2025 iCARDIO联盟全球心力衰竭实施指南

Preamble

The International CARDIO Alliance to Improve Disease Outcomes (iCARDIO Alliance: https://icardioalliance.org ) aims to gather leading cardiovascular societies around the globe as partner organizations to improve the quality of cardiovascular care, from prevention and diagnosis to treatment and follow-up. The goal of these global implementation guidelines is to achieve global representation in writing panels and to produce concise and practical guidelines applicable to all cardiovascular care worldwide. In addition to clinical practice guidelines developed by other medical associations, the recommendations by iCARDIO Alliance take into account resource availability on at least 3 economic levels (with no economic consideration; resources somewhat limited; resources severely limited). They are written by a team including world-renowned experts with a maximum of $50\%$ of the writing task force representing Europe and North America and $50\%$ or more from the rest of the world. The peer review team is also made up of worldwide experts further enriching these documents and leading to a fi nal phase of public review open to all. The viewpoints of persons with lived experience are embedded within this global implementation guideline process including also a public review phase. Through this innovative approach iCARDIO Alliance hopes to enhance guideline dissemination and implementation on a global scale.

Introduction

Heart failure (HF) is a leading public health challenge, with over 64 million prevalent cases worldwide [ 1 ]. Studies from the USA have projected a $46\%$ increase in HF cases from 2012 to 2030 due to ageing population, with a signi fi cant rise in HF with preserved ejection fraction (HFpEF). In addition, healthcare costs associated with HF are expected to rise by approximately $127\%$ [ 2 ]. By 2050, nearly 11 million adults are expected to be affected by HF in the USA [ 3 ]. To mitigate this growing public health threat, it is essential to improve the understanding of this condition, promote lifestyle modi fi cations, and implement early detection strategies, and treatment modalities. In 1994, the US Agency for Healthcare Policy and Research published the fi rst clinical guidelines for managing HF, which were subsequently followed by the American Heart Association and the American College of Cardiology guidelines in 1995 [ 4 , 5 ]. Since then, several countries- and region-speci fi c guidelines have emerged, predominantly from Western countries, which in fl uence decision-making across multiple stakeholders, including patients, clinicians, healthcare leaders, and payers [ 6 – 17 ]. However, uniform implementation of these guidelines across all regions remains a challenge due to variations in infrastructure and local practices [ 18 ]. Current evidence suggests that guideline-directed medical therapies (GDMT) signi fi - cantly decrease mortality and hospitalizations among individuals with HF, particularly HF with reduced ejection fraction (HFrEF), and are therefore recommended as highly

cost-effective interventions by the Disease Control Priorities Project [ 19 ]. Despite strong evidence supporting GDMT, its utilization remains limited in low- and middle-income countries (LMIC), where barriers at the health system, provider, and patient levels contribute to a $22\%$ to $58\%$ higher 1- year mortality rate compared to high-income countries [ 1 , 20 , 21 ].

Furthermore, there is a lack of substantial data to ascertain the relevance of current guidelines to diverse populations across the globe. Often, where evidence is strong, the recommendations are unlikely to adjust to accommodate economic constraints and availability [ 18 ]. For example, in the Middle East where economic constraints may not play a big role, but a particularly high burden of HF exists, even after accounting for variations in age demographics [ 22 – 24 ], there remains a huge gap in reaching the guideline-recommended doses for all the medications. We lack an understanding of the reasons behind this gap in practice [ 20 , 21 ]. Similarly, subSaharan Africa and Asia face signi fi cant challenges in HF management, with limited access to essential medications and therapies due to economic constraints, underdeveloped healthcare infrastructure, and a high prevalence of risk factors such as hypertension and rheumatic heart disease [ 1 , 25 – 27 ]. These global disparities underscore the need for new, universally applicable guidelines that can ensure both relevance and effectiveness in HF management.

Thus, this document strives to usher in a new era of practical guidelines that are responsive to unique challenges faced by individual patients and healthcare providers during HF management. By integrating past guidelines with the latest research and evidence, it offers an updated, comprehensive approach, that equips healthcare providers with the tools needed to address the evolving challenges in diagnosis, prevention, and management of acute and chronic HF. Lastly, HF management can be overwhelming due to economic burden, particularly in resource-limited countries with restricted access to advanced therapies. To address this, we have proposed alternative treatment strategies where recommended or strongly recommended grading was given. In cases of suggestive grading, we have not provided economic considerations as these were suggestions, and may be acceptable to forego in cases of economic limitations. These considerations ensure that the guidelines remain adaptable to diverse healthcare settings while maintaining their ef fi cacy in improving patient outcomes.

Grading/Recommendations

Based on the available evidence and consensus among the committee members regarding the risks and bene fi ts of interventions, the recommendations were classi fi ed as strongly recommend (SR), recommend (R), suggest (Su), and do not do (DND) ( Table 1 ). To make the document more readable and concise, we decided to not reference each recommendation. Also, we acknowledge that there have been discussions whether to use the term “ people with $\mathrm{HF^{\prime\prime}}$ or “ patients

Global Implementation Guidelines on Heart Failure

with $\mathrm{HF^{\prime\prime}}$ . In this document, we will use “ patients with HF ” as this is more commonly used globally.

When recommendations were made, also more recent published evidence was taken into account, for instance regarding device therapies (i.e. on RESHAPE-HF2 and an MTEER-meta-analysis, for MONITOR-HF, and the TRILUMINATE trial) [ 28 – 34 ], drug therapy in HF (FAIR-HF2, a metaanalysis on intravenous iron, ATTRibute-CM, HELIOS-B trial, FINEARTS-HF, 2 STEP-HFpEF trials, STEP-HFpEF meta-analysis, and the SUMMIT trial) [ 35 – 45 ]. On the issue of fl uid restriction, we considered also the FRESH-UP trial [ 46 ].

## Prevention of Heart Failure

Therapeutic interventions and lifestyle modi fi cation in patients at risk of HF have been associated with a decreased incidence of HF and the likelihood of hospitalization due to HF. Considering the available data, the following recommendations have been proposed for the prevention of HF ( Figure 1 , Table 2 ).

Diagnostics

The diagnosis of HF requires the presence of symptoms and/ or signs of HF and objective evidence of cardiac dysfunction. Symptoms and signs lack suf fi cient accuracy to be used alone to make the diagnosis of HF, thus under- and misdiagnosis of HF can commonly occur. To address this, several diagnostic modalities should be utilized to diagnose or determine the prognosis of HF ( Figure 1 , Table 3 ).

Of note, this guideline diagnostically and therapeutically distinguishes between HFrEF and HFpEF. It is recognized that for all practical intents and purposes patients that elsewhere are considered as HF patients with “ mid-range ” or “ mildly-reduced ” LVEF (termed patients with “ HFmrEF ” and typically de fi ned as patients with an LVEF of $40\%–49\%$ ) are considered as patients with HFrEF. It is recognized that diagnostic certainty in these patients is somewhat reduced (due to the variability of LVEF assessment) and that the absolute bene fi t of GDMT may be somewhat less than in patients with LVEF ${<}40\%$ .

Treatment

Drugs

Pharmacological therapies have been shown to improve symptoms, reduce hospitalizations and reduce mortality in patients with HF by improving cardiac function and slowing the disease progression. Despite strong evidence supporting the bene fi ts of certain medications for HFrEF, several other classes of medications still have either unproven bene fi ts or potential risks of increased fl uid retention, drug interactions, HF hospitalization, or mortality. Recommendations regarding the pharmacological therapies for patients with HF are summarized in Figure 2 and Figure 3 as well as in

Table 4 focusing on drugs commercially available in major parts of the world.

Devices

A crucial role has been played by RCTs in shaping decisions regarding cardiac implantable devices such as implantable cardioverter-de fi brillators (ICDs), and cardiac resynchronization therapy (CRT) over the past two decades. While subgroup analyses of these trials have provided additional insights, it is important to note that they were not the primary endpoints of these studies and should be interpreted cautiously. Recently, cardiac contractility modulation (CCM) and barore fl ex activation therapy (BAT) have shown benefi cial effects in patients with HF. Strategies and recommendations regarding device therapies are summarized in Table 5 and Figure 2 .

Surgery and Trans-Catheter Procedures

Strategies for invasive management and device-based therapies for patients with severe valvular diseases or coronary artery diseases are mentioned in Table 6 and Figure 2 .

Special Consideration

Heart failure management becomes more challenging in the presence of various comorbidities, such as amyloidosis. Moreover, in pregnancy, certain medications should be avoided due to potential risks to the fetus and other adverse effects. Recommendations about the management of HF in such special conditions are highlighted in Table 7 and Table 8 , and Figure 4 .

Conclusions

The recommendations provided in this document offer a comprehensive framework for HF management, drawing on the most recent evidence to support physicians in their practice. However, it is pertinent to note that they should not replace clinical judgment. Effective HF management requires adapting these guidelines to the unique circumstances of each patient and the resources available in their region. A comprehensive overview of the recommendations for management of patients with HFpEF and HFrEF is given in Figures 5 and 6 . It is crucial for healthcare providers to offer personalized care tailored to each patient ’ s speci fi c clinical pro fi le, symptoms, comorbidities, and individual preferences. Recognizing potential obstacles to implementing these recommendations, including resource constraints, access to particular interventions and technologies, cultural in fl uences and local standards of care is essential for effective application of these guidelines. By integrating these recommendations with individualized patient care and addressing local healthcare dynamics, clinicians can optimize HF management and improve quality of life for patients.

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Table 1 Grading and recommendations.

|No. Definition|Level of Recommendation| |---|---| |1-01 Evidence or consensus that a specific diagnostic test or treatment is effective, beneficial and valuable.|Strongly recommend (SR)| |1-02 Majority of evidence or opinions support the benefits or effectiveness.|Recommend (R)| |1-03 Usefulness or effectiveness is less clearly supported by evidence or opinion.|Suggest (Su)| | 1-04 Evidence or consensus suggests that it is ineffective and, in some cases, may even be harmful.|Do not do (DND)|

Table 2 Recommendations for the prevention of heart failure.

|No.|Guideline Statement|Level of Recommendation| |---|---|---| |2-01| Counsel against sedentary habits, tobacco, and alcohol abuse to decrease the risk of HF. |SR| |||| |2-02||R| |2-03| Request genetic counseling and testing (if available) to facilitate early diagnosis and prevent or delay the progression of disease in family members of patients with non-ischemic cardiomyopathy. Treat hypertension to recommended blood pressure targets to prevent subsequent HF. Use evidence-based SGLT2 inhibitors to reduce HF hospitalizations in patients with T2DM or CKD regardless of glycemic status. |SR| |||| | 2-04 Resources severely limited | Use evidence-based SGLT2 inhibitors to reduce HF hospitalizations in patients with T2DM or CKD regardless of glycemic status. Use empagliflozin, dapagliflozin or any regionally approved SGLT2 inhibitor to reduce HF hospitalization in patients with T2DM or CKD regardless of glycemic |SR| ||status.|| |2-05|Use evidence-based GLP-1 RA based therapies to reduce HF|R| |2-06|hospitalizations in patients with T2DM.|Su| || Use evidence-based SGLT2 inhibitors to reduce HF hospitalization in post- AMI patients with LVEF ||

Abbreviations: SR, strongly recommend; R, recommend; Su, suggest; DND, do not do; ACEi, angiotensin-converting enzyme inhibitors; ACS, acute coronary syndrome; AMI, acute myocardial infarction; ARB, angiotensin receptor blocker; BMI, body mass index; CVD, cardiovascular disease; CKD, chronic kidney disease; GDMT, guideline-directed medical therapy; GLP-1RA, glucagon-like peptide 1 receptor agonist; HF, heart failure; LMIC, low- and middle-income countries; LVEF, left ventricular ejection fraction; MI, myocardial infarction; MRA, mineralocorticoid receptor antagonist; RHD, rheumatic heart disease; RF, rheumatic fever; SGLT2, sodium-glucose cotransporter-2; T2DM, type 2 diabetes mellitus.

 Figure 1 Recommendations for prevention and diagnosis of heart failure. Abbreviations: SR, strongly recommend; R, recommend; Su, suggest; and DND, Do not do. ACEi, angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor blocker; BNP, brain natriuretic peptide; CMR, cardiac magnetic resonance; CPET, cardiopulmonary exercise training; CT, computed tomography; CVD, cardiovascular disease; CXR, chest X-ray; DPD, 3,3-diphosphono-1,2-propanodicarboxylic acid; GDMT, guideline-directed medical therapy; GLP-1RA, glucagon-like peptide 1 receptor agonist; HF, heart failure; HMDP, hydroxymethylene diphoshonate; NT-proBNP, N-terminal pro-B-type natriuretic peptide; POCUS, point of care ultrasound; PET, positron emission tomography; PYP, pyrophosphate; TTE, transthoracic echocardiography; SGLT2, sodium-glucose co-transporter 2.

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Table 3 Recommendations for the diagnostic tests in patients with heart failure.

|No.|Guideline Statement|Level of Recommendation| |---|---|---| |3-01| Inquire regarding family history, previous malignancy, acromegaly, hypo- or|SR| ||hyperthyroidism, exposure to metals or chemicals, alcohol, illit drug use and|| ||exposure to HIV, chemotherapy, immunotherapy or cardiac irradiation in patients|| ||with suspected cardiomyopathy.|| |3-02| Perform EKG and chest X-ray on all patients with suspected HF.|SR| |3-03| Measure BNP or NT-proBNP or MR-proANP, where available, to make or exclude|| || new diagnosis of HF in patients presenting with dyspnea.|SR| ||The best use for natriuretic peptides is to rule-out presence of heart failure.*|| | Resources severely|When use of natriuretic peptides is not covered or reimbursed, consider echocardiography|| |limited|and/or chest X-ray to aid diagnosis of HF and treatment decisions.|| |3-04| Perform serological tests to diagnose Chagas disease in patients with suspected|R| |3-05|HF, specifically in endemic areas such as Latin America.|(a): SR| || Perform TTE during the initial assessment (recommendation a), and 3-6 months after optimization of therapies for patients with HFrEF (b); to evaluate cardiac || || structure and function, and to guide management.|(b): R| |Resources somewhat| Perform TTE during the initial assessment and diagnosis and then subsequently, only if there are significant changes to the patient's clinical status. || |limited||| |3-06| Perform CMR, where available/affordable, to evaluate myocardium in possible cases of inflammatory diseases like myocarditis or sarcoidosis, infiltrative diseases like amyloidosis or Fabry's disease, or iron overload/hemochromatosis, |R| |||R| |Resources somewhat|hypertrophic cardiomyopathy, and suspected previous infarction.|R| |limited|initial clinical eoaluation and patient's clinical status changes significantly despite being|| ||on GDMT to rule out infiltrative diseases.|| |3-07| Perform PET/CT scan in patients with suspected sarcoidosis.|R| |3-08|Perform point of care ultrasound in patients with HF to monitor congestion.|R| |3-09| Perform DPD/PYP/HMDP scintigraphy in patients with suspected TTR amyloidosis. |SR| |3-10| Evaluate patients with HF for possible ischemic heart disease etiology to identify|| ||the cause of HF and assess the anatomy and functional status. The choice of|SR| |||SR| || evaluation method should depend on pre-test probability, availability of the diagnostic modality, and local expertise. || |3-11| Perform invasive hemodynamic monitoring to guide the management of selected|Su| || patients with HF and persistent or worsening NYHA class II/IV symptoms, signs,|| |3-12|or diagnostic parameters when hemodynamic status is uncertain.|| || Perform endomyocardial biopsy in patients with HF, if a specific diagnosis is|Su| || suspected that could affect the management and prognosis. Perform non-invasive home tele-monitoring in patients with HF, to decrease || |3-13|hospitalization for HF and risk of CV death.|Su| |3-14| Perform CPET for selected patients with HF to help determine the cause and|R| || severity of exercise intolerance and eligibility for advanced therapies such as MCS and heart transplant. || |||| | Resources severely limited | When resources are limited, the 6MWT can help determine the need for referral for advanced therapies such as MCS and heart transplant. || |||| |3-15| Perform RHC in patients with persistent right-sided HF to determine PAPI, PASP, PVR, transpulmonary gradient, PCWP, RVSWI and to exclude left-sided HF as |R| |3-16|underlying cause.|| ||Consider genetic counselling and testing in patients with suspected non-ischemic|Su| ||cardiomyopathy and relevant family history or cardiomyopathy with arrhythmias.||

Global Implementation Guidelines on Heart Failure

Table 3. (continued).

|No.| Guideline Statement |Level of Recommendation| |---|---|---| |Resources somewhat|Patients who have presentation or family history suggestioe of genetic dilated|| |limited|cardiomyopathy but lack either the access or interest for genetic testing should nonetheless|| || be counseled about screening family members with EKG and echocardiography Perform a formal sleep study to determine the presence of CSA in patients being || |3-17||Su| |3-17|considered for positive pressure mask therapy of sleep apnea with HF.||

\*Note: Best cut-offs to rule-out heart failure in the chronic setting using natriuretic peptides are for BNP: ${<}35\,\mathrm{ps}/\mathrm{mL},$ for NT-proBNP: ${<}125\,\mathrm{pg}/\mathrm{mL},$ and for MRproANP: , 120 pmol/L.

Abbreviations: SR, strongly recommend; R, Recommend; Su, suggest; DND, do not do; 6MWT, 6-minute walk test; BNP, B-type natriuretic peptide; CMR, cardiac magnetic resonance; CSA, central sleep apnea; CPET, cardiopulmonary exercise testing; CV, cardiovascular; DPD, 3,3-diphosphono1,2-propanodicarboxylic acid, GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; HMDP, hydroxymethylene diphoshonate; MCS, mechanical circulatory support; NT-proBNP, N-terminal prohormone of B-type natriuretic peptide; NYHA, New York Heart Association; PAPI, pulmonary artery pulsatility index; PASP, pulmonary artery systolic pressure; PCWP, pulmonary capillary wedge pressure; PET, positron emission tomography; PVR, pulmonary vascular resistance; PYP, pyrophosphate; TTE, transthoracic echocardiography; RHC, right heart catheterization; RVSWI, right ventricular stroke work index.

Table 4 Recommendations for pharmacological therapies in patients with heart failure.

|No.|Guideline Statement|Level of Recommendation| |---|---|---| |4-01| Use diuretics in patients with HF and signs and symptoms of congestion to |SR| ||alleviate symptoms, improve functional status and decrease the risk of HF|| ||hospitalization, irrespective of LVEF.|| |4-02|Use higher dose of IV loop diuretics or addition of a second diuretic|| |4-02| (thiazide, metolazone or acetazolamide) in patients hospitalized /non-|R| ||hospitalized with HF when diuresis is inadequate to relieve signs and|| ||symptoms of congestion.|| |4-03||SR| || Among RAASi, use ARNI as first-line therapy in ambulatory patients with HFrEF to reduce mortality and morbidity. If ARNI is contraindicated, use ACEi or ARB. || |4-04| In patients with HFrEF and NYHA I and II class symptoms who can|SR| |4-04|tolerate ACEi or ARB, use ARNI as a replacement therapy to reduce|SR| || mortality and morbidity.|| |Resources severely|Any ACEi or ARB can be used instead of ARNI among patients with HFrEF and|| |limited||| |4-05| Do not use ARNI simultaneously with ACEi or within 36 hours of the last ACEi dose. |DND| |4-06| Do not use ARNI or ACEi in patients with a history of angioedema.|DND| |4-07|Use bisoprolol, carvedilol, nebivolol, or sustained-release metoprolol|SR| ||succinate in patients with HFrEF to reduce the risk of cardiovascular|| |4-08| Use MRA in patients with HFrEF, eGFR >30 mL/min/1.73m? and potassium ||

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Table 4. (continued).

|No.|Guideline Statement|Level of Recommendation| |---|---|---| | Resources somewhat limited |Use eplerenone in patients oho develop gynecomastia on spironolactone.|| |4-12| Use evidence based SGLT2 inhibitors in patients with HF regardless of|SR| |||| |4-13| Optimize GDMT and attempt to achieve target doses to ensure maximum therapeutic benefits and improved patients' outcomes. |SR| |Resources somewhat| Advocate for the use of affrdable, generic medications and explore strategies to overcome barriers to drug access in resource-limited settings. || | or severely limited||| || Use a combination of hydralazine and isosorbide dinitrate in Black patients with NYHA class II-IV symptoms, despite receiving optimal therapy, to |Su| |4-15|Use ivabradine in patients with HFrEF (LVEF ||

Global Implementation Guidelines on Heart Failure

Table 4. (continued).

| No. |Guideline Statement|Level of Recommendation| |---|---|---| |4-29| Use intravenous iron supplementation with ferric carboxymaltose or ferric |R| ||derisomaltose to reduce the risk of HF hospitalization and CV death in|R| || patients with HFrEF and iron deficiency with or without anemia.|R| |Resources somewhat|Use iron sucrose, ferric carboxymaltose or ferric derisomaltose (whichever is|| |limited|affordable) instead of the above.|| |Resources severely| Use of any non-dextran containing intravenous iron supplementation may be considered, whichever is accessible. Initiate all 4 foundational therapies (ARNI, SGLT2 inhibitors, beta-blockers and MRA) in patients with HFrEF, at low doses once hemodynamically || | limited 4-30 ||R| || Initiate all 4 foundational therapies (ARNI, SGLT2 inhibitors, beta-blockers and MRA) in patients with HFrEF, at low doses once hemodynamically stabilized and then optimize dosages every 1-2 weeks, depending on symptoms, vitals and labs, and then at 3-4 months follow-up. || |Resources somewhat| stabilized and then optimize dosages every 1-2 weeks, depending on symptoms, vitals and labs, and then at 3-4 months follow-up. Initiate the least expensive combination of quadruple therapy in patients with HFrEF,at low doses once hemodynamically stabilized and then optimize dosages || |limited| Initiate the least expensive combination of quadruple therapy in patients with HFrEF,at low doses once hemodynamically stabilized and then optimize dosagesHFrEF,at low doses once hemodynamically stabilized and then optimize dosages every 1-2 weeks, depending on symptoms, vitals and labs, and then at 3-4every 1-2 weeks, depending on symptoms, vitals and labs, and then at 3-4 months followo-up. Use foundational triple therapy (ACEi/ARB, beta-blockers and MRA) at optimized doses and diuretics as needed. || |Resources severely||| |limited||| | 4-31 4-32 | Refer patients with HF to cardiac rehabilitation program (for tailored exercises at least 30 minutes 3 times per week for 30 days) to improve symptoms and QoL. |R| || Do not use thiazolidinediones and non-dihydropyridine calcium channel blockers in patients with HF and LVEF ||

In patients with LVEF $40\%\!-\!49\%$ , diagnostic accuracy of test is less certain (due to the variability of LVEF assessments) and the absolute amount of therapeutic bene fi t of GDMT is somewhat less than in patients with LVEF ${<}40\%$ . Abbreviations: SR, strongly recommend; R, recommend; Su, suggest; DND, do not do; ACEi, angiotensin converting enzyme inhibitors; ACS, acute coronary syndrome; AMI, acute myocardial infarction; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor neprilysin inhibitors; BPM, beats per minute; BNP, B-type natriuretic peptide; COX-2, cyclo-oxygenase-2; CV, cardiovascular; CVD, cardiovascular disease; DPP-4, dipeptidyl peptidase-4; eGFR, estimated glomerular fi ltration rate; GDMT, guideline-directed medical therapy; GLP-1RA, glucagon-like peptide 1 receptor agonist; HF, heart failure; HFimpEF, heart failure with improved ejection fraction; HFpEF, heart failure with preserved ejection fraction; heart failure with mildly reduced ejection fraction; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MCS, mechanical circulatory support; MRA, mineralocorticoid receptor antagonist; NT-proBNP, N-terminal prohormone of B-type natriuretic peptide; NSAIDs, non-steroidal anti-in fl ammatory drugs; NYHA, New York Heart Association; PDE5, phosphodiesterase-5; QoL, quality of life; RAASi, Renin-angiotensin-aldosterone system inhibitors; SGLT2, sodium-glucose cotransporter-2; SP, systolic blood pressure; T2DM, type 2 diabetes mellitus; TSAT, transferrin saturation.

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Table 5 Recommendations for the device therapies in patients with heart failure.

|No.||Level of Recommendation| |---|---|---| |5-01| Guideline Statement Evaluation for ICD candidacy for primary prevention of SCD in || || Evaluation for ICD candidacy for primary prevention of SCD in patients with HFrEF must not be made for at least 3 months of |SR| || maximally tolerated quadruple GDMT as the LVEF improves in significant portion of patients thereby decreasing the need for ICD. |(a): SR| |5-02| Consider ICD therapy to decrease the risk of SCD and mortality in patients with ischemic/non-ischemic HFrEF; LVEF ||

Global Implementation Guidelines on Heart Failure

Table 5. (continued).

|No.|Guideline Statement|Level of Recommendation| |---|---|---| |5-13|Use CCM with the Optimizer Smart system to improve symptoms,|R| ||QOL and exercise tolerance in patients with HF with LVEF 25% -45%|| ||on GDMT not suitable for CRT.|| |5-14| Use baroreflex stimulation with the Barostim Neo System to improve symptoms, QOL and exercise tolerance in patients with HF and LVEF ≤35% on GDMT. |Su| |5-15||| || Use phrenic nerve stimulation with the Remede System to improve symptoms, sleep quality and QOL in adult patients (including those with HF) with central sleep apnea. |Su| |5-16| symptoms, sleep quality and QOL in adult patients (including those with HF) with central sleep apnea. Implant durable LVAD in patients with advanced HFrEF with NYHA class IV symptoms who are deemed to be dependent on continuous IV inotropes or temporary MCS or are either already taking or are intolerant to GDMT. Use long-term MCS in patients with advanced HFrEF who have NYHA class IV symptoms despite GDMT and not eligible for cardiac transplantation. Use temporary MCS, including percutaneous and extracorporeal ventricular assist devices, as a bridge to recovery or a bridge to decision in patients with advanced HFrEF and hemodynamic |SR| |5-17| inotropes or temporary MCS or are either already taking or are intolerant to GDMT. Use long-term MCS in patients with advanced HFrEF who have NYHA class IV symptoms despite GDMT and not eligible for cardiac transplantation. Use temporary MCS, including percutaneous and extracorporeal ventricular assist devices, as a bridge to recovery or a bridge to decision in patients with advanced HFrEF and hemodynamic compromise and shock. Use long-term MCS in patients with HFrEF refractory to medical and || |5-18||R| |5-19||Su| || Use long-term MCS in patients with HFrEF refractory to medical and device therapy and waiting for cardiac transplantation, as a bridge to |R| |5-20| Use remote system HF monitoring/telemedicine devices to guide HF management. |R| |5-21||| || Use CardioMems in eligible patients on GDMT to reduce the risk of HF hospitalization. |R|

Abbreviations: SR, strongly recommend; R, recommend; Su, suggest; DND, do not do; AV, atrioventricular; BAT, barore fl ex activation therapy; CCM, cardiac contractility modulation; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; HCM, hypertrophic cardiomyopathy; ICD, implantable cardioverter-de fi brillator; IV, intravenous; LAP, left atrial pressure; LBBB, left bundle branch block; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MCS, mechanical circulatory support; MI, myocardial infarction; NSVT, non-sustained ventricular tachycardia; NYHA, New York Heart Association; QoL, quality of life; SCD, sudden cardiac death; SR, sinus rhythm; VAD, ventricular assist device.

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Table 6 Recommendations for the invasive management in patients with heart failure.

|No.|Guideline Statement|Level of Recommendation|| |---|---|---|---| |6-01| Perform surgical revascularization (CABG) plus GDMT in selected patients ||R| ||with HFrEF (LVEF |||

Abbreviations: SR, strongly recommend; R, recommend; Su, suggest; DND, do not do; AF, atrial fi brillation; AS, aortic stenosis; AR, aortic regurgitation; CABG, coronary artery bypass grafting; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diameter; MR, mitral regurgitation; M-TEER, mitral transcatheter edge-to-edge repair; NYHA, New York Heart Association; PASP, pulmonary artery systolic pressure; QoL, quality of life; RAAS, Renin-angiotensinaldosterone system; SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation; TEER, transcatheter edge-to-edge repair; TR, tricuspid regurgitation.

Global Implementation Guidelines on Heart Failure

Table 7 Recommendations for the special conditions in patients with heart failure.

|No.| Guideline Statement |Level of Recommendation| |---|---|---| ||Cardiac amyloidosis|| |7-01| Use serum and urine immunofixation electrophoresis and serum free light|SR| ||chains in patients with increased pre-test likelihood of cardiac amyloidosis|| |7-02| Use bone scintigraphy to confirm TTR amyloidosis in patients with clinical|SR| || suspicion of amyloidosis without evidence of serum or urine monoclonal light chains. || |7-03| Perform genetic testing for TTR gene sequencing, in patients with diagnosis of TTR cardiac amyloidosis, to differentiate hereditary from wild-type amyloidosis. Strain echocardiogram could be used to diagnose cardiac amyloidosis in resource |SR| |Resources severely limited| Strain echocardiogram could be used to diagnose cardiac amyloidosis in resource limited countries. || |7-04| Use TTR tetramer stabilizer therapy (tafamidis [partial stabilizer], and acoramidis [near complete stabilizerl) to improve symptoms, and reduce |SR| |||| || cardiovascular death and HF hospitalizations in patients with wild or variant type TTR cardiac amyloidosis and NYHA class I to I symptoms. Diflunisal, an alternative TTR stabilizer, is recommended when newer agents are || |Resources severely limited| Diflunisal, an alternative TTR stabilizer, is recommended when newer agents are cost prohibitive to relieve symptoms and improve mortality in patients woith wild or variant type cardiac amyloidosis and NYHA class I to II HF symptoms. Use hepatic TTR production inhibitor (vutrisiran) in patients with wild or variant type TTR cardiac amyloidosis and NYHA class I to II symptoms to || |7-05| variant type TTR cardiac amyloidosis and NYHA class I to II symptoms to improve symptoms, and reduce cardiovascular death and HF hospitalizations |SR| |7-06||R| |7-07| Use anticoagulation to prevent stroke in patients with cardiac amyloidosis and AF, regardless of CHA2DS2-VA score. |R| |7-08| and AF, regardless of CHA2DS2-VA score. Refer to multidisciplinary team and/or referral to neurology due to systemic nature of TTR amyloidosis and need for specific therapies. Hypertrophic cardiomyopathy Use cardiac myosin inhibitors (mavacamten/aficamten) in patients with || || Use cardiac myosin inhibitors (mavacamten/aficamten) in patients with symptomatic obstructive HCM despite beta-blockers or non- dihydropyridine calcium channel blockers to improve QoL and decreasedihydropyridine calcium channel blockers to improve QoL and decrease the need for septal reduction therapies. |R| |7-09||R| || LVOT >50 mmHg (at rest or with provocation), and who are moderate to severely symptomatic despite optimal medical therapy to improve symptoms and QoL. || |7-10||DND| |7-11||R| || be guided by family history of sudden death and other high risk factors as included in the specific HCM risk scores. || |7-12| Use anticoagulation to prevent stroke in patients with HCM and AF, regardless of CHA2DS2-VA score. Other co-morbidities |R| |7-13||SR| || Request screening for anemia and iron deficiency with complete blood count, serum ferritin concentration and TSAT in all patients with HF. || |7-14| Use the standard definition of iron deficiency in HF: ferritin ||

V. Chopra et al.

Table 7. (continued).

|No.|Guideline Statement|Level of Recommendation| |---|---|---| | Resources severely limited 7-16 | TSAT alone may be used for iron deficiency diagnosis in HF Request a formal sleep assessment in patients with HF and suspicion of || | Resources severely limited 7-16 ||R| |7-17| sleep- disordered breathing, to differentiate between obstructive and central sleep apnea. |R| |7-17| obstructive sleep apnea, to improve symptoms, sleep quality and daytime sleepiness. |Su| |7-18|Use Remede phrenic nerve stimulator in patients with HFrEF and|| || predominant central sleep apnea, to improve symptoms, sleep quality and daytime sleepiness. |Su| |7-19| Use GLP-1 RAs based therapies (tirzepatide or semaglutide) in patients|SR| |7-19|with moderate-to-severe OSA and obesity, to reduce apnea-hypopnea|| || index, body weight, and improved sleep-related patient-reported outcomes. Do not use adaptive servo-ventilation in patients with NYHA classI to IV || |7-20||DND| |||| |Resources severely limited| Lifestyle interventions such as diet and exercise may be considered instead of semaglutide or tirzepatide among patients with morbid obesity to reduce weight and improve QoL and symptoms. || |7-21| Use chronic anticoagulation to prevent stroke in patients with HF and|SR| |7-22| permanent-persistent-paroxysmal AF based on CHADS2 VA score of ≥2, without differences by gender. Use long-term treatment with an oral anticoagulant in patients with HF and AF with a CHADS2-VA score of 1, without differences by gender, to decrease the risk of stroke. Use beta-blockers in patients with HFrEF and AF with high ventricular rate (unless congested), to improve symptoms and control ventricular rate. Use digoxin in patients with HF and AF with high ventricular rate despite beta-blockers or if beta-blockers are contraindicated, to improve the || |7-23|| R R | |7-24| Use beta-blockers in patients with HFrEF and AF with high ventricular rate (unless congested), to improve symptoms and control ventricular rate. Use digoxin in patients with HF and AF with high ventricular rate despite beta-blockers or if beta-blockers are contraindicated, to improve the symptoms and control ventricular rate. Use bolus of amiodarone or digoxin in patients with AF with high ventricular rate in NYHA class IV HF, in addition to treatment for AHF, to reduce the ventricular rate. Perform catheter ablation in patients with HFrEF and symptoms attributable to AF despite medical therapy, to improve symptoms and QoL. Perform AV nodal ablation in patients with HF and LVEF ||

Global Implementation Guidelines on Heart Failure

Table 7. (continued).

|No.|Guideline Statement|Level of Recommendation| |---|---|---| |7-31| Monitor LV function/ global longitudinal strain, LV mass, and cardiac |Su| ||biomarkers (NT-proBNP, troponin, etc.) regularly to allow early detection|| || and management of cardiotoxicity in patients with CV risk factors or known cardiac disease being considered for potentially cardiotoxic ||

Abbreviations: SR, strongly recommend; R, recommend; Su, suggest; and DND, do not do; ACEi, angiotensin-converting enzyme inhibitors; AHF, acute heart failure; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor neprilysin inhibitors; AF, atrial fi brillation; AS, aortic stenosis; AV, atrioventricular; biPAP, bilevel positive airway pressure; CPAP, continuous positive airway pressure; CV, cardiovascular; GDMT, guideline-directed medical therapy; GLP-1RA, glucagon-like peptide 1 receptor agonist; HCM, hypertrophic cardiomyopathy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter de fi brillator; LV, left ventricular; LVEF, left ventricular ejection fraction; LVOT, left ventricular out fl ow tract; LVOTO, left ventricular out fl ow tract obstruction; MRA, mineralocorticoid receptor antagonist; NYHA, New York Heart Association; NSAIDs, non-steroidal anti-in fl ammatory drugs; NT-proBNP, N-terminal prohormone of B-type natriuretic peptide; OSA, obstructive sleep apnea, PDE5, phosphodiesterase-5; QoL, quality of life; SGLT2, sodium-glucose cotransporter-2; T2DM, type 2 diabetes mellitus; TSAT, transferrin saturation; TTR, transthyretin.

Table 8 Recommendations for special considerations.

|No.|Guideline Statement|Level of Recommendation| |---|---|---| |8-01| HF and pregnancy|| |8-01| Counsel related to contraception and risks of cardiovascular deterioration during pregnancy in|SR| || Women with a history of HF or cardiomyopathy, including previous peripartum cardiomyopathy. || |8-02| Do not use ACEi, ARB, ARNI, MRA, SGLT2 inhibitors, cardiac myosin inhibitors, ivabradine and vericiguat in women with HF or cardiomyopathy, who are pregnant or currently planning for pregnancy because of unclear safety. |DND| |||| |8-03| Use LMWH in the 1st and 3rd trimester, and VKA or LMWH for the 2nd trimester in pregnant women with AF and HF. || |||R| |8-04| Do not use DOACs in pregnant women with HF and AF, due to unclear safety.|DND| |8-05| Continue beta-blocker in women with HF or cardiomyopathy who are pregnant or currently planning for pregnancy. || |8-06| Adjust diuretic dosing in women with HF or cardiomyopathy who are pregnant or currently planning for pregnancy, to minimize the risk of placental hypoperfusion. |R| |||| |8-07| Use fluid restriction to ~ 2 L/d and daily monitoring of body weight in patients with HF and fluid retention not easilycontrolled withdiuretics, to reduce symptoms related tocongestion. Avoid a very low target for fluid restriction of 1.5 L/d, particularly when patients frequently complain of thirst. Administer pneumococcal and influenza vaccines in patients with HF to reduce the risk of |R| |8-08||SR| |||| |8-09| Advise exercise training in patients with HF to improve exercise capacity, QoL and reduce the risk of HF hospitalization, if possible. Recommend multidisciplinary team care (including a cardiologist, HF nurse, dietitians, and |SR| |8-10| Recommend multidisciplinary team care (including a cardiologist, HF nurse, dietitians, and community workers) for high-risk patients with HF during discharge to optimize care. |R| |8-11|Counsel and educate patients with HF about the climate/temperature changes, their effects on|R| || CV health and mortality, and strategies to reduce those risks.|| |8-12||| |8-12| Use palliative and supportive care focusing on effective communication, conveying prognosis,|SR| ||clarifying goals of care, shared decision-making, symptom management, and caregiver support|| || for HF patients to improve QoL and relieve suffering.||

Abbreviations: SR, strongly recommend; R, recommend; Su, suggest; DND, do not do; ACEi, angiotensin converting enzyme inhibitors; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor neprilysin inhibitors; CV, cardiovascular; CVD, cardiovascular disease; DOACs, direct oral anticoagulants; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LMWH, low molecular weight heparin; MRA, mineralocorticoid receptor antagonist; QoL, quality of life; SGLT2, sodium-glucose cotransporter-2; VKA, vitamin K antagonist.

 Figure 2 Recommendations for the management of heart failure with reduced ejection fraction. Note: In patients with LVEF $40\%–49\%$ , diagnostic accuracy of test is less certain (due to the variability of LVEF assessments) and the absolute amount of therapeutic bene fi t of GDMT is somewhat less than in patients with LVEF ${<}40\%$ . Abbreviations: SR, strongly recommend; $\mathrm{R},$ recommend; Su, suggest; and DND, Do not do. ACEi, angiotensin-converting enzyme inhibitors; AF, atrial fi brillation; ARB, angiotensin receptor blocker; AHF, acute heart failure; AR, aortic regurgitation; AS, aortic stenosis; AV, atrioventricular; ARNI, angiotensin receptor neprilysin inhibitor; CAD, coronary artery disease; CABG, coronary artery bypass grafting; COX-2, cyclo-oxygenase-2; CRT, cardiac resynchronization therapy, DPP-4, dipeptidyl peptidase-4; eGFR, estimated glomerular fi ltration rate; GDMT, guideline-directed medical therapy; HCM, hypertrophic cardiomyopathy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter-de fi brillator; LBBB, left bundle branch block; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MI, myocardial infarction; MR, mitral regurgitation; MRA, mineralocorticoid receptor antagonist; M-TEER, mitral transcatheter edge-to-edge repair; NSAIDs, non-steroidal anti-in fl ammatory drugs; NT-proBNP, N-terminal prohormone of B- type natriuretic peptide; NYHA, New York Heart Association; PDE5, phosphodiesterase-5;RAAS, Renin-angiotensinaldosterone system; RV, right ventricle; SGLT2, sodium-glucose co-transporter 2; TSAT, transferrin saturation; TR, tricuspid regurgitation; VAD, ventricular assist device.

Global Implementation Guidelines on Heart Failure

 Figure 3 Recommendations for the management of heart failure with preserved ejection fraction. Abbreviations: SR, strongly recommend; R, recommend; Su, suggest; and DND, Do not do. ACEi, angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor blocker; ARNI, Angiotensin receptor neprilysin inhibitor; COX-2, cyclooxygenase-2; DPP-4, dipeptidyl peptidase-4; GDMT, guideline-directed medical therapy; GLP-1RA, glucagon-like peptide 1 receptor agonist; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; NSAIDs, non-steroidal anti-infl ammatory drugs; MRA, mineralocorticoid receptor antagonist; SGLT2, sodium-glucose co-transporter 2.

 Figure 4 Recommendations for the management of special conditions in patients with heart failure. Note: In patients with LVEF $40\%–49\%$ , diagnostic accuracy of tests is less certain (due to the variability of LVEF assessments) and the absolute amount of therapeutic bene fi t of GDMT is somewhat less than in patients with LVEF ${<}40\%$ . Abbreviations: SR, strongly recommend; $\mathrm{R},$ recommend; Su, suggest; and DND, Do not do. ACEi, angiotensin-converting enzyme inhibitors; AF, atrial fi brillation; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor neprilysin inhibitor; bi-PAP, bilevel positive airway pressure; CPAP, continuous positive airway pressure; DPP-4, dipeptidyl peptidase-4; GDMT, guideline-directed medical therapy; GLP-1RA, glucagon-like peptide 1 receptor agonist; HCM, hypertrophic cardiomyopathy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction;, heart failure with mildly reduced ejection fraction; ICD, implantable cardioverter de fi brillator; LV, left ventricle; LVOT, left ventricular out fl ow tract; LVEF, left ventricular ejection fraction; LMWH, low molecular weight heparin; MRA, mineralocorticoid receptor antagonist; NTproBNP, N-terminal prohormone of B-type natriuretic peptide; PDE5, phosphodiesterase-5; SCD, sudden cardiac death; SGLT2, sodium-glucose co-transporter 2, T2DM, type 2 diabetes mellitus; TSAT, transferrin saturation; VKA, vitamin K antagonist.

Global Implementation Guidelines on Heart Failure

 Figure 5

Overview of HFpEF management.

Abbreviations: SR, strongly recommend; R, recommend; Su, suggest; and DND, Do not do. ACEi, angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor neprilysin inhibitor; bi-PAP, bilevel positive airway pressure; CV, cardiovascular; CPAP, continuous positive airway pressure; GLP-1RA, glucagon-like peptide 1 receptor agonist; HCM, hypertrophic cardiomyopathy; HFpEF, heart failure with preserved ejection fraction; MRA, mineralocorticoid receptor antagonist; OSA, obstructive sleep apnea; SGLT2, sodium-glucose co-transporter 2.

 Figure 6

Overview of HFrEF management. Adapted from S. Mishra et al. Indian Heart Journal (2018).

Note: In patients with LVEF $40\%49\%,$ diagnostic accuracy is less certain (due to the variability of LVEF assessments) and the absolute amount of therapeutic bene fi t of GDMT is somewhat less than in patients with LVEF ${<}40\%$ . Abbreviations: SR, strongly recommend; R, recommend; Su, suggest; and DND, Do not do. ACEi, angiotensin-converting enzyme inhibitors; AF, atrial fi brillation; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor neprilysin inhibitor; bi-PAP, bilevel positive airway pressure; CPAP, continuous positive airway pressure; CAD, coronary artery disease; CABG, coronary artery bypass grafting; CRT, cardiac resynchronization therapy, GLP-1RA, glucagon-like peptide 1 receptor agonist; HCM, hypertrophic cardiomyopathy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter- de fi brillator; ISDN, isosorbide dinitrate; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; LVAD, left ventricular assist device; MCS, mechanical circulatory support; MR, mitral regurgitation; MRA, mineralocorticoid receptor antagonist; M-TEER, mitral transcatheter edge-to-edge repair; NT-proBNP, N-terminal prohormone of B-type natriuretic peptide; NYHA, New York Heart Association; OSA, obstructive sleep apnea; SD, sudden death; SGLT2, sodium-glucose co-transporter 2; T2DM, type 2 diabetes mellitus; and TSAT, transferrin saturation.

Please cite this article in press as: Chopra V, et al. iCARDIO Alliance Global Implementation Guidelines on Heart Failure 2025. Heart, Lung and Circulation (2025), https://doi.org/10.1016/j.hlc.2025.05.094

V. Chopra et al.

Author Af fi liations

Task Force Members: Vijay Chopra , Heart Failure Programme and Research, Max Super Specialty Hospital, Saket, New Delhi, India; Muhammad Shahzeb Khan , Baylor Scott and White Research Institute, Dallas, TX - Baylor Scott and White Health, The Heart Hospital, Plano, TX, USA; Magdy Abdelhamid , Faculty of Medicine, Cairo University, Cairo, Egypt; William T. Abraham , Division of Cardiovascular Medicine and The Davis Heart and Vascular Research Institute, The Ohio State University (OSU) College of Medicine and OSU Wexner Medical Center, Columbus, OH, USA; Offer Amir , Heart Institute, Hadassah Medical Center & Hebrew University, Jerusalem, Israel; Stefan D. Anker , Department of Cardiology (CVK) of German Heart Center Charité; German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany; John J. Atherton , University of Queensland Faculty of Medicine, Cardiology Department, Royal Brisbane and Women ’ s Hospital, Herston, Brisbane, QLD, Australia; Fernando Bacal , Heart Institute (InCor), Medical School, University of Sao Paulo; Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Ralph Stephan von Bardeleben , Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany; Dulce Brito , Cardiology Department, ULSSM, Hospital de Santa Maria, CCUL@RISE, Lisboa, Portugal; Lucrecia Maria Burgos , Heart Failure, Pulmonary Hypertension and Heart Transplantation Department, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina; Javed Butler , Department of Medicine, University of Mississippi Medical Centre, Jackson, MS and Baylor Scott and White Research Institute, Dallas, TX, USA; Maria Rosa Costanzo , Midwest Cardiovascular Institute, Naperville, IL, USA; Albertino Damasceno , Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique; Justin A. Ezekowitz , University of Alberta, Edmonton, Canada; Ishaque Hameed , Department of Medicine, MedStar Health, Baltimore, MD, USA; Sivadasanpillai Harikrishnan , Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Tiny Jaarsma , Department of Health, Medicine and Caring Sciences, Linköping University, Sweden; Anuradha Lala , Mount Sinai Fuster Heart Hospital, Icahn School of Medicine, New York, NY, USA; Ileana L. Piña , Thomas Jefferson University, Philadelphia, PA, USA; Clara Saldarriaga , Clinica CardioVID, University of Antioquia, Medellin, Colombia; David Sim , National Heart Centre Singapore, Singapore; John R. Teerlink , Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco and School of Medicine, University of California San Francisco, San Francisco, CA, USA; Nqoba Tsabedze , Division of Cardiology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand and the Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg,

South Africa; Hiroyuki Tsutsui , International University of Health and Welfare, Fukuoka, Japan; Jing Yu , Heart Failure Center, Department of Cardiology, Lanzhou University Second Hospital, Lanzhou, Gansu, China; Yuhui Zhang , Heart Failure Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Mohammad Zubaid , Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait.

Reviewers:

Nikhil Balankhe , Department of Medicine and Critical Care Medicine, Viveka Hospitals, Nagpur, Maharashtra, India; Juan Esteban Gomez-Mesa , Servicio de Cardiología, Fundación Valle del Lili, Cali - Departamento de Ciencias de la Salud, Universidad Icesi, Cali, Colombia; James L. Januzzi , Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Baim Institute for Clinical Research, Boston, MA, USA; Marvin Konstam , Tufts Medical Center, Boston, MA, USA; Rhonda Monroe , Better Outcomes Optimal Scienti fi c Therapies (BOOST), Washington D.C., USA; Elijah Ogola , Department of Clinical Medicine and Therapeutics, Faculty of Health Sciences, University of Nairobi, Kenya; Vinayagam Palaniappan , Dr. V. Palaniyappen ’ s Diabetes Specialities Centre, Near Bus Stand, Guziliamparai, Dindigul (Dt), Tamil Nadu, India; Mark C. Petrie , School of Cardiovascular and Metabolic Health, University of Glasgow, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, UK; Fausto J. Pinto , Centro Academico de Medicina de Lisboa, CCUL@- RISE, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal; Girish C. Rajadhyaksha , Department of Medicine, Topiwala National Medical College & B.Y.L. Nair Ch Hospital, Mumbai, Maharashtra, India; Amina Rakisheva , Cardiology Department, City Cardiology Center, Almaty, Kazakhstan; Carlos E. Ramos , Instituto Nacional Cardiopulmonar, Tegucigalpa, Honduras; Victor Rossel , Council of Heart Failure and Pulmonary Hypertension, Inter-American Society of Cardiology, México; Hospital del Salvador/Faculty of Medicine, University of Chile, Santiago, Chile; Naoki Sato , Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital, Kawaguchi, Japan; P. Christian Schulze , Department of Internal Medicine I, Cardiology, University Hospital Jena, Jena, Germany; Andrew Sindone , Heart Failure Unit and Department of Cardiac Rehabilitation, Concord Hospital and Department of Cardiology, Ryde Hospital, Sydney, Australia; Hadi N. Skouri , Cardiology Division, Balamand University Faculty of Medicine and Medical Sciences, Beirut, Lebanon; Cardiology Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates; Harriette G.C. Van Spall , Department of Medicine, Department of Health Research Methods Evidence, and Impact, Population Health Research Institute, McMaster University Hamilton, Ontario, Canada; Aist e Starait e , Global Heart Hub, The International Alliance of Heart Patient Organisations,

Lithuania / Ireland; Lynne Warner Stevenson , Vanderbilt University Medical School, Nashville, TN, USA; Kadhim Sulaiman , National Heart Center, Royal Hospital, Muscat, Oman; Tzung-Dau Wang , Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei City, Taiwan; Michael Böhm , Universitätsklinikum des Saarlandes, HOMICAREM (HOMburg Institute for CArdioREnalMetabolic Medicine), Klinik für Innere Medizin III, Saarland University, Homburg/Saar, Germany; Andrew J.S. Coats , Heart Research Institute, Sydney, Australia; Shelley Zieroth , University of Manitoba, St. Boniface Hospital, Cardiac Sciences Manitoba, Canada.

Declaration of Competing Interest

Author disclosures are included in the Appendix .

Acknowledgements

The work towards this document is supported by Translational Medicine Academy [ 47 ], as well as by the iCARDIO Alliance and the iCARDIO Alliance Partner Societies ( https://icardioalliance.org/partner-societies/ ).

Appendix

Supplementary material with author disclosures associated with this article can be found at https://doi.org/10.1016/j. hlc.2025.05.094

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