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ESC HEART FAILURE REVIEW
ESC Heart Failure (2022)
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/ehf2.14255

ACC/AHA/HFSA 2022 and ESC 2021 guidelines on

heart failure comparison
Amir Hossein Behnoush1 , Amirmohammad Khalaji1 , Nasim Naderi2, Haleh Ashraf2,3* and
Stephan von Haehling4,5
1
School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; 2Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran,
Iran; 3Cardiac Primary Prevention Research Center (CPPRC), Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; 4Department of
Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany; and 5German Center for Cardiovascular Research (DZHK), Partner Site Göttingen,
Göttingen, Germany

Abstract
The 2022 American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) and
the 2021 European Society of Cardiology (ESC) both provide evidence-based guides for the diagnosis and treatment of heart
failure (HF). In this review, we aimed to compare recommendations suggested by these guidelines highlighting the differences
and latest evidence mentioned in each of the guidelines. While the staging of HF depends on left ventricular ejection fraction,
the Universal Definition of HF, suggested in 2021, is described in 2022 ACC/AHA/HFSA guidelines. Both guidelines recommend
invasive and non-invasive tests to diagnose. Despite being identical in the backbone, some differences exist in medical therapy
and devices, which can be partially attributed to the recent trials published that are presented in the American guidelines. The
recommendation of implantable cardioverter defibrillator for prevention in HF with reduced ejection fraction (HFrEF) patients,
made by ACC/AHA/HFSA guidelines, is among the bold differences. It seems that ACC/AHA/HFSA guidelines emphasize the
quality of life, cost-effectiveness, and optimization of care given to patients. On the other hand, the ESC guidelines provide
recommendations for certain comorbidities. This comparison can guide clinicians in choosing the proper approach for their
own settings and the writing committees in addressing the differences in order to have better consistency in future guidelines.

Keywords Heart failure; American College of Cardiology; European Society of Cardiology; Guidelines
Received: 12 August 2022; Revised: 12 November 2022; Accepted: 21 November 2022
*Correspondence to: Haleh Ashraf, Cardiac Primary Prevention Research Center (CPPRC), Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences,
Tehran, Iran. Email: hashraf@sina.tums.ac.ir
Amir Hossein Behnoush and Amirmohammad Khalaji contributed equally as co-first authors.

Introduction factors for HF. Coronary artery disease (CAD), hypertension,

Heart failure (HF) is defined as any structural and/or func-
tional impairment of cardiac blood ejection resulting in a
complex clinical syndrome with typical symptoms and clinical
signs.1 The increasing age of the world population, in addition
to changes in lifestyle, has led to a higher incidence of cardio-
vascular diseases (CVDs) worldwide, and HF is not an excep-
tion. In the United States, HF incidence decreased from
35.7 per 1000 in 2011 to 26.5 per 1000 in 2016 among Medi-
care beneficiaries.2 The number of annual deaths from HF
also increased in the country by about 13% from 2009 to
2014.3 In Europe, the prevalence of HF was reported to be
1%–2%,4,5 while its incidence was about 5/1000 person-years
in adults.6,7 A large part of the world population has risk
valve diseases, and arrhythmias are common causes of
HF.1,8 Hypertension, obesity, atherosclerotic CVD,
prediabetes, and diabetes are also major risk factors with
high relative risk and high prevalence.1,9 In developing
countries, there may be some additional aetiologies for HF,
including valve disease and infective diseases (such as Chagas
disease, Lyme disease, and HIV-AIDS). Management of the
aforementioned risk factors can play a crucial role in
preventing and treating CVDs that lead to HF.
HF guidelines have been designed and used for several
years in the United States and in Europe, intended to provide
healthcare workers, especially physicians, with the newest lit-
erature regarding HF management and help them in decision
making via the most up-to-date evidence. The European Soci-

© 2022 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

2 A.H. Behnoush et al.
ety of Cardiology (ESC) guidelines published in 2021 and the
American College of Cardiology/American Heart
Association/Heart Failure Association of America (ACC/AHA/
HFSA) guidelines published in 2022 are the latest
evidence-based clinical guidelines for the management of pa-
tients with HF.1,8 In this report, we aimed to compare these
two guidelines and evaluate their consistencies and differ-
ences. The sections of interest for the present report em-
brace staging, evaluation and diagnosis, prevention, treat-
ment of HF with reduced ejection fraction (HFrEF),
treatment of HF with mildly reduced EF (HFmrEF), treatment
of HF with preserved EF (HFpEF), advanced HF, acute HF, co-
morbidities, and special populations.
Staging
ACC/AHA/HFSA guidelines suggest four stages of HF based on
the Universal Definition of HF.10 As this was suggested after
the release of the 2021 ESC guidelines, they lack this
universal definition. Stage A refers to patients ‘at risk for
HF’ without any symptoms, structural heart disease, or in-
creased cardiac biomarkers of stretch or injury who have
CVD risk factors such as hypertension, atherosclerosis, diabe-
tes, metabolic syndrome, or obesity. Stage B is considered
‘pre-HF’, which means that no symptoms or signs of HF are
available, but one of the followings is present: (1) structural
heart disease; (2) evidence for increased filling pressures;
(3) patients with risk factors and increased levels of B-type
natriuretic peptide (BNP) or persistently elevated cardiac tro-
ponin. Patients with structural heart disease with current or
previous symptoms of HF are known as ‘symptomatic HF’
and Stage C. ‘Advanced HF’ refers to patients with marked
HF symptoms with recurrent hospitalizations despite their
medical therapy, and their symptoms interfere with their
daily lives. These patients are categorized as stage D.
Left ventricular ejection fraction (LVEF) was classically used
to categorize patients diagnosed with HF. Based on both
guidelines, HF can be classified into HFrEF, HFmrEF, and
HFpEF. In the latest ACC/AHA/HFSA guidelines, HF with im-
Table 1 Heart failure classification criteria
Type of HF ACC/AHA/HFSA criteria
HFrEF LVEF ≤ 40%
HFimpEF Previous LVEF ≤ 40% and follow-up LVEF > 40%
HFmrEF LVEF 41%–49% and evidence of spontaneous or
provokable increased LV filling pressures
HFpEF LVEF ≥ 50% and evidence of spontaneous or provokable
increased LV filling pressures
HF, 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; LV, left ventricular; LVEF, left ven-
tricular ejection fraction; N/A, not available.
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proved LVEF (HFimpEF) has been added to the list. Criteria
for the classification of HF are available in Table 1.
Evaluation and diagnosis
The diagnostic approach is the same between ACC/AHA/HFSA
2022 and ESC 2021 guidelines with the clinical assessment,
followed by natriuretic peptide measurement, echocardiog-
raphy, staging, and treatment initiation (Figure 1). The diag-
nosis of HF is based on clinical signs and symptoms in addi-
tion to para-clinical evaluations. History and physical
examination still play a significant role in the diagnosis and
provide information regarding the underlying mechanism
for HF, including known cardiomyopathy with or without a
positive family history, prior myocardial infarction, CAD, alco-
hol misuse, known cancer with cardiotoxic chemotherapy,
chronic kidney disease (CKD), and diabetes mellitus; however,
reduced accuracy of history and physical examination is seen
when used alone.11,12 The main signs observed are those re-
lated to congestion, such as jugular vein distension,
orthopnoea, oedema, third heart sound, and hepatojugular
reflex, in addition to symptoms including breathlessness, fa-
tigue, and paroxysmal nocturnal dyspnea.13,14
A summary of the comparison between the guidelines’ di-
agnostic evaluation methods is illustrated in Table 2. Both
guidelines emphasize the role of a thorough history and phys-
ical examination. Three-generation family history for patients
with cardiomyopathy, comprehensive history for finding spe-
cific causes of HF, and evaluation of the New York Heart As-
sociation (NYHA) class are among them. Both guidelines have
similar requirements for 12-lead electrocardiogram (ECG) and
laboratory testing to rule out arrhythmias and myocardial in-
jury. Chest X-ray and transthoracic echocardiography (TTE)
are recommended with the highest class of recommendation
(CoR) in both ESC 2021 and ACC/AHA/HFSA 2022 guidelines.
TTE is used to classify HF to HFrEF, HFmrEF, and HFpEF, as
mentioned.
The importance of BNP/NT-proBNP is reported in both
guidelines. They have high sensitivity in the emergency set-
ting, thus ruling out HF. However, various cardiac and
ESC criteria
LVEF ≤ 40%
N/A
LVEF 41%–49%
LVEF ≥ 50% and objective evidence of cardiac structural and/or
functional abnormalities consistent with the presence of LV
diastolic dysfunction/raised LV filling pressures, including
raised natriuretic peptides
ESC Heart Failure (2022)
DOI: 10.1002/ehf2.14255

ACC/AHA/HFSA 2022 and ESC 2021 guidelines on heart failure comparison
Figure 1 Diagnostic algorithm for patients with suspected HF; ECG, electrocardiography; BNP, brain natriuretic factor; 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.
non-cardiac causes can lead to their increase, such as acute
coronary syndrome (ACS), myocarditis, valvular heart disease,
anaemia, kidney disease, and pulmonary embolism.15,16 The
ACC/AHA/HFSA 2022 guidelines also recommend its mea-
surement for risk stratification and establishment of progno-
sis. Genetic screening in first-degree relatives of patients with
inherited cardiomyopathy is advised in both guidelines; how-
ever, the ACC/AHA/HFSA 2022 guidelines recommended it
with the highest CoR.
Cardiac magnetic resonance (CMR) imaging is highly rec-
ommended by both guidelines in situations where TTE is in-
adequate or of poor quality. However, the application of
CMR is not confined to this in the ESC guidelines. Character-
ization of myocardial tissue morphology in suspected infiltra-
tive disease, Fabry disease, and myocarditis, in addition to
distinguishing ischaemic and non-ischaemic myocardial dam-
age in dilated cardiomyopathy (DCM), are other applications
of CMR recommended by the ESC HF guidelines.17 Computed
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3
tomography (CT) coronary angiography can be used in pa-
tients with angina despite pharmacological treatment, ac-
cording to the ESC guidelines with CoR of IIa. However,
non-invasive stress imaging such as stress echocardiography,
single-photon emission CT (SPECT), and positron emission to-
mography (PET) are not strictly recommended and may be
used for patients with CAD.
The ESC guidelines mainly describe invasive angiography
for its application in patients with angina episodes and with-
out clinical improvement after the administration of pharma-
cological treatment. Cardiopulmonary exercise testing (CPET)
for evaluation of advanced treatment of HF or heart trans-
plant is recommended with the highest CoR in both guide-
lines. At the same time, it may help to determine the cause
of dyspnoea (IIa). Finally, although the ACC/AHA/HFSA 2022
guidelines indicate the likely effectiveness of endomyocardial
biopsy in patients with progressive symptoms, just like the
ESC guidelines, it questions its use as a routine diagnostic
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DOI: 10.1002/ehf2.14255
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4 A.H. Behnoush et al.

Table 2 The comparison between guidelines diagnostic evaluation methods

AHA ESC
Recommendation 2022 2021
History and physical examination 1 1
12-lead ECG 1 1
Transthoracic echocardiography (TTE) 1 1
Repeating TTE in case of significant clinical change, or receiving GDMT 1
Chest X-ray 1 1
Blood test 1 1
BNP/NT-proBNP
Patients with dyspnoea for diagnosis or exclusion 1 1
Risk stratification and disease severity 1
Prognosis on HF admission 1
Preventing new-onset HF in patients at risk via screening 2a
Pre-discharge prognosis on admission 2a
Genetic screening in first-degree relatives of patients with inherited cardiomyopathy 1
Genetic counselling in family of patients with non-ischaemic cardiomyopathy 2a
CMR in patients with poor echocardiogram 1 1
CMR for tissue characterization 1
CMR to distinguish ischaemic or non-ischaemic myocardial damage 2a
CMR for diagnosis or management 2a
CTCA in patients with low to intermediate pre-test probability of CAD to rule out coronary stenosis 2a
Noninvasive stress imaging (stress echocardiography, single-photon emission CT [SPECT], CMR, or positron emission 2b 2b
tomography [PET]) for detection of ischaemia
Invasive coronary angiography in patients with angina despite pharmacological treatment 1
Invasive coronary angiography in patients with HFrEF with intermediate to high probability of CAD and ischaemia in 2b
non-invasive stress test
Endomyocardial Biopsy in patients with progressive symptoms or suspecting a specific diagnosis 2a 2a
Endomyocardial Biopsy in routine evaluation of HF 3
Assessment and documentation of NYHA classification for eligibility of treatment 1
Cardiopulmonary exercise testing (CPET) for evaluation for advanced treatment or heart transplant 1 1
Cardiopulmonary exercise testing (CPET) for assessment of functional capacity or prescribing training 2a 2a
Cardiopulmonary exercise testing (CPET) for identification of cause of dyspnoea 2a 2a
Right heart catheterization in severe HF for evaluation of heart transplant or mechanical circulatory support 1
Right heart catheterization in HF due to constrictive pericarditis, restrictive cardiomyopathy, congenital heart disease, and 2a
high output states.
Right heart catheterization in patients with probable pulmonary hypertension for confirmation of diagnosis 2a
Right heart catheterization in HFpEF for confirmation of diagnosis 2b
Routine right heart haemodynamic monitoring for HF patients 3
Validated multivariable risk scores to predict risk of mortality 2a
AHA, American heart association; BNP, brain natriuretic peptide; CAD, coronary artery disease; CMR, cardiovascular magnetic resonance
imaging; computed tomography coronary angiography; ECG, electrocardiogram; ESC, European society of cardiology; GDMT,
guideline-directed medical therapy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with re-
duced ejection fraction; NT, N-terminal; NYHA, New York heart association.

evaluation in patients with suspected HF, mainly due to its
complications such as perforation, tamponade, and thrombus
formation while providing not much additional value.18,19
In summary, in terms of the diagnostic approach, the back-
bones of both guidelines are similar with regard to history
taking and physical examination, natriuretic peptide testing,
TTE, ECG, and routine blood tests. However, minor differ-
ences in particular situations with a concurrent disorder such
as CAD are highlighted.
Prevention of patients at risk and
pre-HF
The ACC/AHA/HFSA guidelines suggest pharmacological and
non-pharmacological recommendations for patients at risk
for HF and pre-HF with different classes of recommendation;
however, the ESC guidelines only provided preventive strate-
gies as potential corrective actions in patients with risk fac-
tors for developing HF.
For the general population without risk factors of HF being
present, ACC/AHA/HFSA and ESC suggested regular physical
activity, healthy diet, maintaining a normal weight, smoking
cessation, no/light alcohol intake, and influenza vaccination
as primary strategies for preventing HF. In the ACC/AHA/
HFSA guidelines and for the general population, validated
multivariable risk scores, including Framingham Heart Failure
Risk Score,20 Health ABC Heart Failure Score,21 ARIC Risk
Score,22 and PCP-HF23 are suggested as valuable tools to esti-
mate the risk of HF incidence with a CoR of IIa.
The ACC/AHA/HFSA and ESC guidelines recommend strate-
gies for populations with specific risk factors for HF, which
are summarized in Table 3. In a population in contact with in-

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ACC/AHA/HFSA 2022 and ESC 2021 guidelines on heart failure comparison 5

Table 3 Recommended strategies for populations with specific Preventing the syndrome of clinical HF in patients with
risk factors for heart failure
pre-HF is discussed only in the ACC/AHA/HFSA guidelines.
Risk factor Recommendation CoR ACC/AHA/HFSA categorizes patients based on their LVEF, re-
ACC/AHA/HFSA 2022 cent or remote (>40 days) MI or ACS history, and expected
Hypertension Optimal control of BP 1 survival. Angiotensin-converting enzyme inhibitors (ACEis)
Type 2 diabetes and SGLT2 inhibitors 1
CVD or high risk for CVD
and beta-blockers should be used to prevent symptomatic
CVDs Optimal management of CVD 1 HF and reduce mortality in patients with LVEF ≤ 40%. In pa-
Exposure to cardiotoxic Multidisciplinary evaluation for 1 tients who are intolerant of ACEi, have a history of MI, and
agents management
Cardiomyopathies in Genetic screening and counselling 1
have an LVEF ≤ 40%, angiotensin (II) receptor blockers (ARBs)
first-degree relatives should be used. Other situations and relevant recommenda-
Patients at risk for HF Natriuretic peptide biomarker 2a tions are available in Table 4.
screening
Patients at risk for HF Validated multivariable risk scores 2a
ESC 2021
Sedentary habit Regular physical activity NR
Smoking Smoking cessation NR
Obesity Healthy diet and physical activity NR HFrEF treatment
Excessive alcohol intake Abstain from alcohol in patients NR
with alcohol-induced CMP and no/ Pharmacological therapy is the backbone of HFrEF treatment.
light intake in general population
Influenza Vaccination NR The overall structure of pharmacological treatment is almost
Microbes Early diagnosis and antimicrobial NR the same in both guidelines, presenting commonly prescribed
therapy for either prevention and/ medical agents for HF patients. These findings are mainly
or treatment
Cardiotoxic drugs Cardiac function and side effect NR based on large-scale clinical trials conducted in patients with
monitoring, dose adaptation, and HFrEF.
change of chemotherapy The summary of CoR for medications suggested for HF is
Chest radiation Cardiac function and side effect NR
monitoring, dose adaptation illustrated in Table 5. Loop diuretics can be used for patients
Hypertension Lifestyle changes and NR with symptoms of congestion, while the ACC/AHA/HFSA 2022
anti-hypertensive therapy guidelines indicate the addition of thiazide diuretics to loop
Dyslipidaemia Healthy diets and statin NR
Diabetes mellitus Physical activity, healthy diet, and NR diuretics in case of non-response. Similarly, the ESC guide-
SGLT2 inhibitors lines mentioned the synergistic effect of the combination of
CAD Lifestyle changes and statin NR thiazide and loop diuretics for HFrEF patients with diuretic
AHA, American heart association; BP, blood pressure; CAD, coro- resistance.
nary artery disease; CVD, cardiovascular disease; ESC, European
While being massively used by physicians, ACEis are rec-
society of cardiology; HF, heart failure; SGLT2, sodium-glucose
cotransporter-2; NR, not reported. ommended by the ESC as the first line. This is also advised
by ACC/AHA/HFSA as an alternative for angiotensin
receptor–neprilysin inhibitor (ARNi) when not possible. The
fectious microorganisms, early diagnosis and use of antimi- use and efficacy of ARNis have increased in HF management,
crobial therapy for the prevention and/or treatment are rec- compared with previous guidelines.24,25 Additional benefits
ommended in the ESC guidelines. Moreover, cardiac function of ARNis are mentioned in ESC guidelines, including improve-
assessment, side effect monitoring, and dose adaptation are ment of quality of life, reduction of diabetes incidence,
recommended preventive strategies in populations using slowing down the drop in eGFR, and reduced rate of
cardiotoxic drugs such as anthracyclines or chest radiation.8 hyperkalaemia.26–29 The only currently available ARNi is com-
Hypertension as a risk factor for the incidence of HF should posed of the ARB valsartan and the inhibitor of neprilysin sa-
be controlled by lifestyle changes and antihypertensive ther- cubitril, as in the large trial of PARADIGM-HF, its efficacy was
apy suggested by both guidelines (CoR of I in the ACC/AHA/ reported to be higher than that of enalapril.26 ARBs also can
HFSA guidelines). Physical activity, a healthy diet, and be used as a substitute for ACEis and ARNIs. Beta-blockers,
sodium-glucose co-transporter 2 (SGLT2) inhibitors are rec- specifically bisoprolol, carvedilol, and sustained-release met-
ommended for all patients with diabetes mellitus in the ESC oprolol succinate, can be prescribed to reduce HF hospitaliza-
guidelines. On the other hand, ACC/AHA/HFSA suggests the tion and mortality in HFrEF patients. The addition of mineral-
mentioned recommendations for patients with type 2 diabe- ocorticoid receptor antagonists (MRAs) such as
tes and either established CVD or high cardiovascular risk spironolactone and eplerenone is mentioned in both guide-
(CoR: I). The ACC/AHA/HFSA 2022 guidelines suggested natri- lines; however, caution should be exercised in patients with
uretic peptide biomarker screening and validated multivari- impaired renal function and hyperkalaemia (K > 5 meq/L).
able risk scores for patients at risk for HF (CoR: IIa). ESC rec- SGLT2 inhibitors, first used as anti-diabetic medications, have
ommends statin therapy, a healthy diet, and lifestyle changes proven to have beneficial effects on cardiovascular death and
for patients with dyslipidaemia or CAD. HF irrespective of the presence of diabetes.30,31 They are

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6 A.H. Behnoush et al.

Table 4 Recommendations for patients with pre heart failure

Recommendation AHA 2022

ACE inhibitors in patients with LVEF ≤40% to prevent HF and reduce mortality 1
Statins in patients with history of MI or ACS to prevent HF and adverse cardiovascular events 1
ARB in patients with recent MI, LVEF ≤40%, and intolerant to ACE inhibitors to prevent HF and reduce mortality 1
Beta blockers in patients with history of MI or ACS, and LVEF ≤40% to reduce mortality 1
ICD for primary prevention of sudden cardiac death in patients have a history of remote MI (>40 days), LVEF ≤30%, NYHA 1
class I while receiving GDMT and expected survival >1 year to reduce mortality
Beta blockers in patients with LVEF ≤40% to prevent HF 1
Avoid to use thiazolidinediones in patients with LVEF <50% because they increase the risk of HF and hospitalization. 3 (H)
Nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful in patients with LVEF <50% 3 (H)
AHA, American heart association; ACE, angiotensin-converting enzyme; LVEF, left ventricular ejection fraction; ARB, angiotensin receptor
blocker; ASC, acute coronary syndrome; ICD, implantable cardioverter-defibrillator; GDMT, guideline-directed medical therapy; HF, heart
failure; MI, myocardial infarction; NYHA, New York heart association; H, harm.

highly recommended in both ESC and ACC/AHA/HFSA guide-
lines. The ACC/AHA/HFSA guidelines emphasize using hydral-
azine and isosorbide dinitrate in African American patients
with NYHIII/IV who receive optimal therapy to reduce mortal-
ity and morbidity (CoR: I). On the other hand, according to
the ESC guidelines, it also should be considered in this popu-
lation with lower CoR (IIa).
Omega-3 polyunsaturated fatty acid (PUFA) supplementa-
tion and potassium binders are only mentioned in the Amer-
ican guidelines and might be helpful for HFrEF patients (CoR:
IIb). Ivabradine, an If channel blocker in the sinoatrial node
whose use results in heart rate reduction, is recommended
with a CoR of IIa in patients with LVEF ≤35% and a resting
heart rate ≥70 bpm despite high-dose beta-blocker therapy.
Finally, digoxin might benefit HFrEF patients with normal si-
nus rhythm despite optimal therapy (CoR of IIb in both
guidelines).
The titration of guideline-directed medical therapy (GDMT)
to achieve target doses is recommended by the ACC/AHA/
HFSA guidelines for HF (CoR: I), while there is also a recom-
mendation for up-titration to the dose recommended by clin-
ical trials in the ESC guidelines. In contrast, its more frequent

Table 5 Summary of CoR for medications suggested for HFrEF

AHA ESC
Recommendation 2022 2021
Diuretics for patients with fluid retention in order to relieve congestion and improve symptoms 1 1
Addition of thiazide to a loop diuretic with decreased response to moderate or high-dose loop diuretics 1
ARNi in patients to reduce mortality and morbidity (in ESC in replacement of ACEi) 1 1
ACEi to reduce HFrEF hospitalization and death (in AHA when ARNi not possible) 1 1
ARB for patients who cannot tolerate ACEi (cough or angioedema) or ARNi in order to reduce mortality and morbidity 1 1
ARNi to replace ACEi or ARB to further reduce mortality and morbidity 1 1
One of three beta-blockers (bisoprolol, carvedilol and sustained release succinate) to reduce mortality 1
A beta-blocker to reduce risk of HF hospitalization and death 1
MRA in patients with HFrEF to reduce hospitalization and death 1 1
MRA is not indicated in patients whose serum potassium cannot be maintained <5.5 meq/L 3
SGLT2 inhibitors to reduce hospitalization and death related to HF, irrespective of presence of type 2 diabetes 1 1
Hydralazine and isosorbide dinitrate in African American patients with NYHA III/IV who are receiving optimal therapy to 1 2a
reduce mortality and morbidity
Hydralazine and isosorbide dinitrate in patients with intolerance to ACEi, ARB or ARNi to reduce death rate 2b 2b
PUFA supplementation in HF patients with NYHA II/IV as adjunctive therapy to reduce mortality and hospitalization 2b
Potassium binders (patiromer, sodium zirconium cyclosilicate) in HF patients with hyperkalaemia while taking RAAS 2b
inhibitor
Anticoagulation in patients with HFrEF without specific indication 3 (NB)
Dihydropyridine CCB for HFrEF 3 (NB)
Vitamins, nutritional supplements and hormonal therapy other than deficiencies 3 (NB)
Ivabridine for HF patients with HR ≥ 70 bpm at rest despite beta-blockers, ACEi and MRA to reduce mortality and 2a 2a
morbidity
Ivabridine for HF patients with contraindications for beta blockers and resting HR ≥ 70 bpm to reduce CV 2a
hospitalization and death, ACEi and MRA should still be used
Digoxin for patients with sinus rhythm to reduce HF hospitalizations 2b 2b
Vericiguat for patients with NYHA II-IV with worsening symptoms HF despite treatment with an ACEi or ARNi, a 2b 2b
bet-blocker and MRA to reduce the risk of CV mortality
ACEi, angiotensin-converting enzyme inhibitor; AHA, American heart association; ARB, angiotensin receptor blocker; ARNi, angiotensin
receptor-neprilysin inhibitor; CCB, calcium channel blockers; CV, cardiovascular; ESC, European society of cardiology; HF, heart failure;
HFrEF, heart failure with reduced ejection fraction; HR, heart rate; MRA, mineralocorticoid receptor antagonists; NB, no benefit; NYHA,
New York heart association; PUFA, polyunsaturated fatty acids; RAAS, renin-angiotensin-aldosterone system; SGLT2, sodium-glucose
cotransporter-2.

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ACC/AHA/HFSA 2022 and ESC 2021 guidelines on heart failure comparison 7

dose management should be considered every 1 to 2 weeks
(CoR: IIa). It should be noted that in GDMT, the target dose
should be achieved even if improved symptoms are observed
already at lower doses.
Implantable cardioverter-defibrillators (ICDs) are indicated
in HFrEF patients with ischaemic heart disease, LVEF≤35%,
and NYHA II/III with an expected survival of >1 year, due to
both guidelines. In ACC/AHA/HFSA criteria, ICDs are sug-
gested for patients with NYHA I class, at least 40-days post-
MI and LVEF ≤30% with the same expected survival of
>1 year to reduce the risk of sudden cardiac death and over-
all mortality. However, the ESC guidelines mention ICD im-
plantation for patients recovering from ventricular arrhyth-
mia and causing haemodynamic instability. For better
clarification, all indications for ICD implantation based on
both criteria and their comparison are summarized in Table 6.
Cardiac resynchronization therapy (CRT) is strongly advised
by both guidelines in cases of LVEF ≤35%, left bundle branch
block (LBBB), QRS duration of more than 150 ms, and in the
presence of sinus rhythm. The ESC guidelines emphasize the
administration of CRT for patients requiring right ventricular
pacing, while CoR in ACC/AHA/HFSA is IIa. In cases with a
non-LBBB pattern and QRS duration >150 ms or LBBB with
QRS duration of 120 to 149, CRT should be considered, simi-
larly in both guidelines. The cut-off for QRS duration for not
indicating CRT is <120 ms in the ACC/AHA/HFSA guidelines
and <130 ms in the ESC guidelines.
Non-pharmacological management of HFrEF is extensively
described in the ACC/AHA/HFSA guidelines. Affected patients
should receive care from multidisciplinary teams to facilitate
the implementation of GDMT, in addition to specific educa-
tion and support to facilitate HF self-care (CoR: I). Moreover,

Table 6 Indications for ICD and CRT based on both criteria and their comparison

AHA ESC
Recommendation 2022 2021
ICD therapy for non-ischaemic DCM or ischaemic heart disease, LVEF ≤35% and NYHA III/IV with expected good 1 1
functional survival of >1 year to reduce SCD and mortality
ICD for patients at least 40-days post MI, LVEF ≤30% and NYHA I with expected good functional survival of >1 year to 1
reduce SCD and mortality
ICD for patients recovering from a ventricular arrhythmia causing haemodynamic instability with expected good 1
functional survival of >1 year to reduce SCD and mortality, unless arrhythmia occurred <48 h after MI
ICD for patients with arrhythmogenic cardiomyopathy with high risk of SCD and LVEF ≤45%, to reduce SCD 2a
ICD for patients with symptomatic HF of a non-ischaemic aetiology and LVEF ≤35% with expected good functional 2a
survival of >1 year to reduce SCD and mortality
Wearable ICD in patients at risk of SCD as a bridge to an implanted device 2b
ICD for patients within 40 days of MI does not improve prognosis 3
ICD for HF patients with NYHA IV with severe symptoms refractory to pharmacological therapy 3
ICD is not recommended for patients whose comorbidities or frailty limit survival with good functional capacity to 3
<1 year
CRT for patients who have LVEF ≤35%, sinus rhythm, left bundle branch block (LBBB) with a QRS duration ≥150 ms, 1 1
and NYHA class II, III, or ambulatory IV symptoms to reduce mortality, hospitalization and improve symptoms
CRT rather than RV pacing is recommended for patients with HFrEF regardless of NYHA class or QRS width who have 2a 1
an indication for ventricular pacing for high degree AV block in order to reduce morbidity, including patients with AF
CRT in patients with high-degree or complete heart block and LVEF between 36% and 50% to reduce mortality, 2a
hospitalization and improve symptoms
CRT for patients who have LVEF ≤35%, sinus rhythm, non-left bundle branch block (LBBB) QRS morphology, QRS 2a 2a
duration ≥150 ms, and NYHA class II, III, or ambulatory IV symptoms to reduce mortality and morbidity
CRT for HF patients with LVEF ≤35%, sinus rhythm, LBBB with a QRS duration of 120 to 149 ms, and NYHA class II, III, 2a 2a
or ambulatory IV symptoms to reduce mortality, hospitalization and improve symptoms and QoL
CRT who has LVEF ≤35% and are undergoing placement of a new or replacement device implantation with anticipated 2a 2a
requirement for significant (>40%) ventricular pacing, CRT can be useful to reduce total mortality, reduce
hospitalizations, and improve symptoms and QoL
CRT for HF patients with LVEF ≤35%, sinus rhythm, non-LBBB pattern with a QRS duration of 120 to 149 ms, and NYHA 2b 2b
class II, III, or ambulatory IV symptoms to reduce mortality, hospitalization and improve symptoms and QoL
CRT for patients who have LVEF ≤30%, ischaemic cause of HF, sinus rhythm, LBBB with a QRS duration ≥150 ms, and 2b
NYHA class I symptoms to reduce symptoms and decrease hospitalization rate
CRT is not recommended for patients with QRS duration of <120 ms 3 (NB)
CRT is not recommended in patients with a QRS duration <130 ms who do not have an indication for pacing due to 3
high degree AV block
CRT is not recommended for patients with NYHA class I or II symptoms and non-LBBB pattern with QRS duration 3 (NB)
<150 ms
CRT is not recommended for patients whose comorbidities or frailty limit survival with good functional capacity to 3 (NB)
<1 year
AHA, American heart association; AV, atrioventricular; CRT, cardiac resynchronization therapy; DCM, dilated cardiomyopathy; ESC,
European society of cardiology; ICD, implantable cardioverter-defibrillator; LVEF, left ventricular ejection fraction; MI, myocardial infarc-
tion; NB, no benefit; NYHA, New York heart association; QoL, quality of life; QRS, HFrEF, heart failure with reduced ejection fraction;
RV, right ventricle; SCD, sickle cell disease.

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8 A.H. Behnoush et al.

vaccination against respiratory illnesses and screening for de-
pression, social isolation, frailty, and low literacy should be
considered (CoR: IIa). ACC/AHA/HFSA recommends dietary
sodium restriction of <2300 mg/day to reduce congestion.32
However, it is mentioned that currently, there is no trial to
support this level.33 Finally, exercise is strongly suggested in
patients who can participate, while cardiac rehabilitation
can be helpful for them (CoR: IIa). There is a thorough discus-
sion in the ESC guidelines, as well. Multidisciplinary HF man-
agement programmes, self-management strategies, and exer-
cise to improve quality of life were all recommended as CoR I.
Influenza and pneumococcal vaccines and supervised
exercise-based cardiac rehabilitation programmes are also
highly suggested by the European guidelines (CoR: IIa).
HFmrEF treatment
HF with mildly reduced EF (HFmrEF) is diagnosed in the pres-
ence of HF signs and symptoms and/or mildly reduced LVEF
(41%–49%), while elevated natriuretic peptides (NPs), and
other evidence of structural heart disease make the diagnosis
more probable based on the ESC guidelines definition. Up to
now, there are no prospective RCTs to evaluate treatment
and prognosis specifically in patients with HFmrEF; however,
subset and post-hoc analyses from previous high-quality
studies gathered required data in these patients. HFmrEF is
more similar, especially in lower LVEF (near 41%), to HFrEF
than HFpEF. Thus, the management of HFmrEF is very similar
to HFrEF even though the evidence base for the recommen-
dations is less robust.
The summary of recommendations and CoR for HFmrEF is
available in Table 7. ACC/AHA/HFSA and ESC recommend di-
uretics as needed to alleviate symptoms and signs (CoR: I).
SGLT2 inhibitors are recommended in ACC/AHA/HFSA with
CoR of IIa, without being mentioned in the ESC guidelines.
As both guidelines suggest, an ACEi, ARB, beta-blocker,
MRA, or ARNI may reduce the risk of HF hospitalization and
death (CoR: IIb).
As the term HFimpEF was only defined in ACC/AHA/HFSA
guidelines, the only recommendation for these patients is
continuing GDMT in order to prevent relapse of HF and LV
dysfunction (CoR: I). This should be performed even if the pa-
tient becomes asymptomatic, while in the ones without im-
provement, GDMT should be optimized.
HFpEF treatment
The management of this group of patients is limited as there
is no definite pharmacological therapy, and the medication
therapy is mainly based on symptom management. Both
guidelines highly recommend the management of hyperten-
sion according to guidelines to reach blood pressure targets
(CoR: I). Screening and treatment of both cardiovascular
and non-cardiovascular (CV) comorbidities are mentioned in
the ESC guidelines because these are more common in pa-
tients with HFpEF than in HFrEF.34 These include atrial fibril-
lation (AF), CKD, and non-CV comorbidities, among which
the ESC guidelines emphasize the consideration of AF treat-
ment with anticoagulation treatment with the highest CoR.
Diuretics are also indicated to reduce congestion, as sug-
gested by both guidelines. The case for SGLT2 inhibitors is
quite interesting. While the ACC/AHA/HFSA guidelines rec-
ommend considering SGLT2 inhibitors in all HF patients
(CoR: IIa), ESC only suggests their administration in diabetic
HF patients (CoR: I). However, the ESC guidelines was pub-
lished only shortly after the publication of the results of the
EMPEROR-Preserved trial (empagliflozin vs. placebo in pa-
tients with HFpEF)35; thus, the usage of this publication fell
just outside the review timeframe to be considered for guide-
line recommendations by the ESC.
Statin therapy for patients at high risk of CV disease is the
other mentioned recommendation for HFpEF patients. MRAs,
ARBs, and ARNIs may be beneficial for patients in the lower
spectrum of LVEF to reduce hospitalization, according to
the ACC/AHA/HFSA 2022 guidelines. Finally, as the
ACC/AHA/HFSA guidelines suggest, although nitrates seem
to benefit patients with HFrEF by reducing pulmonary con-
gestion and improving exercise tolerance, no such evidence
of efficacy was observed in HFpEF patients.36 The same is
true for phosphodiesterase-5 inhibitors, which showed no im-
provement in oxygen consumption or exercise tolerance in

Table 7 Summary of recommendations and CoR for HFmrEF

Recommendation AHA 2022 ESC 2021

Diuretics are recommended in patients with congestion to alleviate symptoms and signs 1 1
SGLT2 inhibitors are recommended to decrease the risk of hospitalizations and cardiovascular mortality 2a
ACE inhibitors are recommended to reduce risk of hospitalizations and death 2b 2b
ARBs are recommended to reduce risk of hospitalizations and death 2b 2b
ARN inhibitors (sacubitril/valsartan) are recommended to reduce the risk of hospitalizations and death 2b 2b
MRAs are recommended to reduce the risk of hospitalizations and death 2b 2b
Beta-blockers are recommended to reduce the risk of hospitalizations and death 2b 2b
ACE, angiotensin-converting-enzyme; AHA, American Heart Association; ARB, angiotensin II receptor blocker; ARN, angiotensin receptor
neprilysin; ESC, European Society of Cardiology; MRA, mineralocorticoid receptor antagonists; SGLT2, sodium-glucose cotransporter-2.

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ACC/AHA/HFSA 2022 and ESC 2021 guidelines on heart failure comparison 9

Table 8 The summary of CoR for medications suggested for HFpEF
AHA ESC
Recommendation 2022 2021
Hypertension management to achieve blood 1 1
pressure targets in clinical practice guidelines
Screening, and treatment of aetiologies and 1
cardiovascular and non-cardiovascular
comorbidities
Diuretics in congested patients 1 1
SGLT2 inhibitors in diabetic patients for decreasing 1 Acute heart failure
HF hospitalizations
SGLT2 inhibitors for decreasing HF hospitalizations 2a
and CV mortality
Statins for patients at high risk of CV disease 1 vere enough for patients to seek urgent medical attention.
AF treatment in order to improve symptoms 2a
MRAs to reduce hospitalization, particularly among 2b
patients with lower LVEF
ARBs to reduce hospitalization, particularly among 2b
patients with lower LVEF
ARNIs to reduce hospitalization, particularly among 2b
patients with lower LVEF
Routine use of nitrates or phosphodiesterase-5 3 medical team are acute decompensated HF, acute pulmonary
inhibitors to increase activity
AF, atrial fibrillation; AHA, American Heart Association; ARB, angio-
tensin II receptor blocker; ARN, angiotensin receptor neprilysin; CV,
cardiovascular; ESC, European Society of Cardiology; LVEF, left
ventricular ejection fraction; MRA, mineralocorticoid receptor
antagonists; SGLT2, sodium-glucose cotransporter-2.
this population.37 The summary of CoR for medications sug-
gested for HFpEF is illustrated in Table 8.
Advanced heart failure
According to the definition proposed by ESC in 2018, the
main focus for diagnosing advanced HF is refractory symp-
toms despite maximal therapy, not necessarily reduced LVEF.
In addition, other organ failure may also be present, but this
is not mandatory.38 Seven profiles were defined by the
INTERMACS (Interagency Registry for Mechanically Assisted
Circulatory Support) for the stratification of patients with ad-
vanced HF.39 As described in both guidelines, these profiles
can be used to assess the prognosis of the patients undergo-
ing urgent heart transplantation or LV assist device (LVAD)
implantation.40,41 The most critical point in this population
is identifying warning signs, as they often refer to medical
care late.42 The summary of recommended management
points according to both guidelines is illustrated in Table 9.
Acute HF (AHF) is a sudden or gradual onset of symptoms se-
AHF can be a sign of new-onset HF or acute chronic HF de-
compensation. Diagnostic tools available are ECG, echocardi-
ography, and plasma NPs. Normal concentrations of NPs with
no signs on ECG and imaging can rule out AHF. The most
common presentations with which patients can refer to the
oedema, isolated right ventricular failure, and cardiogenic
shock.8
Diuretics for congestion resolution and thromboembolism
prophylaxis are highly recommended by both guidelines
(CoR: I), while vasodilators may be beneficial (CoR: IIa). One
of the main differences among them may be the administra-
tion of intravenous inotropic agents, considered the first line
in cardiogenic shock patients according to ACC/AHA/HFSA
guidelines to maintain systemic perfusion and preserve
end-organ performance. However, ESC recommends possible
beneficial effects of it in patients not responding to the fluid
challenge and after it (CoR: IIa). Short-term mechanical circu-
latory support (MCS) should be considered, as suggested by
both guidelines (CoR: IIa), as a bridge treatment and to sup-
port the end-organ perfusion.43 The ACC/AHA/HFSA guide-
lines emphasize maintenance and optimization of GDMT in
affected patients at least after discharge or reaching a stable
state. Similarly, the European guidelines suggest the
up-titration of optimal medical therapy. At last, the ESC
guidelines recommend that patients’ oral treatment be mod-
ified to lower the risk of 30-day readmission episodes, as
proven by different studies.44,45 Table 10 illustrates all recom-
mended management recommendations for patients with
AHF.

Table 9 Advanced heart failure management

Recommendation AHA 2022 ESC 2021

Heart transplantation for advanced HF, refractory to medical/device therapy and without contraindication 1 1
Good compliance and appropriate capacity for device handling and psychosocial support for patients being 1
considered for long-term MCS
Long-term MCS in advanced HF patients to improve functional class and reduce mortality 2a 2a
MCS in advanced HF patients to be considered as a bridge to cardiac transplantation or to improve symptoms 2a 2a
Renal replacement therapy 2b
Fluid restriction in patients with advanced HF and hyponatremia 2b
Inotropes and vasopressors as a bridge to MCS or heart transplantation 2a 2a
Inotropes and vasopressors as a palliative therapy in ineligible patients for MCS or cardiac transplantation 2b
AHA, American Heart Association; ESC, European Society of Cardiology; HF, heart failure; MCS, mechanical circulatory support;

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10 A.H. Behnoush et al.

Table 10 Acute heart failure management

AHA ESC
Recommendation 2022 2021
Diuretics for patients with acute HF with the evidence of fluid overload 1 1
Diuretics in addition to guideline-directed medical therapy to reduce congestion 1
Diuretics and adjustment of treatment for patients discharging from the hospital in order to resolve congestion 1 1
Second diuretic (thiazide) or higher doses of loop diuretics for patients with inadequate response to normal diuretic 2a 2a
regimen during hospitalization
Vasodilators such as venous nitroglycerin or nitroprusside to reduce congestion 2b 2b
Thromboembolism prophylaxis with anticoagulant agents (e.g., LMWH) to reduce deep venous thrombosis and 1 1
pulmonary embolism
Inotropic agents for patients with sign of cardiogenic shock 1
Inotropic agents for patients with SBP < 90 mmHg and evidence of hypoperfusion refractory to fluid challenge 2b
Inotropic agents should not be routinely used unless symptomatic hypotension 3
Short term MCS in cardiogenic shock patients as a bridge 2a 2a
Temporary MCS in cases where there is no initial rapid response to shock MCS may be considered 2b
Multidisciplinary management of cardiogenic shock 2a
Intra-aortic Balloon Pump in cardiogenic shock patients as a bridge 2b
Intra-aortic Balloon Pump is not routinely recommended in post-MI cardiogenic shock 3
PA line for patients with cardiogenic shock in order to define haemodynamic subsets and management strategies 2b
Vasopressors, preferably norepinephrine, may be considered in patients with cardiogenic shock to increase blood 2b
pressure
Opiates should not be routinely recommended unless in patients with severe pain or anxiety 3
Oxygen for patients with SpO2 < 90% 1
Intubation in progressive respiratory failure despite oxygen administration 1
Non-invasive positive pressure ventilation in patients with respiratory distress 2a
GDMT should be retained and further optimized 1
Referral to multidisciplinary HF disease management programmes for those with HFrEF particularly those with recurrent 1
hospitalization for HF
Patient-centred discharge instructions with a clear plan for transitional care before discharge 1
Early follow-up visits are recommended at 1–2 weeks after discharge 1
Ferric carboxymaltose for patients with iron deficiency 1
AHA, American Heart Association; ESC, European society of cardiology; GDMT, guideline-directed medical therapy; HF, heart failure;
HFrEF, heart failure with reduced ejection fraction; LMWH, low molecular weight heparin; MI, myocardial infarction; PA, pulmonary artery;
SBP, systolic blood pressure; SpO2, oxygen saturation.

Comorbidities The ACC/AHA/HFSA 2022 guidelines suggested surgical re-

Both cardiac and non-cardiac comorbidities are well estab-
lished in the ESC 2021 guidelines, while ACC/AHA/HFSA
mainly focuses on CV comorbidities. Hypertension is the most
frequent comorbidity in all adults, as discussed in the
ACC/AHA/HFSA 2022 guidelines (84.2% in age ≥65 and 80.7
in age <65). ischaemic heart disease, hyperlipidaemia, anae-
mia, diabetes, and arthritis are the most common comorbid-
ities after hypertension.
There are several CV comorbidities known in patients with
HF. Arrhythmias and conduction disturbances, chronic coro-
nary syndromes, valvular heart disease, and stroke are major
comorbidities that frequently coexist with HF. In patients
with AF and HF, in addition to a CHA2DS2-VASc score ≥2 in
men and ≥3 in women, chronic anticoagulant therapy is sug-
gested as the main therapy with CoR I in both guidelines.
Moreover, DOACs are preferred over warfarin in eligible pa-
tients (CoR: I). Beta-blockers and digoxin are highly recom-
mended by the European guidelines (CoR: IIa) for rate control
in AF patients. With the support of trials, both guidelines sug-
gest AF catheter ablation in case of a clear association be-
tween AF and worsening HF and tolerance to medical
therapy.46–48
vascularization for HF patients with CAD and LVEF ≤35% and
suitable coronary anatomy (CoR: I). Similarly, the ESC 2021
guidelines considered CABG as the first-choice therapy in all
patients eligible for surgery, especially if they have a
multi-vessel disease or are diabetic (CoR: IIa).
Valvular heart disease (VHD) comorbidities are described
in both guidelines, more specifically in the ESC guidelines.
First, GDMT applies to all HFrEF patients, with or without
VHD. ACC/AHA/HFSA specifically addresses multidisciplinary
management of VHD to prevent HF worsening and adverse
clinical outcomes (CoR: I). According to the American guide-
lines, secondary mitral regurgitation also should be treated
by optimization of GDMT before any intervention targeting
it. On the contrary, the European guidelines suggest percuta-
neous edge-to-edge mitral valve repair in case of not eligible
for surgery and not needing coronary revascularization (CoR:
IIa). Aortic stenosis was also suggested to be managed via
transcatheter aortic valve replacement (TAVR) or surgical aor-
tic valve replacement (SAVR), based on shared decision mak-
ing, indications, and assessment, in patients with HF and se-
vere high-gradient aortic stenosis (CoR: I in ESC guidelines).
Up-titration of GDMT to the maximally tolerated dose was
recommended by the ACC/AHA/HFSA for hypertensive pa-

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ACC/AHA/HFSA 2022 and ESC 2021 guidelines on heart failure comparison
tients with HFrEF. The ESC 2021 guidelines suggest the same
treatment strategy for hypertension in HFrEF and HFpEF. This
strategy includes neurohormonal antagonists, diuretics, and
lifestyle modification, including weight loss, reduced sodium
intake, and physical activity. Finally, stroke was described as
frequent comorbidity in the ESC 2021 guidelines due to the
overlap of shared risk factors.
Diabetes, cancer, iron deficiency and anaemia, and
sleep-disordered breathing are mentioned as non-cardiac co-
morbidities of HF in the ACC/AHA/HFSA 2022 guidelines. The
ESC 2021 guidelines mention thyroid disorders, obesity, ca-
chexia, sarcopenia, frailty, kidney dysfunction, electrolyte dis-
orders, hyperlipidaemia, gout and arthritis, erectile dysfunc-
tion, depression, and infection. Both guidelines suggest
SGLT2i in diabetic patients to manage hyperglycaemia (CoR:
I). The ACC/AHA/HFSA 2022 guidelines recommend multidis-
ciplinary management for cancer comorbidity, while the ESC
mentions anthracycline chemotherapy, HER2-targeted thera-
pies, vascular endothelial growth factor (VEGF) inhibitors,
multi-targeted kinase inhibitors, proteasome inhibitors, im-
munomodulatory drugs, combination RAF and MEK inhibi-
tors, androgen deprivation therapies, and immune check-
point inhibitors as potential cancer drugs causing LV
dysfunction or HF due to their cardiotoxic potential. ESC rec-
ommends that all patients with HF be screened periodically
for anaemia and iron deficiency (CoR: I). Both guidelines sug-
gest intravenous iron supplements for iron-deficient HFrEF
patients, with the ESC guidelines specifically mentioning fer-
ric carboxymaltose (CoR: IIa). Moreover, ACC/AHA/HFSA sug-
gests avoidance of erythropoietin-stimulating agents in pa-
tients with HF and anaemia (CoR: III; harm). They also
suggest a formal sleep study in patients with HF and suspi-
cion of sleep-disordered breathing (CoR: IIa) and continuous
positive airway pressure (CPAP) for patients diagnosed with
obstructive sleep apnoea (CoR: IIa). Other comorbidities
mentioned in the ESC 2021 guidelines should be treated the
same as in a non-HF population.
Special populations
Descriptions of the management of HF in special populations
are provided in both guidelines. The ACC/AHA/HFSA guide-
lines emphasize HF risk assessment and multidisciplinary
management strategies to reduce outcome disparities when
a specific population is at risk for health disparity, such as
Black and Hispanic patients, women, the elderly, Asian popu-
lations, Native American populations, and patients with lower
socioeconomic status (CoR: I).
The next special population discussed in the guidelines in-
cludes cardio-oncology cases. In patients developing cancer
therapy-related cardiomyopathies, the multidisciplinary dis-
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11
cussion about cancer therapy interruption, discontinuation,
or continuation options is highly recommended. In addition,
cancer-related cardiomyopathies can be treated with ARB,
ACEis, and beta-blockers to prevent HF (CoR: IIa according
to both guidelines). In patients with CV risk factors that
may be the subject of cardiotoxic anticancer therapy, evalua-
tion of baseline cardiac function and identification of
drug-induced cardiomyopathies should be considered (CoR:
IIa, similar in both guidelines). Moreover, the ESC guidelines
highly recommend CV evaluation of these patients at in-
creased risk before cancer therapy (CoR: I).
HF can considerably complicate pregnancy as women with
pre-existing HF are at higher risk of CV problems during the
course of their pregnancy.49,50 First, in these populations,
patient-centred counselling regarding contraception, and all
the risks should be provided, as suggested by the ACC/AHA/
HFSA guidelines (CoR: I). Second, all ACEi, ARB, ARNi, MRA,
SGLT2i, ivabradine, and vericiguat medications are highly
contraindicated by both guidelines during pregnancy due to
their teratogenic potential. However, beta-blockers can be
continued, preferably a beta-1-selective one such as
bisoprolol or metoprolol. Third, as pregnancy is a hypercoag-
ulable state, patients with concurrent AF should be given low-
molecular-weight heparin in the first and last trimesters. The
ACC/AHA/HFSA guidelines also recommend (CoR: IIb) antico-
agulation until 6–8 weeks postpartum, although the efficacy
and safety are not established well.
Other mentioned populations described in the ESC guide-
lines are those with cardiomyopathies, left ventricular non-
compaction, atrial disease, myocarditis, and amyloidosis.
The diagnosis and treatment of cardiac amyloidosis as restric-
tive cardiomyopathy is discussed in the ACC/AHA/HFSA in
more detail. Namely, serum and urine screening, bone scin-
tigraphy, and genetic testing are the main diagnostic tools
available. Treatment with transthyretin tetramer stabilizer
therapy (tafamidis) for reduction of cardiovascular mortality
and morbidity is recommended by CoR of I in the
ACC/AHA/HFSA guidelines. Moreover, anticoagulation is also
recommended to reduce the risk of stroke (CoR: IIa).
Conclusions
Both ACC/AHA/HFSA 2022 and ESC 2021 HF guidelines pro-
vide valuable guidance for clinicians and help in clinical man-
agement and decision making, with the support of large tri-
als. While mainly having the same structure and points of
emphasis, in some cases, each of the guidelines may have
elaborated more on a specific topic, which should be consid-
ered in these conditions. These differences may stem from
the timing of the publication of these two guidelines, for
which the American guidelines include newer evidence and
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12 A.H. Behnoush et al.

trials. Universal Definition of HF10 and the recently published
EMPEROR-Preserved trial are among them. Also, the point of
view in the US and Europe can contribute to these differ-
ences, as the American guidelines give more value to the
quality of life, cost-effectiveness, and quality of care provided
for the patients and the ESC guidelines emphasize more spe-
cific suggestions such as the exact management for certain
comorbidities and special populations. Finally, further consis-
tency between guidelines in some classes of recommenda-
tions is warranted by highlighting the differences.
Conflict of interest
Stephan von Haehling has been a paid consultant for and/or
received honoraria payments from AstraZeneca, Bayer,
Boehringer Ingelheim, BRAHMS, Chugai, Grünenthal, Helsinn,
Hexal, Novartis, Pharmacosmos, Respicardia, Roche, Servier,
Sorin, and Vifor. Stephan von Haehling reports research sup-
port from Amgen, Boehringer Ingelheim, IMI, and the Ger-
man Center for Cardiovascular Research (DZHK).

References
1. 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. J Am Coll
Cardiol 2022; 79: e263–e421.
2. Khera R, Kondamudi N, Zhong L,
Vaduganathan M, Parker J, Das SR,
Grodin JL, Halm EA, Berry JD, Pandey
A. Temporal trends in heart failure inci-
dence among Medicare beneficiaries
across risk factor strata, 2011 to 2016.
JAMA Netw Open 2020; 3: e2022190.
3. Ni H, Xu J. Recent trends in heart
failure-related mortality: United States,
2000–2014. NCHS Data Brief 2015;
231: 1–8.
4. Global, regional, and national incidence,
prevalence, and years lived with disabil-
ity for 354 diseases and injuries for 195
countries and territories, 1990–2017:
a systematic analysis for the Global
Burden of Disease Study 2017. Lancet
2018; 392: 1789–1858.
5. Smeets M, Vaes B, Mamouris P, Van Den
Akker M, Van Pottelbergh G, Goderis G,
Janssens S, Aertgeerts B, Henrard S.
Burden of heart failure in Flemish gen-
eral practices: a registry-based study in
the Intego database. BMJ Open 2019;
9: e022972.
6. Meyer S, Brouwers FP, Voors AA, Hillege
HL, de Boer RA, Gansevoort RT, van der
Harst P, Rienstra M, van Gelder IC, van
Veldhuisen DJ, van Gilst WH, van der
Meer P. Sex differences in new-onset
heart failure. Clin Res Cardiol 2015;
104: 342–350.
7. Brouwers FP, de Boer RA, van der Harst
P, Voors AA, Gansevoort RT, Bakker SJ,
Hillege HL, van Veldhuisen DJ, van Gilst
WH. Incidence and epidemiology of
new onset heart failure with preserved
vs. reduced ejection fraction in a
community-based cohort: 11-year
follow-up of PREVEND. Eur Heart J
2013; 34: 1424–1431.
8. McDonagh TA, Metra M, Adamo M,
Gardner RS, Baumbach A, Böhm M,
Burri H, Butler J, Čelutkienė J, Chioncel
O, Cleland JGF, Coats AJS, Crespo-Leiro
MG, Farmakis D, Gilard M, Heymans S,
Hoes AW, Jaarsma T, Jankowska EA,
Lainscak M, Lam CSP, Lyon AR,
McMurray J, Mebazaa A, Mindham R,
Muneretto C, Francesco PM, Price S,
Rosano GMC, Ruschitzka F, Kathrine
Skibelund A, ESC Scientific Document
Group. 2021 ESC guidelines for the di-
agnosis and treatment of acute and
chronic heart failure: developed by the
task force for the diagnosis and treat-
ment of acute and chronic heart failure
of the European Society of Cardiology
(ESC) with the special contribution of
the Heart Failure Association (HFA) of
the ESC. Eur Heart J 2021; 42:
3599–3726.
9. Virani SS, Alonso A, Aparicio HJ, Benja-
min EJ, Bittencourt MS, Callaway CW,
Carson AP, Chamberlain AM, Cheng S,
Delling FN, Elkind MSV, Evenson KR,
Ferguson JF, Gupta DK, Khan SS, Kissela
BM, Knutson KL, Lee CD, Lewis TT, Liu
J, Loop MS, Lutsey PL, Ma J, Mackey J,
Martin SS, Matchar DB, Mussolino ME,
Navaneethan SD, Perak AM, Roth GA,
Samad Z, Satou GM, Schroeder EB,
Shah SH, Shay CM, Stokes A, Van
Wagner L, Wang NY, Tsao CW, American
Heart Association Council on Epidemiol-
ogy and Prevention Statistics Committee
and Stroke Statistics Subcommittee.
Heart disease and stroke statistics-2021
update: a report from the American
Heart Association. Circulation 2021;
143: e254–e743.
10. Bozkurt B, Coats AJS, Tsutsui H,
Abdelhamid CM, Adamopoulos S, Albert
N, Anker SD, Atherton J, Böhm M, Butler
J, Drazner MH, Michael Felker G,
Filippatos G, Fiuzat M, Fonarow GC,
Gomez-Mesa JE, Heidenreich P, Imamura
T, Jankowska EA, Januzzi J, Khazanie P,
Kinugawa K, Lam CSP, Matsue Y, Metra
M, Ohtani T, Francesco Piepoli M,
Ponikowski P, Rosano GMC, Sakata Y,
Seferović P, Starling RC, Teerlink JR,
Vardeny O, Yamamoto K, Yancy C, Zhang
J, Zieroth S. Universal definition and clas-
sification of heart failure: a report of the
Heart Failure Society of America, Heart
Failure Association of the European Soci-
ety of Cardiology, Japanese Heart Failure
Society and Writing Committee of the
Universal Definition of Heart Failure: En-
dorsed by the Canadian Heart Failure So-
ciety, Heart Failure Association of India,
Cardiac Society of Australia and New
Zealand, and Chinese Heart Failure Asso-
ciation. Eur J Heart Fail 2021; 23:
352–380.
11. Kelder JC, Cramer MJ, van Wijngaarden
J, van Tooren R, Mosterd A, Moons KG,
Lammers JW, Cowie MR, Grobbee DE,
Hoes AW. The diagnostic value of physi-
cal examination and additional testing
in primary care patients with suspected
heart failure. Circulation 2011; 124:
2865–2873.
12. Mant J, Doust J, Roalfe A, Barton P,
Cowie MR, Glasziou P, Mant D,
McManus R, Holder R, Deeks J, Fletcher
K, Qume M, Sohanpal S, Sanders S,
Hobbs FD. Systematic review and indi-
vidual patient data meta-analysis of di-
agnosis of heart failure, with modelling
of implications of different diagnostic
strategies in primary care. Health
Technol Assess 2009; 13: 1–207 iii.
13. Drazner MH, Rame JE, Stevenson LW,
Dries DL. Prognostic importance of ele-
vated jugular venous pressure and a
third heart sound in patients with heart
failure. N Engl J Med 2001; 345:
574–581.
14. Drazner MH, Hellkamp AS, Leier CV,
Shah MR, Miller LW, Russell SD, Young
JB, Califf RM, Nohria A. Value of clini-
cian assessment of hemodynamics in ad-
vanced heart failure: the ESCAPE trial.
Circ Heart Fail 2008; 1: 170–177.
15. Anwaruddin S, Lloyd-Jones DM,
Baggish A, Chen A, Krauser D, Tung R,
Chae C, Januzzi JL Jr. Renal function,

ESC Heart Failure (2022)

DOI: 10.1002/ehf2.14255
 20555822, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14255 by INASP- NICARAGUA, Wiley Online Library on [06/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ACC/AHA/HFSA 2022 and ESC 2021 guidelines on heart failure comparison 13

congestive heart failure, and
amino-terminal pro-brain natriuretic
peptide measurement: results from the
ProBNP Investigation of Dyspnea in the
Emergency Department (PRIDE) Study.
J Am Coll Cardiol 2006; 47: 91–97.
16. Redfield MM, Rodeheffer RJ, Jacobsen
SJ, Mahoney DW, Bailey KR, Burnett JC
Jr. Plasma brain natriuretic peptide con-
centration: impact of age and gender. J
Am Coll Cardiol 2002; 40: 976–982.
17. Messroghli DR, Moon JC, Ferreira VM,
Grosse-Wortmann L, He T, Kellman P,
Mascherbauer J, Nezafat R, Salerno M,
Schelbert EB, Taylor AJ, Thompson R,
Ugander M, van Heeswijk R, Friedrich
MG. Clinical recommendations for car-
diovascular magnetic resonance map-
ping of T1, T2, T2* and extracellular vol-
ume: a consensus statement by the
Society for Cardiovascular Magnetic
Resonance (SCMR) endorsed by the
European Association for Cardiovascular
Imaging (EACVI). J Cardiovasc Magn
Reson 2017; 19: 75.
18. Deckers JW, Hare JM, Baughman KL.
Complications of transvenous right ven-
tricular endomyocardial biopsy in adult
patients with cardiomyopathy: a
seven-year survey of 546 consecutive di-
agnostic procedures in a tertiary referral
center. J Am Coll Cardiol 1992; 19:
43–47.
19. Veress G, Bruce CJ, Kutzke K, Click RL,
Scott CG, Oh JK, Rihal CS. Acute throm-
bus formation as a complication of right
ventricular biopsy. J Am Soc
Echocardiogr 2010; 23: 1039–1044.
20. Kannel WB, D’Agostino RB, Silbershatz
H, Belanger AJ, Wilson PW, Levy D. Pro-
file for estimating risk of heart failure.
Arch Intern Med 1999; 159: 1197–1204.
21. Butler J, Kalogeropoulos A,
Georgiopoulou V, Belue R, Rodondi N,
Garcia M, Bauer DC, Satterfield S, Smith
AL, Vaccarino V, Newman AB, Harris TB,
Wilson PW, Kritchevsky SB, Health ABC
Study. Incident heart failure prediction
in the elderly: the health ABC heart fail-
ure score. Circ Heart Fail 2008; 1:
125–133.
22. Agarwal SK, Chambless LE, Ballantyne
CM, Astor B, Bertoni AG, Chang PP,
Folsom AR, He M, Hoogeveen RC, Ni
H, Quibrera PM, Rosamond WD, Russell
SD, Shahar E, Heiss G. Prediction of inci-
dent heart failure in general practice:
the Atherosclerosis Risk in Communities
(ARIC) Study. Circ Heart Fail 2012; 5:
422–429.
23. Khan SS, Ning H, Shah SJ, Yancy CW,
Carnethon M, Berry JD, Mentz RJ,
O’Brien E, Correa A, Suthahar N, de
Boer RA, Wilkins JT, Lloyd-Jones DM.
10-year risk equations for incident heart
failure in the general population. J Am
Coll Cardiol 2019; 73: 2388–2397.
24. Yancy CW, Jessup M, Bozkurt B, Butler
J, Casey DE Jr, Drazner MH, Fonarow
GC, Geraci SA, Horwich T, Januzzi JL,
Johnson MR, Kasper EK, Levy WC,
Masoudi FA, McBride PE, McMurray JJ,
Mitchell JE, Peterson PN, Riegel B, Sam
F, Stevenson LW, Tang WH, Tsai EJ,
Wilkoff BL, American College of Cardiol-
ogy Foundation; American Heart Associ-
ation Task Force on Practice Guidelines.
2013 ACCF/AHA guideline for the man-
agement of heart failure: a report of the
American College of Cardiology
Foundation/American Heart Association
task force on practice guidelines. J Am
Coll Cardiol 2013; 62: e147–e239.
25. Ponikowski P, Voors AA, Anker SD,
Bueno H, Cleland JG, Coats AJ, Falk V,
González-Juanatey JR, Harjola VP,
Jankowska EA, Jessup M, Linde C,
Nihoyannopoulos P, Parissis JT, Pieske
B, Riley JP, Rosano GM, Ruilope LM,
Ruschitzka F, Rutten FH, van der Meer
P, Authors/Task Force Members, Docu-
ment Reviewers. 2016 ESC guidelines
for the diagnosis and treatment of acute
and chronic heart failure: the task force
for the diagnosis and treatment of acute
and chronic heart failure of the Euro-
pean Society of Cardiology (ESC). De-
veloped with the special contribution of
the heart failure association (HFA) of
the ESC. Eur J Heart Fail 2016; 18:
891–975.
26. McMurray JJ, Packer M, Desai AS, Gong
J, Lefkowitz MP, Rizkala AR, Rouleau JL,
Shi VC, Solomon SD, Swedberg K, Zile
MR, PARADIGM-HF Investigators and
Committees. Angiotensin-neprilysin in-
hibition versus enalapril in heart failure.
N Engl J Med 2014; 371: 993–1004.
27. Seferovic JP, Claggett B, Seidelmann SB,
Seely EW, Packer M, Zile MR, Rouleau
JL, Swedberg K, Lefkowitz M, Shi VC,
Desai AS, McMurray JJV, Solomon SD.
Effect of sacubitril/valsartan versus enal-
april on glycaemic control in patients
with heart failure and diabetes: a
post-hoc analysis from the
PARADIGM-HF trial. Lancet Diabetes
Endocrinol 2017; 5: 333–340.
28. Damman K, Gori M, Claggett B, Jhund
PS, Senni M, Lefkowitz MP, Prescott
MF, Shi VC, Rouleau JL, Swedberg K,
Zile MR, Packer M, Desai AS, Solomon
SD, McMurray JJV. Renal effects and as-
sociated outcomes during angiotensin-
neprilysin inhibition in heart failure.
JACC Heart Fail 2018; 6: 489–498.
29. Desai AS, Vardeny O, Claggett B,
McMurray JJ, Packer M, Swedberg K,
Rouleau JL, Zile MR, Lefkowitz M, Shi
V, Solomon SD. Reduced risk of
hyperkalemia during treatment of heart
failure with mineralocorticoid receptor
antagonists by use of sacubitril/
valsartan compared with enalapril:
a secondary analysis of the
PARADIGM-HF Trial. JAMA Cardiol
2017; 2: 79–85.
30. McMurray JJV, Solomon SD, Inzucchi
SE, Køber L, Kosiborod MN, Martinez
FA, Ponikowski P, Sabatine MS, Anand
IS, Bělohlávek J, Böhm M, Chiang CE,
Chopra VK, de Boer RA, Desai AS, Diez
M, Drozdz J, Dukát A, Ge J, Howlett
JG, Katova T, Kitakaze M, Ljungman
CEA, Merkely B, Nicolau JC, O’Meara
E, Petrie MC, Vinh PN, Schou M,
Tereshchenko S, Verma S, Held C,
DeMets DL, Docherty KF, Jhund PS,
Bengtsson O, Sjöstrand M, Langkilde
AM, DAPA-HF Trial Committees and In-
vestigators. Dapagliflozin in patients
with heart failure and reduced ejection
fraction. N Engl J Med 2019; 381:
1995–2008.
31. Zelniker TA, Wiviott SD, Raz I, Im K,
Goodrich EL, Bonaca MP, Mosenzon O,
Kato ET, Cahn A, Furtado RHM, Bhatt
DL, Leiter LA, McGuire DK, Wilding
JPH, Sabatine MS. SGLT2 inhibitors for
primary and secondary prevention of
cardiovascular and renal outcomes in
type 2 diabetes: a systematic review
and meta-analysis of cardiovascular out-
come trials. Lancet 2019; 393: 31–39.
32. Van Horn L, Carson JA, Appel LJ, Burke
LE, Economos C, Karmally W, Lancaster
K, Lichtenstein AH, Johnson RK,
Thomas RJ, Vos M, Wylie-Rosett J,
Kris-Etherton P, American Heart Associ-
ation Nutrition Committee of the Coun-
cil on Lifestyle and Cardiometabolic
Health; Council on Cardiovascular Dis-
ease in the Young; Council on Cardio-
vascular and Stroke Nursing; Council
on Clinical Cardiology; and Stroke
Council. Recommended dietary pattern
to achieve adherence to the American
Heart Association/American College of
Cardiology (AHA/ACC) guidelines: a
scientific statement from the American
Heart Association. Circulation 2016;
134: e505–e529.
33. Mahtani KR, Heneghan C, Onakpoya I,
Tierney S, Aronson JK, Roberts N,
Hobbs FDR, Nunan D. Reduced salt in-
take for heart failure: a systematic re-
view. JAMA Intern Med 2018; 178:
1693–1700.
34. Borlaug BA. Evaluation and manage-
ment of heart failure with preserved
ejection fraction. Nat Rev Cardiol 2020;
17: 559–573.
35. Anker SD, Butler J, Filippatos G, Ferreira
JP, Bocchi E, Böhm M, Brunner–la Rocca
HP, Choi DJ, Chopra V, Chuquiure-
Valenzuela E, Giannetti N, Gomez-Mesa
JE, Janssens S, Januzzi JL, Gonzalez-
Juanatey JR, Merkely B, Nicholls SJ,
Perrone SV, Piña IL, Ponikowski P, Senni
M, Sim D, Spinar J, Squire I, Taddei S,
Tsutsui H, Verma S, Vinereanu D, Zhang
J, Carson P, Lam CSP, Marx N, Zeller C,
Sattar N, Jamal W, Schnaidt S, Schnee
JM, Brueckmann M, Pocock SJ, Zannad
F, Packer M. Empagliflozin in heart fail-
ure with a preserved ejection fraction.
N Engl J Med 2021; 385: 1451–1461.
36. Redfield MM, Anstrom KJ, Levine JA,
Koepp GA, Borlaug BA, Chen HH,
LeWinter M, Joseph SM, Shah SJ,
Semigran MJ, Felker GM, Cole RT,
Reeves GR, Tedford RJ, Tang WH,
McNulty S, Velazquez EJ, Shah MR,
Braunwald E, NHLBI Heart Failure Clin-
ical Research Network. Isosorbide
mononitrate in heart failure with pre-

ESC Heart Failure (2022)

DOI: 10.1002/ehf2.14255

14
served ejection fraction. N Engl J Med
2015; 373: 2314–2324.
37. Redfield MM, Chen HH, Borlaug BA,
Semigran MJ, Lee KL, Lewis G, LeWinter
MM, Rouleau JL, Bull DA, Mann DL,
Deswal A, Stevenson LW, Givertz MM,
Ofili EO, O’Connor CM, Felker GM,
Goldsmith SR, Bart BA, McNulty SE,
Ibarra JC, Lin G, Oh JK, Patel MR, Kim
RJ, Tracy RP, Velazquez EJ, Anstrom
KJ, Hernandez AF, Mascette AM,
Braunwald E, RELAX Trial. Effect of
phosphodiesterase-5 inhibition on exer-
cise capacity and clinical status in heart
failure with preserved ejection fraction:
a randomized clinical Trial. JAMA 2013;
309: 1268–1277.
38. Crespo-Leiro MG, Metra M, Lund LH,
Milicic D, Costanzo MR, Filippatos G,
Gustafsson F, Tsui S, Barge-Caballero E,
de Jonge N, Frigerio M, Hamdan R,
Hasin T, Hülsmann M, Nalbantgil S,
Potena L, Bauersachs J, Gkouziouta A,
Ruhparwar A, Ristic AD, Straburzynska-
Migaj E, McDonagh T, Seferovic P,
Ruschitzka F. Advanced heart failure: a
position statement of the Heart Failure
Association of the European Society of
Cardiology. Eur J Heart Fail 2018; 20:
1505–1535.
39. Stevenson LW, Pagani FD, Young JB,
Jessup M, Miller L, Kormos RL, Naftel
DC, Ulisney K, Desvigne-Nickens P,
Kirklin JK. INTERMACS profiles of ad-
vanced heart failure: the current pic-
ture. J Heart Lung Transplant 2009; 28:
535–541.
40. Szczurek W, Szyguła-Jurkiewicz B,
Siedlecki Ł, Gąsior M. Prognostic scales
in advanced heart failure. Kardiochir
Torakochirurgia Pol 2018; 15: 183–187.
41. Goldstein DJ, Meyns B, Xie R, Cowger J,
Pettit S, Nakatani T, Netuka I, Shaw S,
Yanase M, Kirklin JK. Third annual re-
port from the ISHLT mechanically
assisted circulatory support registry: a
comparison of centrifugal and axial
continuous-flow left ventricular assist
devices. J Heart Lung Transplant 2019;
38: 352–363.
42. Baumwol J. “I need help”—a mnemonic
to aid timely referral in advanced heart
failure. J Heart Lung Transplant 2017;
36: 593–594.
43. Chioncel O, Parissis J, Mebazaa A,
Thiele H, Desch S, Bauersachs J, Harjola
VP, Antohi EL, Arrigo M, Ben Gal T,
Celutkiene J, Collins SP, DeBacker D,
Iliescu VA, Jankowska E, Jaarsma T,
Keramida K, Lainscak M, Lund LH, Lyon
AR, Masip J, Metra M, Miro O, Mortara
A, Mueller C, Mullens W, Nikolaou M,
Piepoli M, Price S, Rosano G, Vieillard-
Baron A, Weinstein JM, Anker SD,
Filippatos G, Ruschitzka F, Coats AJS,
Seferovic P. Epidemiology, pathophysiol-
ogy and contemporary management of
cardiogenic shock—a position statement
from the Heart Failure Association of
the European Society of Cardiology.
Eur J Heart Fail 2020; 22: 1315–1341.
44. Gayat E, Arrigo M, Littnerova S, Sato N,
Parenica J, Ishihara S, Spinar J, Müller
C, Harjola VP, Lassus J, Miró Ò,
Maggioni AP, AlHabib KF, Choi DJ, Park
JJ, Zhang Y, Zhang J, Januzzi JL Jr,
Kajimoto K, Cohen-Solal A, Mebazaa A,
on behalf of the GREAT Network. Heart
failure oral therapies at discharge are
associated with better outcome in acute
heart failure: a propensity-score
matched study. Eur J Heart Fail 2018;
20: 345–354.
45. Bhagat AA, Greene SJ, Vaduganathan
M, Fonarow GC, Butler J. Initiation, con-
tinuation, switching, and withdrawal of
heart failure medical therapies during
hospitalization. JACC Heart Fail 2019;
7: 1–12.
46. Marrouche NF, Brachmann J, Andresen
D, Siebels J, Boersma L, Jordaens L,
Merkely B, Pokushalov E, Sanders P,
20555822, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14255 by INASP- NICARAGUA, Wiley Online Library on [06/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
A.H. Behnoush et al.
Proff J, Schunkert H, Christ H, Vogt J,
Bänsch D. Catheter ablation for atrial fi-
brillation with heart failure. N Engl J
Med 2018; 378: 417–427.
47. Packer DL, Mark DB, Robb RA, Monahan
KH, Bahnson TD, Poole JE, Noseworthy
PA, Rosenberg YD, Jeffries N, Mitchell
LB, Flaker GC, Pokushalov E, Romanov
A, Bunch TJ, Noelker G, Ardashev A,
Revishvili A, Wilber DJ, Cappato R, Kuck
KH, Hindricks G, Davies DW, Kowey PR,
Naccarelli GV, Reiffel JA, Piccini JP,
Silverstein AP, al-Khalidi HR, Lee KL,
for the CABANA Investigators. Effect of
catheter ablation vs antiarrhythmic drug
therapy on mortality, stroke, bleeding,
and cardiac arrest among patients with
atrial fibrillation: the CABANA random-
ized clinical trial. JAMA 2019; 321:
1261–1274.
48. Packer DL, Piccini JP, Monahan KH, Al-
Khalidi HR, Silverstein AP, Noseworthy
PA, Poole JE, Bahnson TD, Lee KL, Mark
DB, CABANA Investigators. Ablation ver-
sus drug therapy for atrial fibrillation in
heart failure: results from the CABANA
trial. Circulation 2021; 143: 1377–1390.
49. Mehta LS, Warnes CA, Bradley E, Burton
T, Economy K, Mehran R, Safdar B,
Sharma G, Wood M, Valente AM,
Volgman AS, American Heart Associa-
tion Council on Clinical Cardiology;
Council on Arteriosclerosis, Thrombosis
and Vascular Biology; Council on Car-
diovascular and Stroke Nursing; and
Stroke Council. Cardiovascular consider-
ations in caring for pregnant patients: a
scientific statement from the American
Heart Association. Circulation 2020;
141: e884–e903.
50. Schaufelberger M. Cardiomyopathy and
pregnancy. Heart 2019; 105:
1543–1551.
ESC Heart Failure (2022)
DOI: 10.1002/ehf2.14255