2022 AHA/ACC/HFSA heart failure guideline: key recommendations

Who it applies to

Adults at risk of or diagnosed with heart failure across all ejection fraction categories, in outpatient and inpatient settings.

Key recommendations

• Heart failure is reclassified into four stages: at risk (A), pre-heart failure (B), symptomatic heart failure (C), and advanced heart failure (D), replacing older terminology.
• For HFrEF, four pillars of therapy are recommended: an ACE inhibitor, ARB, or ARNI, a beta-blocker, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor, ideally initiated and titrated promptly rather than sequentially.
  Class 1
• ARNI (sacubitril-valsartan) is preferred over ACE inhibitors or ARBs for patients with chronic symptomatic HFrEF where appropriate.
  Class 1
• SGLT2 inhibitors are recommended for HFrEF regardless of diabetes status, reducing heart failure hospitalization and cardiovascular death.
  Class 1
• In heart failure with mildly reduced or preserved ejection fraction, SGLT2 inhibitors are recommended to reduce hospitalization and cardiovascular mortality.
  Class 2a
• Mineralocorticoid receptor antagonists and ARNI may be considered in HFmrEF and HFpEF, particularly in patients with lower ejection fractions within these ranges.
  Class 2b
• Natriuretic peptide biomarker screening followed by multidisciplinary intervention can be useful in patients at risk of heart failure to prevent progression to left ventricular dysfunction or symptomatic disease.
  Class 2a
• Routine use of vasodilators or inotropes is not recommended outside of specific advanced heart failure or cardiogenic shock scenarios.
• Hydralazine-isosorbide dinitrate is recommended as an option for self-identified Black patients with NYHA class III-IV HFrEF already on optimal therapy.
  Class 1
• Patients with advanced heart failure should be referred for specialty evaluation, including consideration of mechanical circulatory support or transplantation, when appropriate.

What is new in this edition

• Introduction of revised terminology for the existing four-stage classification system (A-D)
• Simultaneous or rapid sequence initiation of all four GDMT drug classes rather than stepwise titration
• SGLT2 inhibitors added as a core therapy for HFrEF and extended to HFmrEF/HFpEF
• Expanded role of ARNI across the ejection fraction spectrum
• Greater emphasis on natriuretic peptide-based screening for primary prevention

Practice points for students

• Think of the four pillars of HFrEF therapy as something to start together and titrate quickly, not necessarily one after another.
• SGLT2 inhibitors now apply across nearly the entire heart failure spectrum, not just in diabetic patients.
• The A-D staging system emphasizes prevention, so patients with risk factors or asymptomatic structural disease are captured earlier than before.
• Remember hydralazine-nitrate combination therapy has a specific, guideline-supported role in Black patients with persistent NYHA III-IV symptoms.

Condition

Other guidelines on this topic

• 2026 ESC Guidelines for the management of heart failureESC2026Official guideline
• Chronic heart failure in adults: diagnosis and management (NG106)NICE2025Official guideline

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by AHA/ACC. It is not medical advice: always read the original guideline before applying it to patients.