Treatment Protocol

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.