Summary

Comprehensive update replacing the 2013 and 2017 ACCF/AHA HF guidelines, covering prevention, diagnosis, staging, and management across the full spectrum of heart failure. Key changes include four-pillar GDMT for HFrEF with addition of SGLT2 inhibitors, new recommendations for HFpEF (SGLT2i Class 2a; MRA and ARNi Class 2b), revised stage terminology (“at-risk” stage A, “pre-HF” stage B), introduction of HFimpEF category, expanded cardiac amyloidosis diagnostic/treatment recommendations, and cost-value statements for selected therapies.

Key Recommendations

Initiate four-pillar GDMT for HFrEF: ARNi (preferred over ACEi/ARB), evidence-based beta blocker (bisoprolol, carvedilol, or sustained-release metoprolol succinate), MRA, and SGLT2 inhibitor (dapagliflozin or empagliflozin) regardless of diabetes status.
Switch chronic symptomatic HFrEF patients tolerating ACEi/ARB to ARNi (sacubitril-valsartan) to reduce morbidity and mortality; allow ≥36 hours between ACEi and ARNi doses.
For HFpEF (LVEF ≥50%), SGLT2 inhibitors are Class 2a; MRA and ARNi are Class 2b (greater benefit at lower end of EF spectrum); treat hypertension (Class 1) and manage AF (Class 2a); avoid routine nitrates and PDE-5 inhibitors (Class 3).
For HFmrEF (LVEF 41–49%), SGLT2i is Class 2a; weak (Class 2b) recommendations for ACEi/ARB/ARNi, beta blockers, and MRA.
Patients with HFimpEF (previous LVEF ≤40%, now >40%) should continue HFrEF GDMT, as withdrawal causes relapse in ~40%.
Screen for cardiac amyloidosis with serum/urine immunofixation electrophoresis, serum free light chains, and 99mTc-PYP scintigraphy; treat ATTR-CM with tafamidis and consider anticoagulation given high thrombus risk.
Refer advanced HF patients early to a specialty team (I-NEED-HELP triggers) for evaluation for transplantation, durable LVAD, or palliative inotropes.
Treat hypertension in stage A patients to SBP <130 mm Hg; use SGLT2i in type 2 diabetics with CVD or high CVD risk to prevent incident HF.
Initiate ACEi/ARB and beta blocker for stage B patients with LVEF ≤40%; place primary-prevention ICD in post-MI patients with LVEF ≤30% even when asymptomatic.
For acute decompensated HF, continue and optimize GDMT during hospitalization; initiate ARNi pre-discharge; titrate IV loop diuretics aggressively until congestion resolved.
For HF with AF and CHA2DS2-VASc ≥2 (men) or ≥3 (women), anticoagulate with DOAC preferred over warfarin; consider catheter ablation in HFrEF with AF to reduce mortality and hospitalization.
For HFrEF with persistent severe secondary MR despite GDMT, consider transcatheter edge-to-edge MV repair if LVEF 20–50%, LVESD ≤70 mm, and PASP ≤70 mm Hg (COAPT criteria).

Thresholds & Doses

HFrEF defined as LVEF ≤40%; HFmrEF 41–49%; HFpEF ≥50%; HFimpEF previous ≤40% with follow-up >40%.
Sacubitril-valsartan: start 49/51 mg BID (or 24/26 mg BID if low BP/ACEi-naïve); target 97/103 mg BID.
Enalapril target 10–20 mg BID; lisinopril 20–40 mg daily; captopril 50 mg TID; ramipril 10 mg daily.
Carvedilol target 25–50 mg BID; metoprolol succinate 200 mg daily; bisoprolol 10 mg daily.
Spironolactone start 12.5–25 mg daily, target 25–50 mg daily; eplerenone start 25 mg, target 50 mg daily; contraindicated if eGFR ≤30 mL/min/1.73 m² or K ≥5.0 mEq/L.
Dapagliflozin and empagliflozin 10 mg daily; avoid if eGFR <20–25 mL/min/1.73 m².
Ivabradine 5 mg BID titrated to 7.5 mg BID for HFrEF with LVEF ≤35%, sinus rhythm, HR ≥70 bpm on maximally tolerated beta blocker.
Hydralazine/isosorbide dinitrate fixed-dose: 37.5/20 mg TID, target 75/40 mg TID, for self-identified Black patients with NYHA III–IV HFrEF on optimal GDMT.
Digoxin 0.125–0.25 mg daily; target serum level 0.5 to <0.9 ng/mL; lower dose if age >70, renal impairment, or low lean body mass.
Vericiguat start 2.5 mg daily, target 10 mg daily; exclude if SBP <100 mm Hg or eGFR <15.
Tafamidis 61 mg daily (or 80 mg meglumine) for ATTR-CM NYHA I–III.
BNP screening threshold ≥50 pg/mL (STOP-HF) for stage A risk stratification; NT-proBNP ≥125 pg/mL or BNP ≥35 pg/mL supports stage B diagnosis.
ICD: LVEF ≤30% post-MI (≥40 days post-MI, ≥90 days post-revascularization); LVEF ≤35% with NYHA II–III for primary prevention.
CRT indicated for LVEF ≤35%, sinus rhythm, LBBB with QRS ≥150 ms, NYHA II–IV on GDMT.
BP target <130/80 mm Hg for stage A patients with CVD risk ≥10%.
Sodium restriction <2300 mg/day reasonable; aggressive in-hospital restriction (<0.8 g/d) not beneficial.
Peak VO2 ≤14 mL/kg/min (or ≤12 mL/kg/min on beta blocker) suggests transplant candidacy; 6-minute walk <300 m predicts poor 3-year survival.
Loop diuretic dosing in ADHF: at least double home daily dose given IV; furosemide max 600 mg/day, bumetanide 10 mg/day, torsemide 200 mg/day.
Cardiogenic shock criteria: SBP <90 mm Hg >30 min (or vasopressor-dependent) plus hypoperfusion (lactate >2 mmol/L, urine output <30 mL/h, altered mentation, cool extremities).

Citations

Section 2.2/Table 4 — LVEF-based classification of HFrEF, HFmrEF, HFpEF, HFimpEF
Section 7.3.1–7.3.4 — Four-pillar GDMT (ARNi/ACEi/ARB, beta blocker, MRA, SGLT2i) for HFrEF
Section 7.3.8/Table 14 — GDMT target doses, sequencing, and uptitration
Section 7.7.1/Figure 12 — HFpEF recommendations including SGLT2i, MRA, ARNi
Section 7.8/Figure 13 — Cardiac amyloidosis diagnostic algorithm and tafamidis treatment
Section 8.1/Tables 18–19 — Advanced HF referral indicators (I-NEED-HELP) and MCS indications
Section 9.5/Tables 22–24 — Cardiogenic shock SCAI classification and management
Section 10.2 — AF management in HF including anticoagulation and ablation
Top 10 Take-Home Messages — Summary of new recommendations including SGLT2i, HFimpEF, amyloidosis