2022 AHA／ACC／HFSA 指南：心力衰竭的管理（概要）

指南心血管内科· 心力衰竭 · 2022

Authors

Keywords

Paul A. Heidenreich, MD, MS, FACC, FAHA, FHFSA, Chairy Biykem Bozkurt, MD, PHD, FACC, FAHA, FHFSA, Vice Chairy

Abstract

Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 of the full guideline for detailed information. yACC/AHA Representative. zACC/AHA Joint Committee on Clinical Practice Guidelines Liaison. xACC/AHA Task Force on Performance Measures Representative. kHFSA Representative.

TOP 10 TAKE-HOME MESSAGES 1. Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) now includes 4 medication classes that include sodium-glucose cotransporter-2 inhibitors (SGLT2i). 7. Evidence supporting increased filling pressures is important for the diagnosis of HF if the LVEF is > 40%.

Evidence for increased filling pressures can be obtained from noninvasive (e.g., natriuretic peptide, diastolic function on imaging) or invasive testing (e.g., hemodynamic measurement).

8. Patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF. A HF specialty team reviews HF management, assesses suitability for advanced HF therapies and uses palliative care including palliative inotropes where consistent with the patient's goals of care. 9. Primary prevention is important for those at risk for HF (stage A) or pre-HF (stage B). Stages of HF were revised to emphasize the new terminologies of "at risk" for HF for stage A and pre-HF for stage B.

10. Recommendations are provided for select patients with HF and iron deficiency, anemia, hypertension, sleep disorders, type 2 diabetes, atrial fibrillation, coronary artery disease, and malignancy.

# Purpose of the Executive Summary

Purpose of the Executive Summary

The purpose of the "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" (2022 HF guideline) is to provide an update and to consolidate the "2013 ACCF/ AHA Guideline for the Management of Heart Failure" (1)

for adults and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure" (2) into a new document. Related ACC/AHA guidelines include recommendations relevant to HF and, in such cases, the HF guideline refers to these documents.

For example, the 2019 primary prevention of cardiovascular disease guideline (3) includes recommendations that will be useful in preventing HF, and the 2021 valvular heart disease guideline (4) provides recommendations for mitral valve (MV) clipping in mitral regurgitation (MR).

# Areas of focus include:

Areas of focus include:

n Prevention of HF.

n Management strategies in stage C HF, including:

n New treatment strategies in HF, including sodiumglucose cotransporter-2 inhibitors (SGLT2i)

and angiotensin receptor-neprilysin inhibitors (ARNi).

n Management of HF and atrial fibrillation (AF), including ablation of AF.

n Management of HF and secondary MR, including MV transcatheter edge-to-edge repair.

n Specific management strategies, including:

n Cardiac amyloidosis.

n Cardio-oncology.

n Implantable devices.

n Left ventricular assist device (LVAD) use in stage D HF.

The intended primary target audience consists of clinicians who are involved in the care of patients with HF.

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

Document Review and Approval

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

Reviewers' relationships with industry and other entities information is published in Appendix 2 of the full guideline (5).

CLASS OF RECOMMENDATION AND LEVEL OF EVIDENCE

The Class of Recommendation (COR) indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1 ) (6). 2) beta blockers; 3) mineralocorticoid receptor antagonists (MRAs); and 4) the new group, SGLT2i

TAKE-HOME MESSAGE

(Figure 1 ).

Recommendation for SGLT2i

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

COR LOE RECOMMENDATION

1 A 1. In patients with symptomatic chronic HFrEF, SGLT2i are recommended to reduce hospitalization for HF and cardiovascular mortality, irrespective of the presence of type 2 diabetes (31, 32) .

Recommendation for Beta Blockers

1 A

1. In patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations (25) (26) (27) .

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

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

COR LOE RECOMMENDATIONS

1. In patients with HFrEF and New York Heart Association (NYHA) class II to III symptoms, the use of ARNi is recommended to reduce morbidity and mortality (7-11).

1 A 2. In patients with previous or current symptoms of chronic HFrEF, the use of ACEi is beneficial to reduce morbidity and mortality when the use of ARNi is not feasible (12-19).

1 A 3. In patients with previous or current symptoms of chronic HFrEF who are intolerant to ACEi because of cough or angioedema and when the use of ARNi is not feasible, the use of ARB is recommended to reduce morbidity and mortality (20) (21) (22) (23) (24) . 2. Among patients with current or previous symptomatic HFmrEF (LVEF, 41%-49%), use of evidence-based beta blockers for HFrEF, ARNi, ACEi, or ARB, and MRAs may be considered, to reduce the risk of HF hospitalization and cardiovascular mortality, particularly among patients with LVEF on the lower end of this spectrum (34) (35) (36) (37) (38) (39) (40) (41) .

TAKE-HOME MESSAGE NO. 3

Preserved LVEF has new medication recommendations, including use of SGLT2i (Figure 3 ).

New Recommendations for HFpEF

COR LOE RECOMMENDATIONS 2a B-R

1. In patients with HFpEF, SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular mortality (33) . 2b B-R 2. In selected patients with HFpEF, MRAs may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum (38, 42, 43) . 2b B-R 3. In selected patients with HFpEF, ARNi may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum (35, 40) .

TAKE-HOME MESSAGE NO. 4

Improved LVEF is used to refer to those with previous HFrEF who now have an LVEF > 40%

(Figure 4 ). These patients should continue their HFrEF treatment.

Renewed Recommendations for HFpEF

COR LOE RECOMMENDATIONS 1 C-LD 1.

Patients with HFpEF and hypertension should have medication titrated to attain blood pressure targets in accordance with published clinical practice guidelines to prevent morbidity (44) (45) (46) . 2a C-EO 2. In patients with HFpEF, management of AF can be useful to improve symptoms. 2b B-R 3. In selected patients with HFpEF, the use of ARB may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum (47, 48) .

3: No Benefit B-R

4. In patients with HFpEF, routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or quality of life is ineffective (49, 50) . Recommendation for HF With Improved EF (HFimpEF) Referenced studies that support the recommendation are summarized in the Online Data Supplements.

COR LOE RECOMMENDATION 1 B-R 1.

In patients with HFimpEF after treatment, GDMT should be continued to prevent relapse of HF and left ventricular dysfunction, even in patients who may become asymptomatic (36) .

TAKE-HOME MESSAGE NO. 5

Value statements have been created for many treatments.

In accordance with ACC/AHA methodology (51), value statements were created for select recommendations where high-quality, cost-effectiveness studies of the intervention have been published. High value is defined as < $60,000/quality-adjusted life year gained ( < 1 U.S.

GDP/capita/QALY). Low value is defined as > $ 1. In patients with advanced HF, when consistent with the patient's goals of care, timely referral for HF specialty care is recommended to review HF management and assess suitability for advanced HF therapies (e.g., left ventricular assist devices, cardiac transplantation, palliative care, and palliative inotropes) (105) (106) (107) (108) (109) (110) .

TAKE-HOME MESSAGE NO. 9

Primary prevention is important for those at risk for HF (stage A) or pre-HF (stage B). Stages of HF were revised to emphasize the new terminologies of "at-risk for HF"

for stage A and "pre-HF" for stage B (Figure 6 , Table 3 ).

In the full guideline, primary prevention included all health care strategies that prevent the development of

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

1 A 1. In patients with hypertension, blood pressure should be controlled in accordance with GDMT for hypertension to prevent symptomatic HF (46, (111) (112) (113) (114) (115) (116) (117) (118) .

1 A 2. In patients with type 2 diabetes and either established cardiovascular disease or at high cardiovascular risk, SGLT2i should be used to prevent hospitalizations for HF (119) (120) (121) .

1 B-NR 3. In the general population, healthy lifestyle habits such as regular physical activity, maintaining normal weight, healthy dietary patterns, and avoiding smoking are helpful to reduce future risk of HF (122) (123) (124) (125) (126) (127) (128) (129) (130) . 2a B-R 4. For patients at risk of developing HF, natriuretic peptide biomarker-based screening followed by teambased care, including a cardiovascular specialist optimizing GDMT, can be useful to prevent the development of LV dysfunction (systolic or diastolic) or new-onset HF (131, 132) . 2a B-NR 5. In the general population, validated multivariable risk scores can be useful to estimate subsequent risk of incident HF (133) (134) (135) .

TAKE-HOME MESSAGE NO. 10

Specific-treatment recommendations are provided for patients with HF and certain comorbidities (Figure 7 ).

Recommendations are provided for select patients with HF and iron deficiency, anemia, hypertension, sleep disorders, type 2 diabetes, AF, coronary artery disease, and malignancy.

Recommendations for Management of Stage B: Preventing the Syndrome of Clinical HF in Patients With Pre-HF Referenced studies that support the recommendations are summarized in the Online Data Supplements.

1. In patients with LVEF £40%, ACEi should be used to prevent symptomatic HF and reduce mortality (15, 17, 136, 137) .

1 A 2.

In patients with a recent or remote history of myocardial infarction or acute coronary syndrome, statins should be used to prevent symptomatic HF and adverse cardiovascular events (138) (139) (140) (141) (142) .

1 B-R 3.

In patients with a recent myocardial infarction and LVEF £40% who are intolerant to ACEi, ARB should be used to prevent symptomatic HF and reduce mortality (143) .

1 B-R 4.

In patients with a recent or remote history of myocardial infarction or acute coronary syndrome and LVEF £40%, evidence-based beta blockers should be used to reduce mortality (144) (145) (146) .

1 B-R 5.

In patients who are at least 40 days post-myocardial infarction with LVEF £30% and NYHA class I symptoms while receiving GDMT and have reasonable expectation of meaningful survival for > 1 year, an implantable cardioverter-defibrillator is recommended for primary prevention of sudden cardiac death to reduce total mortality (147) .

1 C-LD 6. In patients with LVEF £40%, beta blockers should be used to prevent symptomatic HF (145, 146) .

3: Harm B-R 7. In patients with LVEF < 50%, thiazolidinediones should not be used because they increase the risk of HF, including hospitalizations (148) .

3: Harm C-LD 8. In patients with LVEF < 50%, nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful (149,150).

Recommendations for the Management of Comorbidities in Patients With HF

Management of Anemia or Iron Deficiency

2a B-R

1. In patients with HFrEF and iron deficiency with or without anemia, intravenous iron replacement is reasonable to improve functional status and quality of life (151) (152) (153) (154) .

3: Harm B-R 2. In patients with HF and anemia, erythropoietin-stimulating agents should not be used to improve morbidity and mortality (155, 156) .

Management of Hypertension

1 C-LD 3. In patients with HFrEF and hypertension, uptitration of GDMT to the maximally tolerated target dose is recommended (157) (158) (159) .

Management of Sleep Disorders

4. In patients with HF and obstructive sleep apnea, continuous positive airway pressure may be reasonable to improve sleep quality and decrease daytime sleepiness (160) (161) (162) (163) . 2a C-LD 5. In patients with HF and suspicion of sleep-disordered breathing, a formal sleep assessment is reasonable to confirm the diagnosis and differentiate between obstructive and central sleep apnea (160, 164) .

3: Harm B-R 6. In patients with NYHA class II to IV HFrEF and central sleep apnea, adaptive servo-ventilation causes harm (162, 163) .

Management of Diabetes

1 A 7.

In patients with HF and type 2 diabetes, the use of SGLT2i is recommended for the management of hyperglycemia and to reduce HF-related morbidity and mortality (31, 32, 165, 166) .

Continued

Recommendations for Management of AF in HF Referenced studies that support the recommendations are summarized in the Online Data Supplements.

1 A 1. Patients with chronic HF with permanent-persistent-paroxysmal AF and a CHA 2 DS 2 -VASc score of ‡2 (for men) and ‡3 (for women) should receive chronic anticoagulant therapy (167) (168) (169) (170) (171) .

1 A 2. For patients with chronic HF with permanent-persistent-paroxysmal AF, a direct-acting oral anticoagulant is recommended over warfarin in eligible patients (168) (169) (170) (171) (172) (173) (174) (175) (176) . 2a B-R 3. For patients with HF and symptoms caused by AF, AF ablation is reasonable to improve symptoms and quality of life (177) (178) (179) (180) . 2a B-R 4. For patients with AF and LVEF £50%, if a rhythm control strategy fails or is not desired, and ventricular rates remain rapid despite medical therapy, atrioventricular nodal ablation with implantation of a cardiac resynchronization therapy device is reasonable (181) (182) (183) (184) (185) (186) (187) (188) . 2a B-NR 5. For patients with chronic HF and permanent-persistent-paroxysmal AF, chronic anticoagulant therapy is reasonable for men and women without additional risk factors (189) (190) (191) (192) .

Recommendation for Revascularization for Coronary Artery Disease

In selected patients with HF, reduced EF (EF £35%), and suitable coronary anatomy, surgical revascularization plus GDMT is beneficial to improve symptoms, cardiovascular hospitalizations, and long-term all-cause mortality (193) (194) (195) (196) (197) (198) (199) (200) .

Recommendations for Cardio-Oncology

1 B-NR 1. In patients who develop cancer therapy-related cardiomyopathy or HF, a multidisciplinary discussion involving the patient about the risk-benefit ratio of cancer therapy interruption, discontinuation, or continuation is recommended to improve management (201, 202) .

(continued) 2a B-NR 2. In asymptomatic patients with cancer therapy-related cardiomyopathy (EF < 50%), ARB, ACEi, and beta blockers are reasonable to prevent progression to HF and improve cardiac function (202) (203) (204) . 2a B-NR 3. In patients with cardiovascular risk factors or known cardiac disease being considered for potentially cardiotoxic anticancer therapies, pretherapy evaluation of cardiac function is reasonable to establish baseline cardiac function and guide the choice of cancer therapy (202, (205) (206) (207) (208) (209) (210) (211) (212) (213) (214) (215) (216) .

2a B-NR 4. In patients with cardiovascular risk factors or known cardiac disease receiving potentially cardiotoxic anticancer therapies, monitoring of cardiac function is reasonable for the early identification of druginduced cardiomyopathy (202, 204, 206, 208) .

|||4. In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEi or ARB, replacement|4. In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEi or ARB, replacement| |---|---|---|---|

|1|B-R|by an ARNi is recommended to further reduce morbidity and mortality (7-11).|by an ARNi is recommended to further reduce morbidity and mortality (7-11).|

||TAKE-HOME MESSAGE NO. 2|have a COR 2a in HF with mildly reduced EF||

||||(HFmrEF). Weaker recommendations (COR 2b) are|

||Mildly reduced LVEF has new medication recommen-|made for ARNi, ACEi, ARB, MRA and beta blockers in||

||dations, including use of SGLT2i (Figure 2). SGLT2i|this population.||

|Recommendations for HFmrEF||||

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

|COR|LOE|RECOMMENDATIONS||

|||1. In patients with HFmrEF, SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular|1. In patients with HFmrEF, SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular|

|2a|B-R|mortality (33).||

|2b|B-NR|||

|Value Statements|||| |---|---|---|---|

|Level|||Statements|

|High COR|LOE|4. In patients with HFrEF and NYHA class II to IV symptoms, MRA therapy provides high economic value (52,67-69). RECOMMENDATIONS||

|||1. In select patients with wild-type or variant transthyretin cardiac amyloidosis and NYHA class I to III HF||

|1|B-R|symptoms, transthyretin tetramer stabilizer therapy (tafamidis) is indicated to reduce cardiovascular||

|||morbidity and mortality (102).||

|||2. In patients with cardiac amyloidosis and AF, anticoagulation is reasonable to reduce the risk of stroke||

|2a|C-LD|regardless of the CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age ‡75 years, diabetes melli-||

|||tus, stroke or transient ischemic attack [TIA], vascular disease, age 65 to 74 years, sex category) score||

|||(103,104).||

|TA BLE 2 Classification of HF by LVEF||||

|Type of HF According to LVEF|Criteria|||

|HFrEF (HF with reduced EF)||||

|TAKE-HOME MESSAGE NO. 8|center, reviews HF management, assesses suitability for|||

||||advanced HF therapies (e.g., left ventricular assist de-|

|Patients with advanced HF who wish to prolong survival|vices, cardiac transplantation), and uses palliative care|||

|should be referred to a team specializing in HF. A HF|including palliative inotropes where consistent with the|||

|COR specialty team, typically located at an advanced HF LOE RECOMMENDATIONS|patient's goals of care.|||

|||1. Patients for whom there is a clinical suspicion for cardiac amyloidosis* (94-98) should have screening for||

|1|B-NR|serum and urine monoclonal light chains with serum and urine immunofixation electrophoresis and serum||

|Value Statements Recommendation for Specialty Referral for Advanced HF free light chains (99).||||

|1 COR|B-NR LOE|RECOMMENDATION||

|1|C-LD|||

|TA BLE 3 Stages of HF|| |---|---|

|Stages|Definition and Criteria|

|Stage A: Stage B: Pre-HF|No symptoms or signs of HF and evidence of 1 of the following:|

||Structural heart disease*|

||CardioOncology Society-one trial. Eur J Cancer.| |---|---|

|R E F E R E N C E S|2018;94:126-137.|

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|2021.12.012||

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References

引用 / 出处

2022 AHA／ACC／HFSA 指南：心力衰竭的管理（概要）. 2022.