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Heart failure

HF is a clinical syndrome that results from structural or functional impairment of filling or ejection of blood from the heart. HF can be associated with either reduced ejection fraction (≤ 40%), preserved ejection fraction (≥ 50%), or borderline ejection fraction (41-50%).
The most common causes of HF include ischemic heart disease, hypertensive heart disease, valvular and rheumatic heart disease, genetic cardiomyopathies, and congenital heart disease.
In the US, the age and sex-adjusted incidence of HF is estimated at 219.3 cases per 100,000 person-years. Its prevalence is estimated at 1915 persons per 100,000 population.
Disease course
Clinical manifestations relate to pulmonary edema (dyspnea, orthopnea, paroxysmal nocturnal dyspnea), peripheral edema (ankle swelling, abdominal bloating), and activation of inflammatory pathways (early satiety, cachexia). Severe HF leads to manifestations related to hypoperfusion, spanning from mild fatigue and exertional intolerance to cardiogenic shock.
Prognosis and risk of recurrence
The 1-year and 5-year mortality associated with HF are estimated at 20.2% and 56.2%, respectively. Death is due to non-cardiovascular events in over 50% of patients.
Key sources
The following summarized guidelines for the evaluation and management of heart failure are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC 2023; 2022; 2021), the United Kingdom Kidney Association (UKKA 2023), the European Society of Hypertension (ESH 2023), the Heart Failure Society of America (HFSA/AHA/ACC 2022), the American College of Emergency Physicians (ACEP 2022), the Canadian Cardiovascular Society (CCS 2022), the The Japanese Society for Vascular Surgery (JSVS/JSCVS/JATS/JCS 2022), the European Society of Cardiology (ESC/ERS 2022), the American Heart Association (AHA/HRS/ACC 2018), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the American Heart Association (AHA/ACC 2017; 2013), and the American College of Endocrinology (ACE/AACE 2016).


1.Classification and risk stratification

Risk stratification: consider using validated multivariable risk scores to estimate subsequent risk of incident HF in the general population and mortality in ambulatory or hospitalized patients with HF.
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2.Diagnostic investigations

Clinical evaluation: elicit a thorough history and perform physical examination in patients presenting with HF in order to:
direct diagnostic strategies to uncover specific causes likely to warrant disease-specific management
identify cardiac and noncardiac disorders, lifestyle and behavioral factors and social determinants of health likely to cause or accelerate the development or progression of HF.
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  • Laboratory evaluation

  • ECG

  • Cardiopulmonary exercise testing

  • Natriuretic peptide biomarkers

  • Chest radiography

  • TTE

  • Advanced cardiac imaging

  • Lung ultrasound

  • Psychosocial assessment

3.Diagnostic procedures

Coronary angiography
As per ESC 2021 guidelines:
Perform invasive coronary angiography in patients with angina despite pharmacological therapy or symptomatic ventricular arrhythmias.
Consider performing invasive coronary angiography in patients with HFrEF with an intermediate-to-high pretest probability of coronary artery disease and the presence of ischemia in noninvasive stress tests.

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  • Right heart catheterization

  • Endomyocardial biopsy

4.Respiratory support

Supplemental oxygen: administer oxygen to correct hypoxemia in patients with SpO2 < 90% or PaO2 < 60 mmHg.

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  • Mechanical ventilation

5.Medical management

General principles: as per ACC 2022 guidelines, provide multidisciplinary cate in patients with HF to:
facilitate the implementation of guideline-directed medical therapy
address potential barriers to self-care
reduce the risk of subsequent re-hospitalization for HF
improve survival.
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  • Renin-angiotensin system inhibitors

  • Aldosterone receptor antagonists

  • Hydralazine and isosorbide dinitrate

  • Beta-blockers

  • CCBs

  • Ivabradine

  • Diuretics

  • Digoxin

  • SGLT-2 inhibitors

  • sGC stimulators

  • Anticoagulation therapy

  • Medications to avoid

  • Management of pre-HF

  • Management of HFmrEF

  • Management of HFimpEF

  • Management of HFpEF

  • Management of hypertension (HFrEF)

  • Management of hypertension (HFpEF)

  • Management of AF (anticoagulation)

  • Management of AF (rate control)

  • Management of AF (cardioversion)

  • Management of AF (catheter ablation)

  • Management of VHD

  • Management of hyperkalemia

  • Management of anemia

  • Management of sleep disorders

6.Inpatient care

General principles: continue and optimize preexisting guideline-directed medical therapy to improve outcomes, unless contraindicated, in patients with HFrEF requiring hospitalization.
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  • Invasive hemodynamic monitoring

  • Venous thromboprophylaxis

  • Intravenous diuretics

  • Intravenous inotropes

  • Intravenous nitrates

  • Opioids

  • Management of cardiogenic shock (general principles)

  • Management of cardiogenic shock (inotropes and vasopressors)

  • Management of cardiogenic shock (mechanical circulatory support)

  • Management of cardiogenic shock (intra-aortic balloon pump)

  • Management of cardiogenic shock (coronary revascularization)

7.Nonpharmacologic interventions

Lifestyle modifications: as per AHA 2017 guidelines, control or avoid other conditions likely to lead or contribute to HF, including obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents.

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  • Self-management programs

  • Exercise

  • Cardiac rehabilitation

  • Fluid and sodium restriction

  • Nutritional supplements

8.Therapeutic procedures

Cardiac resynchronization therapy: as per ACC 2022 guidelines, perform CRT to reduce total mortality and hospitalizations and improve symptoms and QoL in patients with LVEF ≤ 35%, sinus rhythm, LBBB with a QRS duration ≥ 150 ms and NYHA class II, III or ambulatory IV symptoms on guideline-directed medical therapy.
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  • ICD

  • Mechanical circulatory support

  • PCI

  • RRT

9.Surgical interventions

Coronary artery bypass graft: as per ACC 2022 guidelines, consider performing surgical revascularization in conjunction with guideline-directed medical therapy to improve symptoms, cardiovascular hospitalizations and long-term all-cause mortality in selected patients with HF, reduced ejection fraction (≤ 35%) and suitable coronary anatomy.

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  • LV aneurysmectomy

  • Aortic valve surgery

  • Mitral valve surgery

  • Heart transplantation

10.Specific circumstances

Pregnant patients: provide patient-centered counseling regarding contraception and the risks of cardiovascular deterioration during pregnancy in patients with a history of HF or cardiomyopathy including previous peripartum cardiomyopathy.
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  • Patients with cardiac amyloidosis (evaluation)

  • Patients with cardiac amyloidosis (management)

  • Patients with cancer therapy-related HF

  • Patients with pulmonary hypertension

11.Patient education

General counseling: as per AHA 2022 guidelines, provide specific education and support to facilitate self-care in a multidisciplinary manner in patients with HF.

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  • Genetic counseling

12.Preventative measures

Primary prevention
As per ESC 2023 guidelines:
Initiate SGLT-2 inhibitors (dapagliflozin or empagliflozin) to reduce the risk of HF hospitalization or cardiovascular death in patients with T2DM and CKD.
Initiate finerenone to reduce the risk of HF hospitalization in patients with T2DM and CKD.

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  • Immunizations

13.Follow-up and surveillance

Telemonitoring: consider offering noninvasive home telemonitoring to reduce the risk of recurrent cardiovascular and HF hospitalizations and cardiovascular death in patients with HF.

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  • Wireless implantable hemodynamic monitoring

  • Discharge from hospital

  • Follow-up after hospital discharge

  • Palliative care

14.Quality improvement

Performance measures
Use performance measures based on professionally developed clinical practice guidelines with the goal of improving quality of care in patients with HF.
Consider participating in quality improvement programs, including patient registries providing benchmark feedback on nationally endorsed, clinical practice guideline-based quality and performance measures in improving the quality of care for patients with HF.