2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

Vital signs and evidence of clinical congestion should be assessed at each encounter to guide overall management, including adjustment of diuretics and other medications.

Clinical factors indicating the presence of advanced HF should be sought via the history and physical examination.

A 3-generation family history should be obtained or updated when assessing the cause of the cardiomyopathy to identify possible inherited disease.

A thorough history and physical examination should direct diagnostic strategies to uncover specific causes that may warrant disease-specific management.

A thorough history and physical examination should be obtained and performed to identify cardiac and noncardiac disorders, lifestyle and behavioral factors, and social determinants of health that might cause or accelerate the development or progression of HF.

The specific cause of HF should be explored using additional laboratory testing for appropriate management.

Laboratory evaluation should include complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, glucose, lipid profile, liver function tests, iron studies, and thyroid-stimulating hormone to optimize management.

A 12-lead ECG should be performed at the initial encounter to optimize management.

Measurement of B-type natriuretic peptide (BNP) or N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) is useful to support a diagnosis or exclusion of HF.

Measurements of BNP or NT-proBNP levels are recommended for risk stratification.

Measurement of BNP or NT-proBNP levels at admission is recommended to establish prognosis.

BNP or NT-proBNP-based screening followed by team-based care, including a cardiovascular specialist, can be useful to prevent the development of LV dysfunction or new-onset HF.

A predischarge BNP or NT-proBNP level can be useful to inform the trajectory of the patient and establish a postdischarge prognosis.

Genetic screening and counseling are recommended to detect cardiac disease and prompt consideration of treatments to decrease HF progression and sudden death.

Referral for genetic counseling and testing is reasonable to identify conditions that could guide treatment for patients and family members.

A chest x-ray should be performed to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient's symptoms.

Transthoracic echocardiography (TTE) should be performed during initial evaluation to assess cardiac structure and function.

Repeat measurement of EF, degree of structural remodeling, and valvular function are useful to inform therapeutic interventions.

Alternative imaging (eg, cardiac magnetic resonance [CMR], cardiac computed tomography [CT], radionuclide imaging) is recommended for assessment of LVEF.

CMR can be useful for diagnosis or management.

An evaluation for possible ischemic heart disease can be useful to identify the cause and guide management.

Noninvasive stress imaging (stress echocardiography, single-photon emission CT [SPECT], CMR, or positron emission tomography [PET]) may be considered for detection of myocardial ischemia to help guide coronary revascularization.

Routine repeat assessment of LV function is not indicated.

Endomyocardial biopsy may be useful when a specific diagnosis is suspected that would influence therapy.

Invasive hemodynamic monitoring can be useful to guide management.

Routine use of invasive hemodynamic monitoring is not recommended.

Endomyocardial biopsy should not be performed because of the risk of complications.

The usefulness of wireless monitoring of PA pressure by an implanted hemodynamic monitor to reduce the risk of subsequent HF hospitalizations is uncertain.

Assessment and documentation of NYHA functional classification are recommended to determine eligibility for treatments.

Cardiopulmonary exercise testing (CPET) is recommended to determine appropriateness of advanced treatments (eg, LVAD, heart transplant).

Performing a CPET or 6-minute walk test is reasonable to assess functional capacity.

CPET is reasonable to evaluate the cause of dyspnea.

Validated multivariable risk scores can be useful to estimate subsequent risk of mortality.

Vital signs and evidence of clinical congestion should be assessed at each encounter to guide overall management, including adjustment of diuretics and other medications.

Clinical factors indicating the presence of advanced HF should be sought via the history and physical examination.

A 3-generation family history should be obtained or updated when assessing the cause of the cardiomyopathy to identify possible inherited disease.

A thorough history and physical examination should direct diagnostic strategies to uncover specific causes that may warrant disease-specific management.

A thorough history and physical examination should be obtained and performed to identify cardiac and noncardiac disorders, lifestyle and behavioral factors, and social determinants of health that might cause or accelerate the development or progression of HF.

The specific cause of HF should be explored using additional laboratory testing for appropriate management.

Laboratory evaluation should include complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, glucose, lipid profile, liver function tests, iron studies, and thyroid-stimulating hormone to optimize management.

A 12-lead ECG should be performed at the initial encounter to optimize management.

Measurement of B-type natriuretic peptide (BNP) or N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) is useful to support a diagnosis or exclusion of HF.

Measurements of BNP or NT-proBNP levels are recommended for risk stratification.

Measurement of BNP or NT-proBNP levels at admission is recommended to establish prognosis.

BNP or NT-proBNP-based screening followed by team-based care, including a cardiovascular specialist, can be useful to prevent the development of LV dysfunction or new-onset HF.

A predischarge BNP or NT-proBNP level can be useful to inform the trajectory of the patient and establish a postdischarge prognosis.

Genetic screening and counseling are recommended to detect cardiac disease and prompt consideration of treatments to decrease HF progression and sudden death.

Referral for genetic counseling and testing is reasonable to identify conditions that could guide treatment for patients and family members.

A chest x-ray should be performed to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient's symptoms.

Transthoracic echocardiography (TTE) should be performed during initial evaluation to assess cardiac structure and function.

Repeat measurement of EF, degree of structural remodeling, and valvular function are useful to inform therapeutic interventions.

Alternative imaging (eg, cardiac magnetic resonance [CMR], cardiac computed tomography [CT], radionuclide imaging) is recommended for assessment of LVEF.

CMR can be useful for diagnosis or management.

An evaluation for possible ischemic heart disease can be useful to identify the cause and guide management.

Noninvasive stress imaging (stress echocardiography, single-photon emission CT [SPECT], CMR, or positron emission tomography [PET]) may be considered for detection of myocardial ischemia to help guide coronary revascularization.

Routine repeat assessment of LV function is not indicated.

Endomyocardial biopsy may be useful when a specific diagnosis is suspected that would influence therapy.

Invasive hemodynamic monitoring can be useful to guide management.

Routine use of invasive hemodynamic monitoring is not recommended.

Endomyocardial biopsy should not be performed because of the risk of complications.

The usefulness of wireless monitoring of PA pressure by an implanted hemodynamic monitor to reduce the risk of subsequent HF hospitalizations is uncertain.

Assessment and documentation of NYHA functional classification are recommended to determine eligibility for treatments.

Cardiopulmonary exercise testing (CPET) is recommended to determine appropriateness of advanced treatments (eg, LVAD, heart transplant).

Performing a CPET or 6-minute walk test is reasonable to assess functional capacity.

CPET is reasonable to evaluate the cause of dyspnea.

Validated multivariable risk scores can be useful to estimate subsequent risk of mortality.

Blood pressure should be controlled in accordance with GDMT for hypertension to prevent symptomatic HF.

SGLT2i should be used to prevent hospitalizations for HF.

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.

Natriuretic peptide biomarker-based screening followed by team-based care, including a cardiovascular specialist optimizing GDMT, can be useful to prevent the development of LV dysfunction (systolic or diastolic) or new-onset HF.

Validated multivariable risk scores can be useful to estimate subsequent risk of incident HF.

ACEi should be used to prevent symptomatic HF and reduce mortality.

Statins should be used to prevent symptomatic HF and adverse cardiovascular events.

ARB should be used to prevent symptomatic HF and reduce mortality.

Evidence-based beta blockers should be used to reduce mortality.

An ICD is recommended for primary prevention of sudden cardiac death (SCD) to reduce total mortality.

Beta blockers should be used to prevent symptomatic HF.

Thiazolidinediones should not be used because they increase the risk of HF, including hospitalizations.

Nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful.

Should receive care from multidisciplinary teams to facilitate the implementation of GDMT, address potential barriers to self-care, reduce the risk of subsequent rehospitalization for HF, and improve survival.

Should receive specific education and support to facilitate HF self-care in a multidisciplinary manner.

Vaccinating against respiratory illnesses (including Influenza, Pneumococcal, and COVID-19) is reasonable to reduce mortality.

Screening for depression, social isolation, frailty, and low health literacy as risk factors for poor self-care is reasonable to improve management.

Avoiding excessive sodium intake is reasonable to reduce congestive symptoms.

Exercise training (or regular physical activity) is recommended to improve functional status, exercise performance, and QOL.

A cardiac rehabilitation program can be useful to improve functional capacity, exercise tolerance, and health-related QOL.

Diuretics are recommended to relieve congestion, improve symptoms, and prevent worsening HF.

Addition of a thiazide (eg, metolazone) to treatment with a loop diuretic should be reserved for patients who do not respond to moderate- or high-dose loop diuretics to minimize electrolyte abnormalities.

The use of ARNi is recommended to reduce morbidity and mortality.

The use of ACEi is beneficial to reduce morbidity and mortality when the use of ARNi is not feasible.

The use of ARB is recommended to reduce morbidity and mortality.

Replacement by an ARNi is recommended to further reduce morbidity and mortality.

ARNi should not be administered concomitantly with ACEi or within 36 hours of the last dose of an ACEi.

ARNi or ACEi should not be administered to patients with any history of angioedema.

Use of 1 of the 3 beta blockers proven to reduce mortality (bisoprolol, carvedilol, or sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations.

An MRA (spironolactone or eplerenone) is recommended to reduce morbidity and mortality. Careful monitoring of potassium, renal function, and diuretic dosing should be performed.

In patients taking MRA whose serum potassium cannot be maintained at <5.5 mEq/L, MRA should be discontinued to avoid life-threatening hyperkalemia.

SGLT2i (dapagliflozin or empagliflozin) are recommended to reduce hospitalization for HF and cardiovascular mortality, irrespective of the presence of type 2 diabetes.

The combination of hydralazine and isosorbide dinitrate is recommended to improve symptoms and reduce morbidity and mortality.

A combination of hydralazine and isosorbide dinitrate might be considered to reduce morbidity and mortality.

Omega-3 polyunsaturated fatty acid (PUFA) supplementation may be reasonable to use as adjunctive therapy to reduce mortality and cardiovascular hospitalizations.

The effectiveness of potassium binders (patiromer, sodium zirconium cyclosilicate) to improve outcomes by facilitating continuation of RAASi therapy is uncertain.

Anticoagulation is not recommended.

In patients with HFrEF, dihydropyridine calcium channel-blocking drugs are not recommended treatment for HF.

In patients with HFrEF, vitamins, nutritional supplements, and hormonal therapy are not recommended other than to correct specific deficiencies.

In patients with HFrEF, nondihydropyridine calcium channel-blocking drugs (diltiazem, verapamil) are not recommended.

In patients with HFrEF, class IC antiarrhythmic medications and dronedarone may increase the risk of mortality.

In patients with HFrEF, thiazolidinediones increase the risk of worsening HF symptoms and hospitalizations.

In patients with type 2 diabetes and high cardiovascular risk, the DPP-4 inhibitors saxagliptin and alogliptin increase the risk of HF hospitalization and should be avoided.

In patients with HFrEF, NSAIDs worsen HF symptoms and should be avoided or withdrawn whenever possible.

Titration of guideline-directed medication dosing to achieve target doses showed to be efficacious in RCTs is recommended, to reduce cardiovascular mortality and HF hospitalizations, unless not well tolerated.

Titration and optimization of guideline-directed medications as frequently as every 1 to 2 weeks depending on the patient's symptoms, vital signs, and laboratory findings can be useful.

Ivabradine can be beneficial to reduce HF hospitalizations and cardiovascular death.

Digoxin might be considered to decrease hospitalizations for HF.

An oral soluble guanylate cyclase stimulator (vericiguat) may be considered to reduce HF hospitalization and cardiovascular death.

ICD therapy is recommended for primary prevention of SCD to reduce total mortality.

ICD therapy is recommended for primary prevention of SCD to reduce total mortality.

CRT is indicated to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL.

CRT can be useful to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL.

CRT is reasonable to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL.

CRT can be useful to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL.

CRT can be useful to reduce total mortality, improve symptoms and QOL, and increase LVEF, if: a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) atrioventricular nodal ablation or pharmacological rate control will allow near 100% ventricular pacing with CRT.

CRT can be useful to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL.

Implantation of ICD is reasonable to decrease sudden death.

CRT may be considered to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL.

CRT may be considered to reduce hospitalizations and improve symptoms and QOL.

CRT is not recommended.

CRT is not recommended.

ICD and cardiac resynchronization therapy with defibrillation (CRT-D) are not indicated.

Surgical revascularization plus GDMT is beneficial to improve symptoms, cardiovascular hospitalizations, and long-term all-cause mortality.

VHD (Valvular Heart Disease) should be managed in a multidisciplinary manner in accordance with clinical practice guidelines for VHD to prevent worsening of HF and adverse clinical outcomes.

Optimization of GDMT is recommended before any intervention for secondary MR related to LV dysfunction.

Should have screening for serum and urine monoclonal light chains with serum and urine immunofixation electrophoresis and serum free light chains.

Bone scintigraphy should be performed to confirm the presence of transthyretin cardiac amyloidosis.

Genetic testing with TTR gene sequencing is recommended to differentiate hereditary variant from wild-type transthyretin cardiac amyloidosis.

Transthyretin tetramer stabilizer therapy (tafamidis) is indicated to reduce cardiovascular morbidity and mortality.

Anticoagulation is reasonable to reduce the risk of stroke regardless of the CHA2DS2-VASc score.

Intravenous iron replacement is reasonable to improve functional status and QOL.

Erythropoietin-stimulating agents should not be used to improve morbidity and mortality.

Uptitration of GDMT to the maximally tolerated target dose is recommended.

A formal sleep assessment is reasonable to confirm the diagnosis and differentiate between obstructive and central sleep apnea.

Continuous positive airway pressure (CPAP) may be reasonable to improve sleep quality and decrease daytime sleepiness.

Adaptive servo-ventilation (ASV) causes harm.

The use of SGLT2i is recommended to reduce HF-related morbidity and mortality.

Should receive chronic anticoagulant therapy.

DOAC is recommended over warfarin.

AF ablation is reasonable to improve symptoms and QOL.

Atrioventricular (AV) nodal ablation with implantation of a CRT device is reasonable.

Palliative and supportive care (communication, prognosis, goals of care, symptom management) should be provided to improve QOL.

The option for discontinuation should be anticipated and discussed through the continuum of care.

Timely referral to hospice can be useful to improve QOL.

Blood pressure should be controlled in accordance with GDMT for hypertension to prevent symptomatic HF.

SGLT2i should be used to prevent hospitalizations for HF.

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.

Natriuretic peptide biomarker-based screening followed by team-based care, including a cardiovascular specialist optimizing GDMT, can be useful to prevent the development of LV dysfunction (systolic or diastolic) or new-onset HF.

Validated multivariable risk scores can be useful to estimate subsequent risk of incident HF.

ACEi should be used to prevent symptomatic HF and reduce mortality.

Statins should be used to prevent symptomatic HF and adverse cardiovascular events.

ARB should be used to prevent symptomatic HF and reduce mortality.

Evidence-based beta blockers should be used to reduce mortality.

An ICD is recommended for primary prevention of sudden cardiac death (SCD) to reduce total mortality.

Beta blockers should be used to prevent symptomatic HF.

Thiazolidinediones should not be used because they increase the risk of HF, including hospitalizations.

Nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful.

Should receive care from multidisciplinary teams to facilitate the implementation of GDMT, address potential barriers to self-care, reduce the risk of subsequent rehospitalization for HF, and improve survival.

Should receive specific education and support to facilitate HF self-care in a multidisciplinary manner.

Vaccinating against respiratory illnesses (including Influenza, Pneumococcal, and COVID-19) is reasonable to reduce mortality.

Screening for depression, social isolation, frailty, and low health literacy as risk factors for poor self-care is reasonable to improve management.

Avoiding excessive sodium intake is reasonable to reduce congestive symptoms.

Exercise training (or regular physical activity) is recommended to improve functional status, exercise performance, and QOL.

A cardiac rehabilitation program can be useful to improve functional capacity, exercise tolerance, and health-related QOL.

Diuretics are recommended to relieve congestion, improve symptoms, and prevent worsening HF.

Addition of a thiazide (eg, metolazone) to treatment with a loop diuretic should be reserved for patients who do not respond to moderate- or high-dose loop diuretics to minimize electrolyte abnormalities.

The use of ARNi is recommended to reduce morbidity and mortality.

The use of ACEi is beneficial to reduce morbidity and mortality when the use of ARNi is not feasible.

The use of ARB is recommended to reduce morbidity and mortality.

Replacement by an ARNi is recommended to further reduce morbidity and mortality.

ARNi should not be administered concomitantly with ACEi or within 36 hours of the last dose of an ACEi.

ARNi or ACEi should not be administered to patients with any history of angioedema.

Use of 1 of the 3 beta blockers proven to reduce mortality (bisoprolol, carvedilol, or sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations.

An MRA (spironolactone or eplerenone) is recommended to reduce morbidity and mortality. Careful monitoring of potassium, renal function, and diuretic dosing should be performed.

In patients taking MRA whose serum potassium cannot be maintained at <5.5 mEq/L, MRA should be discontinued to avoid life-threatening hyperkalemia.

SGLT2i (dapagliflozin or empagliflozin) are recommended to reduce hospitalization for HF and cardiovascular mortality, irrespective of the presence of type 2 diabetes.

The combination of hydralazine and isosorbide dinitrate is recommended to improve symptoms and reduce morbidity and mortality.

A combination of hydralazine and isosorbide dinitrate might be considered to reduce morbidity and mortality.

Omega-3 polyunsaturated fatty acid (PUFA) supplementation may be reasonable to use as adjunctive therapy to reduce mortality and cardiovascular hospitalizations.

The effectiveness of potassium binders (patiromer, sodium zirconium cyclosilicate) to improve outcomes by facilitating continuation of RAASi therapy is uncertain.

Anticoagulation is not recommended.

In patients with HFrEF, dihydropyridine calcium channel-blocking drugs are not recommended treatment for HF.

In patients with HFrEF, vitamins, nutritional supplements, and hormonal therapy are not recommended other than to correct specific deficiencies.

In patients with HFrEF, nondihydropyridine calcium channel-blocking drugs (diltiazem, verapamil) are not recommended.

In patients with HFrEF, class IC antiarrhythmic medications and dronedarone may increase the risk of mortality.

In patients with HFrEF, thiazolidinediones increase the risk of worsening HF symptoms and hospitalizations.

In patients with type 2 diabetes and high cardiovascular risk, the DPP-4 inhibitors saxagliptin and alogliptin increase the risk of HF hospitalization and should be avoided.

In patients with HFrEF, NSAIDs worsen HF symptoms and should be avoided or withdrawn whenever possible.

Titration of guideline-directed medication dosing to achieve target doses showed to be efficacious in RCTs is recommended, to reduce cardiovascular mortality and HF hospitalizations, unless not well tolerated.

Titration and optimization of guideline-directed medications as frequently as every 1 to 2 weeks depending on the patient's symptoms, vital signs, and laboratory findings can be useful.

Ivabradine can be beneficial to reduce HF hospitalizations and cardiovascular death.

Digoxin might be considered to decrease hospitalizations for HF.

An oral soluble guanylate cyclase stimulator (vericiguat) may be considered to reduce HF hospitalization and cardiovascular death.

ICD therapy is recommended for primary prevention of SCD to reduce total mortality.

ICD therapy is recommended for primary prevention of SCD to reduce total mortality.

CRT is indicated to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL.

CRT can be useful to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL.

CRT is reasonable to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL.

CRT can be useful to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL.

CRT can be useful to reduce total mortality, improve symptoms and QOL, and increase LVEF, if: a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) atrioventricular nodal ablation or pharmacological rate control will allow near 100% ventricular pacing with CRT.

CRT can be useful to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL.

Implantation of ICD is reasonable to decrease sudden death.

CRT may be considered to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL.

CRT may be considered to reduce hospitalizations and improve symptoms and QOL.

CRT is not recommended.

CRT is not recommended.

ICD and cardiac resynchronization therapy with defibrillation (CRT-D) are not indicated.

Surgical revascularization plus GDMT is beneficial to improve symptoms, cardiovascular hospitalizations, and long-term all-cause mortality.

VHD (Valvular Heart Disease) should be managed in a multidisciplinary manner in accordance with clinical practice guidelines for VHD to prevent worsening of HF and adverse clinical outcomes.

Optimization of GDMT is recommended before any intervention for secondary MR related to LV dysfunction.

Should have screening for serum and urine monoclonal light chains with serum and urine immunofixation electrophoresis and serum free light chains.

Bone scintigraphy should be performed to confirm the presence of transthyretin cardiac amyloidosis.

Genetic testing with TTR gene sequencing is recommended to differentiate hereditary variant from wild-type transthyretin cardiac amyloidosis.

Transthyretin tetramer stabilizer therapy (tafamidis) is indicated to reduce cardiovascular morbidity and mortality.

Anticoagulation is reasonable to reduce the risk of stroke regardless of the CHA2DS2-VASc score.

Intravenous iron replacement is reasonable to improve functional status and QOL.

Erythropoietin-stimulating agents should not be used to improve morbidity and mortality.

Uptitration of GDMT to the maximally tolerated target dose is recommended.

A formal sleep assessment is reasonable to confirm the diagnosis and differentiate between obstructive and central sleep apnea.

Continuous positive airway pressure (CPAP) may be reasonable to improve sleep quality and decrease daytime sleepiness.

Adaptive servo-ventilation (ASV) causes harm.

The use of SGLT2i is recommended to reduce HF-related morbidity and mortality.

Should receive chronic anticoagulant therapy.

DOAC is recommended over warfarin.

AF ablation is reasonable to improve symptoms and QOL.

Atrioventricular (AV) nodal ablation with implantation of a CRT device is reasonable.

Palliative and supportive care (communication, prognosis, goals of care, symptom management) should be provided to improve QOL.

The option for discontinuation should be anticipated and discussed through the continuum of care.

Timely referral to hospice can be useful to improve QOL.

SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular mortality.

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.

GDMT should be continued to prevent relapse of HF and LV dysfunction, even in patients who may become asymptomatic.

Should have medication titrated to attain blood pressure targets in accordance with published clinical practice guidelines to prevent morbidity.

SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular mortality.

Management of AF can be useful to improve symptoms.

MRAs may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum.

The use of ARB may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum.

ARNi may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum.

Routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or QOL is ineffective.

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 (eg, LVAD, cardiac transplantation, palliative care, and palliative inotropes).

The benefit of fluid restriction to reduce congestive symptoms is uncertain.

Continuous intravenous inotropic support is reasonable as 'bridge therapy'.

Continuous intravenous inotropic support may be considered as palliative therapy for symptom control and improvement in functional status.

Long-term use of either continuous or intermittent intravenous inotropic agents, for reasons other than palliative care or as a bridge to advanced therapies, is potentially harmful.

Durable LVAD implantation is effective to improve functional status, QOL, and survival.

Durable MCS can be beneficial to improve symptoms, improve functional class, and reduce mortality.

Temporary MCS, including percutaneous and extracorporeal ventricular assist devices, are reasonable as a 'bridge to recovery' or 'bridge to decision'.

Cardiac transplantation is indicated to improve survival and QOL.

Patient-centered counseling regarding contraception and risks of cardiovascular deterioration during pregnancy should be provided.

ACEi, ARB, ARNi, MRA, SGLT2i, ivabradine, and vericiguat should NOT be administered because of risks of fetal harm.

Anticoagulation may be reasonable until 6 to 8 weeks postpartum.

Patient-centered counseling regarding contraception and risks of cardiovascular deterioration during pregnancy should be provided.

ACEi, ARB, ARNi, MRA, SGLT2i, ivabradine, and vericiguat should NOT be administered because of risks of fetal harm.

Anticoagulation may be reasonable until 6 to 8 weeks postpartum.