer; and 32 individual content reviewers. Authors’ relationships with industry and other entities information is published in Appendix 1 of the full guideline (5). Reviewers’ relationships with industry and other entities information is published in Appendix 2 of the full guideline (5).

Class of Recommendation and Level of Evidence

The Class of Recommendation (COR) indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1) (6).

Table 1 Applying American College of Cardiology/American Heart Association Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)∗

Table 1 Applying American College of Cardiology/American Heart Association Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)∗

Take-Home Message No. 1

Guideline-directed medical therapy (GDMT) for HF with reduced ejection fraction (HFrEF) now includes 4 medication classes that include SGLT2i. The 4 groups are: 1) renin-angiotensin system inhibition with angiotensin receptor-neprilysin inhibitors (ARNi), angiotensin-converting enzyme inhibitors (ACEi), or angiotensin (II) receptor blockers (ARB) alone; 2) beta blockers; 3) mineralocorticoid receptor antagonists (MRAs); and 4) the new group, SGLT2i (Figure 1).

Figure 1

Treatment of HFrEF Stages C and D

Colors correspond to COR in Table 1. Treatment recommendations for patients with HFrEF are displayed. Step 1 medications may be started simultaneously at initial (low) doses recommended for HFrEF. Alternatively, these medications may be started sequentially, with sequence guided by clinical or other factors, without need to achieve target dosing before initiating next medication. Medication doses should be increased to target as tolerated. ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; COR, Class of Recommendation; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; HF, heart failure; HFimpEF, heart failure with improved ejection fraction; HFrEF, heart failure with reduced ejection fraction; hydral-nitrates, hydralazine and isosorbide dinitrate; ICD, implantable cardioverter-defibrillator; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; MCS, mechanical circulatory support; MRA, mineralocorticoid receptor antagonist; NSR, normal sinus rhythm; NYHA, New York Heart Association; and SGLT2i, sodium-glucose cotransporter 2 inhibitor. ∗Participation in investigational studies is appropriate for stage C, NYHA class II and III HF.

Recommendations for Renin-Angiotensin System Inhibition With ACEi or ARB or ARNi

Referenced studies that support the recommendations are summarized in the Online Data Supplements.

Recommendation for Beta Blockers

Referenced studies that support the recommendation are summarized in the Online Data Supplements.

Recommendation for MRAs

Referenced studies that support the recommendation are summarized in the Online Data Supplements.

Recommendation for SGLT2i

Referenced studies that support the recommendation are summarized in the Online Data Supplements.

Take-Home Message No. 2

Mildly reduced LVEF has new medication recommendations, including use of SGLT2i (Figure 2). SGLT2i have a COR 2a in HF with mildly reduced EF (HFmrEF). Weaker recommendations (COR 2b) are made for ARNi, ACEi, ARB, MRA and beta blockers in this population.

Figure 2

Recommendations for Patients With Mildly Reduced LVEF (41%–49%)

Colors correspond to COR in Table 1. Medication recommendations for HFmrEF are displayed. ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HRmrEF, heart failure with mildly reduced ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; and SGLT2i, sodium- glucose cotransporter 2 inhibitor.

Recommendations for HFmrEF

Referenced studies that support the recommendations are summarized in the Online Data Supplements.

Take-Home Message No. 3

Preserved LVEF has new medication recommendations, including use of SGLT2i (Figure 3). New recommendations for HF with preserved EF (HFpEF) are made for SGLT2i (COR 2a), MRAs (COR 2b), and ARNi (COR 2b). Several previous recommendations have been renewed, including treatment of hypertension (COR 1), treatment of AF (COR 2a), use of ARB (COR 2b), and avoidance of routine use of nitrates or phosphodiesterase-5 inhibitors (COR 3: No Benefit).

Figure 3

Recommendations for Patients With Preserved LVEF (≥50%)

Colors correspond to COR in Table 1. Medication recommendations for HFpEF are displayed. ARB indicates angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; and SGLT2i, sodium-glucose cotransporter-2 inhibitor. ∗Greater benefit in patients with LVEF closer to 50%.

New Recommendations for HFpEF

Referenced studies that support the recommendations are summarized in the Online Data Supplements.

Renewed Recommendations for HFpEF

Referenced studies that support the recommendations are summarized in the Online Data Supplements.

Take-Home Message No. 4

Improved LVEF is used to refer to those with previous HFrEF who now have an LVEF >40% (Figure 4). These patients should continue their HFrEF treatment.

Figure 4

Classification and Trajectories of HF Based on LVEF

See Appendix 1 for suggested thresholds for laboratory findings. The classification for baseline and subsequent LVEF is shown. Patients with HFrEF who improve their LVEF to >40% are considered to have HFimpEF and should continue HFrEF treatment. HF indicates heart failure; HFimpEF, heart failure with improved ejection fraction; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; and LVEF, left ventricular ejection fraction. ∗There is limited evidence to guide therapy for patients who improve their LVEF from mildly reduced (41%–49%) to ≥50%. It is unclear whether to treat these patients as HFpEF or HFmrEF.

Recommendation for HF With Improved EF (HFimpEF)

Referenced studies that support the recommendation are summarized in the Online Data Supplements.

Take-Home Message No. 5

Value statements have been created for many treatments. In accordance with ACC/AHA methodology (51), value statements were created for select recommendations where high-quality, cost-effectiveness studies of the intervention have been published. High value is defined as <$60,000/quality-adjusted life year gained (<1 U.S. GDP/capita/QALY). Low value is defined as >$180,000/quality-adjusted life year gained (>3 U.S. GDP/capita/QALY). High-value therapies include ARNi, ACEi, ARB, beta blocker, MRA, implantable cardioverter-defibrillator, and cardiac resynchronization therapy. Intermediate-value therapies include SGLT2i and cardiac transplantation. The only therapy identified as low value was tafamidis for cardiac amyloidosis. The value of mechanical circulatory support and pulmonary pressure monitoring was considered uncertain.

Take-Home Message No. 6

Amyloid heart disease has new recommendations for treatment. Specific strategies for diagnosis and treatment of cardiac amyloidosis are recommended (Figure 5). In patients with a clinical suspicion for cardiac amyloidosis, screening for serum and urine monoclonal light chains with serum and urine immunofixation electrophoresis and serum free light chains are recommended. If there is no evidence of serum or urine monoclonal light chains, bone scintigraphy is recommended to confirm the presence of transthyretin cardiac amyloidosis. If transthyretin cardiac amyloidosis is identified, genetic sequencing of the TTR gene is recommended to differentiate hereditary variant from wild-type transthyretin cardiac amyloidosis because confirmation of a hereditary variant would trigger genetic counseling and potential screening of family members. Transthyretin tetramer stabilizer therapy (tafamidis) is recommended in select patients with wild-type or variant transthyretin cardiac amyloidosis. Anticoagulation is a reasonable treatment strategy to reduce the risk of stroke in patients with cardiac amyloidosis and AF.

Figure 5

Diagnostic and Treatment of Transthyretin Cardiac Amyloidosis Algorithm

Colors correspond to COR in Table 1. AF indicates atrial fibrillation; AL-CM, amyloid cardiomyopathy; ATTR-CM, transthyretin amyloid cardiomyopathy; ATTRv, variant transthyretin amyloidosis; ATTRwt, wild-type transthyretin amyloidosis; CHA2DS2-VASc, congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category; ECG, electrocardiogram; H/CL, heart to contralateral chest; HFrEF, heart failure with reduced ejection fraction; IFE, immunofixation electrophoresis; MRI, magnetic resonance imaging; NYHA, New York Heart Association; PYP, pyrophosphate; Tc, technetium; and TTR, transthyretin.

Recommendations for Diagnosis of Cardiac Amyloidosis

Referenced studies that support the recommendations are summarized in the Online Data Supplements.

Recommendations for Treatment of Cardiac Amyloidosis

Referenced studies that support the recommendations are summarized in the Online Data Supplements.

Take-Home Message No. 7

Evidence supporting increased filling pressures is important for the diagnosis of HF if the LVEF is >40% (Table 2). The signs and symptoms of HF are nonspecific and thus a diagnosis of HF requires supporting evidence. Increased cardiac filling pressure is a feature of HF, and this is assumed for patients with an LVEF ≤40%. However, if the LVEF is 41% to 49% (mildly reduced) or ≥50% (preserved), evidence of spontaneous or provokable increased LV filling pressures is needed to confirm a diagnosis of HF. Evidence for increased filling pressures can be obtained from noninvasive (e.g., natriuretic peptide, diastolic function on imaging) or invasive testing (e.g., hemodynamic measurement).

Table 2 Classification of HF by LVEF

Take-Home Message No. 8

Patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF. A HF specialty team, typically located at an advanced HF center, reviews HF management, assesses suitability for advanced HF therapies (e.g., left ventricular assist devices, cardiac transplantation), and uses palliative care including palliative inotropes where consistent with the patient’s goals of care.

Recommendation for Specialty Referral for Advanced HF

Take-Home Message No. 9

Primary prevention is important for those at risk for HF (stage A) or pre-HF (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 (Figure 6, Table 3). In the full guideline, primary prevention included all health care strategies that prevent the development of symptomatic HF (stage C). Healthy lifestyle habits, such as maintaining regular physical activity, maintaining normal weight, and a healthy diet, are recommended. Blood pressure should be controlled in accordance with published clinical practice guidelines. SGLT2i are recommended in patients with type 2 diabetes and either established cardiovascular disease or at high cardiovascular risk. Natriuretic peptide biomarker–based screening followed by team-based care, including a cardiovascular specialist, can be useful to prevent the development of left ventricular dysfunction (systolic or diastolic) or new-onset HF (pre-HF, stage B). Validated multivariable risk scores can also be useful to estimate subsequent risk of incident HF. In asymptomatic patients with LVEF ≤40% (pre-HF, stage B), ACEi, ARB, evidence-based beta blockers, statins, and implantable cardioverter-defibrillators are recommended in certain patients.

Figure 6

ACC/AHA Stages of HF

The ACC/AHA stages of HF are shown. ACC indicates American College of Cardiology; AHA, American Heart Association; CVD, cardiovascular disease; GDMT, guideline-directed medical therapy; and HF, heart failure.

Table 3 Stages of HF

Recommendations for Patients at Risk for HF (Stage A: Primary Prevention)

Referenced studies that support the recommendations are summarized in the Online Data Supplements.

Recommendations for Management of Stage B: Preventing the Syndrome of Clinical HF in Patients With Pre-HF

Referenced studies that support the recommendations are summarized in the Online Data Supplements.

Take-Home Message No. 10

Specific-treatment recommendations are provided for patients with HF and certain comorbidities (Figure 7). Recommendations are provided for select patients with HF and iron deficiency, anemia, hypertension, sleep disorders, type 2 diabetes, AF, coronary artery disease, and malignancy.

Figure 7

Recommendations for Treatment of Patients With HF and Selected Comorbidities

Colors correspond to COR in Table 1. Recommendations for treatment of patients with HF and select comorbidities are displayed. ∗Patients with chronic HF with permanent-persistent-paroxysmal AF and a CHA2DS2-VASc score of ≥2 (for men) and ≥3 (for women). ACEi indicates angiotensin-converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin receptor blocker; AV, atrioventricular; CHA2DS2-VASc, congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack [TIA], vascular disease, age 65 to 74 years, sex category; CPAP, continuous positive airway pressure; CRT, cardiac resynchronization therapy; EF, ejection fraction; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; SGLT2i, sodium-glucose cotransporter 2 inhibitor; and VHD, valvular heart disease.

Recommendations for the Management of Comorbidities in Patients With HF

Referenced studies that support the recommendations are summarized in the Online Data Supplements.

Recommendations for Management of AF in HF

Referenced studies that support the recommendations are summarized in the Online Data Supplements.

Recommendation for Revascularization for Coronary Artery Disease

Referenced studies that support the recommendation are summarized in the Online Data Supplements.

Recommendations for Cardio-Oncology

Referenced studies that support the recommendations are summarized in the Online Data Supplements.

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Appendix 1

Appendix for Tables 2 and 3: Suggested Thresholds for Structural Heart Disease and Evidence of Increased Filling Pressures

Footnotes

Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 of the full guideline for detailed information.

This document was approved by the American College of Cardiology Clinical Policy Approval Committee, the American Heart Association Science Advisory and Coordinating Committee, the American College of Cardiology Science and Quality Committee, and the Heart Failure Society of America Executive Committee in December 2021 and the American Heart Association Executive Committee in January 2022.

The American College of Cardiology requests that this document be cited as follows: 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: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022;79:1757-1780.

This article has been copublished in Circulation and the Journal of Cardiac Failure.

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