New guidelines for heart failure (HF) update recommendations for medical therapy across the spectrum of ejection fraction (EF) values. The 2022 American College of Cardiology/American Heart Association/Heart Failure Society of America Guidelines for the Management of Heart Failure make these major recommendations:
- Classifications for HF are separated into 4 categories based on EF and disease history: HF with reduced EF (EF ≤40%), HF with mildly reduced EF (EF 41%–49%), HF with preserved EF (EF ≥50%), and HF with improved EF (EF previously ≤40% with improvement to >40%).
- In patients with chronic HF with reduced EF, angiotensin receptor–neprilysin inhibitors (ARNIs) are preferred over angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs). If ARNI use is not feasible, ACEIs are preferred over ARBs, unless there is significant cough or angioedema (class 1, level of evidence [LOE] A).
- Sodium-glucose cotransporter 2 (SGLT2) inhibitors should be included across all HF categories (symptomatic HF with reduced EF [class 1, LOE A]; HF with mildly reduced EF and HF with preserved EF [class 2a, LOE B-R]).
- Patients with HF with improved EF should continue to receive medical therapy originally indicated for HF with reduced EF (class 1, LOE B-R).
- Evidence-based treatment of HF with preserved EF includes blood pressure control (class 1, LOE C-LD), SGLT2 inhibitors (class 2a, LOE B-R), mineralocorticoid antagonists, ARBs, and ARNIs (class 2b, LOE B-R).