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Decidability – Executability Assessment

GUIDELINE TITLE

Heart Failure 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

TARGET POPULATION Decidable  Y  N
Eligibility  
Inclusion Criterion  
·   
Exclusion Criterion  
·   
       
KNOWLEDGE COMPONENTS    
       
RECOMMENDATION: Assessment
Conditional: A thorough history and physical examination should be obtained/ performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF. (I-C)
    Decision Variable: patients presenting with HF Decidable  Y  N
    Action: A thorough history and physical examination should be obtained or performed Executable  Y  N
       
RECOMMENDATION: Assessment
Conditional: In patients with idiopathic dilated cardiomyopathy (DCM), a 3-generational family history should be obtained to aid in establishing the diagnosis of familial DCM.
    Decision Variable: patients with idiopathic dilated cardiomyopathy Decidable  Y  N
    Action: a 3-generational family history should be obtained Executable  Y  N
       
RECOMMENDATION: Assessment
Conditional: Volume status and vital signs should be assessed at each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venous pressure and the presence of peripheral edema or orthopnea.
    Decision Variable: at each patient encounter Decidable  Y  N
    Action: assess volume status Executable  Y  N
    Action: assess vital signs Executable  Y  N
    Action: serial assessment of weight Executable  Y  N
    Action: estimate jugular venous pressure Executable  Y  N
    Action: assess the presence of peripheral edema or orthopnea Executable  Y  N
       
RECOMMENDATION: Assessment
Conditional: Validated multivariable risk scores can be useful to estimate subsequent risk of mortality in ambulatory or hospitalized patients with HF.
    Decision Variable: ambulatory or hospitalized patients with HF Decidable  Y  N
    Action: obtain validated multivariable risk scores Executable  Y  N
       
RECOMMENDATION: Diagnostic Tests
Conditional: Initial laboratory evaluation of patients presenting with HF should include a complete blood cell count, urinalysis, measurement of serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, glucose, and thyroid-stimulating hormone, a fasting lipid profile, and liver function tests.
    Decision Variable: Initial laboratory evaluation of patients presenting with HF Decidable  Y  N
    Action: perform complete blood cell count, Executable  Y  N
    Action: perform urinalysis Executable  Y  N
    Action: perform measurement of serum electrolytes (including calcium and magnesium), Executable  Y  N
    Action: perform measurement of blood urea nitrogen Executable  Y  N
    Action: perform measurement of serum creatinine Executable  Y  N
    Action: perform measurement of glucose, Executable  Y  N
    Action: perform measurement of thyroid-stimulating hormone Executable  Y  N
    Action: perform a fasting lipid profile test Executable  Y  N
    Action: perform liver function tests Executable  Y  N
       
RECOMMENDATION: Diagnostic Tests
Conditional: Serial monitoring, when indicated, should include serum electrolyte levels and renal function.
    Decision Variable: Serial monitoring indicated Decidable  Y  N
    Action: include serum electrolyte levels and renal function Executable  Y  N
       
RECOMMENDATION: Diagnostic Tests
Conditional: A 12-lead electrocardiogram should be performed initially on all patients presenting with HF
    Decision Variable: patients presenting with HF Decidable  Y  N
    Action: 12-lead electrocardiogram should be performed initially Executable  Y  N
       
RECOMMENDATION: Diagnostic Tests
Conditional: Screening for hemochromatosis or HIV is reasonable in selected patients who present with HF.
    Decision Variable: selected patients who present with HF Decidable  Y  N
    Action: Screening for hemochromatosis or HIV is reasonable Executable  Y  N
       
RECOMMENDATION: Diagnostic Tests
Conditional: Diagnostic tests for rheumatological diseases, amyloidosis, or pheochromocytoma are reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases.
    Decision Variable: patients presenting with HF in whom there is a clinical suspicion of rheumatological diseases, amyloidosis, or pheochromocytoma Decidable  Y  N
    Action: perform diagnostic tests for rheumatological diseases Executable  Y  N
    Action: perform diagnostic tests for amyloidosis Executable  Y  N
    Action: perform diagnostic tests for pheochromocytoma Executable  Y  N
       
RECOMMENDATION: Biomarkers for Prevention (2017)
Conditional: For patients at risk of developing 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 left ventricular dysfunction (systolic or diastolic) or new-onset HF.
    Decision Variable: patients at risk of developing HF Decidable  Y  N
    Action: perform natriuretic peptide biomarker–based screening Executable  Y  N
    Action: perform team-based care, including a cardiovascular specialist optimizing GDMT Executable  Y  N
       
RECOMMENDATION: Biomarkers for Diagnosis (2017)
Conditional: In patients presenting with dyspnea, measurement of natriuretic peptide biomarkers is useful to support a diagnosis or exclusion of HF.
    Decision Variable: patients presenting with dyspnea Decidable  Y  N
    Action: perform measurement of natriuretic peptide biomarkers Executable  Y  N
       
RECOMMENDATION: Biomarkers for Prognosis or Added Stratification (2017)
Conditional: Measurement of BNP or NT-proBNP is useful for establishing prognosis or disease severity in chronic HF.
    Decision Variable: chronic HF Decidable  Y  N
    Action: perform measurement of BNP or NT-proBNP Executable  Y  N
       
RECOMMENDATION: Biomarkers for Prognosis or Added Stratification (2017)
Conditional: Measurement of baseline levels of natriuretic peptide biomarkers and/or cardiac troponin on admission to the hospital is useful to establish a prognosis in acutely decompensated HF.
    Decision Variable: admission to the hospital Decidable  Y  N
    Action: perform measurement of baseline levels of natriuretic peptide biomarkers and/or cardiac troponin Executable  Y  N
       
RECOMMENDATION: Biomarkers for Prognosis or Added Stratification (2017)
Conditional: During a HF hospitalization, a predischarge natriuretic peptide level can be useful to establish a postdischarge prognosis.
    Decision Variable: During a HF hospitalization Decidable  Y  N
    Action: perform a measurement of predischarge natriuretic peptide level Executable  Y  N
       
RECOMMENDATION: Biomarkers for Prognosis or Added Stratification (2017)
Conditional: In patients with chronic HF, measurement of other clinically available tests, such as biomarkers of myocardial injury or fibrosis, may be considered for additive risk stratification.
    Decision Variable: patients with chronic HF Decidable  Y  N
    Action: perform measurement of clinically available tests, such as biomarkers of myocardial injury or fibrosis Executable  Y  N
       
RECOMMENDATION: Noninvasive Cardiac Imaging
Conditional: Patients with suspected or new-onset HF, or those presenting with acute decompensated HF, should undergo a chest x-ray 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.
    Decision Variable: Patients with suspected or new-onset HF, Decidable  Y  N
    Decision Variable: patients presenting with acute decompensated HF Decidable  Y  N
    Action: undergo a chest x-ray Executable  Y  N
       
RECOMMENDATION: Noninvasive Cardiac Imaging
Conditional: A 2-dimensional echocardiogram with Doppler should be performed during initial evaluation of patients presenting with HF to assess ventricular function, size, wall thickness, wall motion, and valve function.
    Decision Variable: initial evaluation of patients presenting with HF Decidable  Y  N
    Action: perform a 2-dimensional echocardiogram with Doppler Executable  Y  N
       
RECOMMENDATION: Noninvasive Cardiac Imaging
Conditional: Repeat measurement of EF and measurement of the severity of structural remodeling are useful to provide information in patients with HF who have had a significant change in clinical status; who have experienced or recovered from a clinical event; or who have received treatment, including GDMT, that might have had a significant effect on cardiac function; or who may be candidates for device therapy.
    Decision Variable: patients with HF Decidable  Y  N
    Decision Variable: who have had a significant change in clinical status Decidable  Y  N
    Decision Variable: who have experienced or recovered from a clinical event Decidable  Y  N
    Decision Variable: who have received treatment, including GDMT, that might have had a significant effect on cardiac function Decidable  Y  N
    Decision Variable: who may be candidates for device therapy Decidable  Y  N
    Action: repeat measurement of EF Executable  Y  N
    Action: measurement of the severity of structural remodeling Executable  Y  N
       
RECOMMENDATION: Noninvasive Cardiac Imaging
Conditional: Noninvasive imaging to detect myocardial ischemia and viability is reasonable in patients presenting with de novo HF, who have known CAD and no angina, unless the patient is not eligible for revascularization of any kind.
    Decision Variable: patients presenting with de novo HF Decidable  Y  N
    Decision Variable: who have known CAD Decidable  Y  N
    Decision Variable: no angina Decidable  Y  N
    Decision Variable: unless the patient is not eligible for revascularization of any kind. Decidable  Y  N
    Action: Executable  Y  N
       
RECOMMENDATION: Noninvasive Cardiac Imaging
Conditional: Viability assessment is reasonable in select situations when planning revascularization in HF patients with CAD.
    Decision Variable: select situations when planning revascularization in HF patients with CAD. Decidable  Y  N
    Action: Viability assessment Executable  Y  N
       
RECOMMENDATION: Noninvasive Cardiac Imaging
Conditional: Radionuclide ventriculography or magnetic resonance imaging can be useful to assess LVEF and volume when echocardiography is inadequate.
    Decision Variable: echocardiography is inadequate Decidable  Y  N
    Action: Radionuclide ventriculography Executable  Y  N
    Action: magnetic resonance imaging Executable  Y  N
       
RECOMMENDATION: Noninvasive Cardiac Imaging
Conditional: Magnetic resonance imaging is reasonable when assessing myocardial infiltrative processes or scar burden.
    Decision Variable: assessing myocardial infiltrative processes Decidable  Y  N
    Decision Variable: assessing scar burden Decidable  Y  N
    Action: Magnetic resonance imaging Executable  Y  N
       
RECOMMENDATION: Noninvasive Cardiac Imaging
Conditional: Routine repeat measurement of LV function assessment in the absence of clinical status change or treatment interventions should NOT be performed.
    Decision Variable: absence of clinical status change Decidable  Y  N
    Decision Variable: absence of treatment interventions Decidable  Y  N
    Action: perform routine repeat measurement of LV function assessment Executable  Y  N
       
RECOMMENDATION: Invasive Evaluation
Conditional: Invasive hemodynamic monitoring with a pulmonary artery catheter should be performed to guide therapy in patients who have respiratory distress or clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment.
    Decision Variable: patients who have respiratory distress Decidable  Y  N
    Decision Variable: patients with clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment Decidable  Y  N
    Action: Invasive hemodynamic monitoring with a pulmonary artery catheter Executable  Y  N
       
RECOMMENDATION: Invasive Evaluation
Conditional: Invasive hemodynamic monitoring can be useful for carefully selected patients with acute HF who have persistent symptoms despite empiric adjustment of standard therapies, and: • Whose fluid status, perfusion, or systemic or pulmonary vascular resistance is uncertain; • Whose systolic pressure remains low, or is associated with symptoms, despite initial therapy; • Whose renal function is worsening with therapy; • Who require parenteral vasoactive agents; or • Who may need consideration for mechanical circulatory support (MCS) or transplantation.
    Decision Variable: carefully selected patients with acute HF Decidable  Y  N
    Decision Variable: who have persistent symptoms despite empiric adjustment of standard therapies, Decidable  Y  N
    Decision Variable: Whose fluid status, perfusion, or systemic or pulmonary vascular resistance is uncertain Decidable  Y  N
    Decision Variable: Whose systolic pressure remains low, or is associated with symptoms, despite initial therapy; Decidable  Y  N
    Decision Variable: Whose renal function is worsening with therapy; Decidable  Y  N
    Decision Variable: Who require parenteral vasoactive agents; or Decidable  Y  N
    Decision Variable: Who may need consideration for mechanical circulatory support (MCS) or transplantation. Decidable  Y  N
    Action: Invasive hemodynamic monitoring Executable  Y  N
       
RECOMMENDATION: Invasive Evaluation
Conditional: When ischemia may be contributing to HF, coronary arteriography is reasonable for patients eligible for revascularization. (IIa-C)
    Decision Variable: ischemia may be contributing to HF Decidable  Y  N
    Decision Variable: for patients eligible for revascularization. Decidable  Y  N
    Action: coronary arteriography Executable  Y  N
       
RECOMMENDATION: Invasive Evaluation
Conditional: Endomyocardial biopsy can be useful in patients presenting with HF when a specific diagnosis is suspected that would influence therapy.
    Decision Variable: patients presenting with HF Decidable  Y  N
    Decision Variable: when a specific diagnosis is suspected that would influence therapy Decidable  Y  N
    Action: Endomyocardial biopsy Executable  Y  N
       
RECOMMENDATION: Invasive Evaluation
Conditional: Routine use of invasive hemodynamic monitoring is NOT recommended in normotensive patients with acute decompensated HF and congestion with symptomatic response to diuretics and vasodilators.
    Decision Variable: normotensive patients with acute decompensated HF Decidable  Y  N
    Decision Variable: congestion with symptomatic response to diuretics and vasodilators Decidable  Y  N
    Action: Routine use of invasive hemodynamic monitoring Executable  Y  N
       
RECOMMENDATION: Invasive Evaluation
Conditional: Endomyocardial biopsy should NOT be performed in the routine evaluation of patients with HF.
    Decision Variable: routine evaluation of patients with HF Decidable  Y  N
    Action: Endomyocardial biopsy Executable  Y  N
       
RECOMMENDATION: Treatment Stage A
Conditional: Hypertension and lipid disorders should be controlled in accordance with contemporary guidelines to lower the risk of HF.
    Decision Variable: lowering the risk of HF Decidable  Y  N
    Action: control hypertension Executable  Y  N
    Action: control lipid disorders Executable  Y  N
       
RECOMMENDATION: Treatment Stage A
Conditional: Other conditions that may lead to or contribute to HF, such as obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents, should be controlled or avoided.
    Decision Variable: obesity Decidable  Y  N
    Decision Variable: diabetes mellitus Decidable  Y  N
    Decision Variable: tobacco use Decidable  Y  N
    Decision Variable: known cardiotoxic agents Decidable  Y  N
    Action: controlled Executable  Y  N
    Action: avoided Executable  Y  N
       
RECOMMENDATION: Treatment Stage B
Conditional: In all patients with a recent or remote history of MI or acute coronary syndrome and reduced EF, angiotensin-converting enzyme (ACE) inhibitors should be used to prevent symptomatic HF and reduce mortality. In patients intolerant of ACE inhibitors, angiotensin-receptor blockers are appropriate unless contraindicated.
    Decision Variable: patients with a recent or remote history of MI Decidable  Y  N
    Decision Variable: acute coronary syndrome Decidable  Y  N
    Decision Variable: reduced EF Decidable  Y  N
    Action: angiotensin-converting enzyme (ACE) inhibitors should be used Executable  Y  N
Conditional: In all patients with a recent or remote history of MI or acute coronary syndrome and reduced EF, angiotensin-converting enzyme (ACE) inhibitors should be used to prevent symptomatic HF and reduce mortality. In patients intolerant of ACE inhibitors, angiotensin-receptor blockers are appropriate unless contraindicated.
    Decision Variable: patients with a recent or remote history of MI Decidable  Y  N
    Decision Variable: acute coronary syndrome Decidable  Y  N
    Decision Variable: reduced EF Decidable  Y  N
    Decision Variable: patients intolerant of ACE inhibitors Decidable  Y  N
    Action: angiotensin-receptor blockers are appropriate unless contraindicated Executable  Y  N
       
RECOMMENDATION: Treatment Stage B
Conditional: In all patients with a recent or remote history of MI or acute coronary syndrome and reduced EF, evidence-based beta blockers should be used to reduce mortality.
    Decision Variable: patients with a recent or remote history of MI Decidable  Y  N
    Decision Variable: acute coronary syndrome Decidable  Y  N
    Decision Variable: reduced EF Decidable  Y  N
    Action: evidence-based beta blockers should be used to reduce mortality Executable  Y  N
       
RECOMMENDATION: Treatment Stage B
Conditional: In all patients with a recent or remote history of MI or acute coronary syndrome, statins should be used to prevent symptomatic HF and cardiovascular events.
    Decision Variable: patients with a recent or remote history of MI Decidable  Y  N
    Decision Variable: acute coronary syndrome Decidable  Y  N
    Action: statins should be used to prevent symptomatic HF and cardiovascular events. Executable  Y  N
       
RECOMMENDATION: Treatment Stage B
Conditional: In patients with structural cardiac abnormalities, including LV hypertrophy, in the absence of a history of MI or ACS, blood pressure should be controlled in accordance with clinical practice guidelines for hypertension to prevent symptomatic HF.
    Decision Variable: patients with structural cardiac abnormalities, including LV hypertrophy Decidable  Y  N
    Decision Variable: the absence of a history of MI or ACS Decidable  Y  N
    Action: blood pressure should be controlled in accordance with clinical practice guidelines for hypertension to prevent symptomatic HF. Executable  Y  N
       
RECOMMENDATION: Treatment Stage B
Conditional: ACE inhibitors should be used in all patients with a reduced EF to prevent symptomatic HF, even if they do not have a history of MI.
    Decision Variable: patients with a reduced EF Decidable  Y  N
    Action: ACE inhibitors should be used Executable  Y  N
       
RECOMMENDATION: Treatment Stage B
Conditional: Beta blockers should be used in all patients with a reduced EF to prevent symptomatic HF, even if they do not have a history of MI.
    Decision Variable: patients with a reduced EF Decidable  Y  N
    Action: Beta blockers should be used Executable  Y  N
       
RECOMMENDATION: Treatment Stage B
Conditional: To prevent sudden death, placement of an implantable cardioverterdefibrillator (ICD) is reasonable in patients with asymptomatic ischemic cardiomyopathy who are ≥40 days post-MI, have an LVEF of ≤30%, are on appropriate medical therapy, and have a reasonable expectation of survival with a good functional status for >1 year.
    Decision Variable: patients with asymptomatic ischemic cardiomyopathy who are ≥40 days post-MI Decidable  Y  N
    Decision Variable: have an LVEF of ≤30%, Decidable  Y  N
    Decision Variable: are on appropriate medical therapy Decidable  Y  N
    Decision Variable: have a reasonable expectation of survival with a good functional status for >1 year. Decidable  Y  N
    Action: placement of an implantable cardioverterdefibrillator (ICD) is reasonable Executable  Y  N
       
RECOMMENDATION: Treatment Stage B
Conditional: Nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful in asymptomatic patients with low LVEF and no symptoms of HF after MI.
    Decision Variable: asymptomatic patients with low LVEF Decidable  Y  N
    Decision Variable: no symptoms of HF after MI. Decidable  Y  N
    Action: Nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful Executable  Y  N
       
RECOMMENDATION: Treatment Stage C Nonpharmacological Interventions Education
Conditional: Patients with HF should receive specific education to facilitate HF self-care.
    Decision Variable: Patients with HF Decidable  Y  N
    Action: should receive specific education to facilitate HF self-care Executable  Y  N
       
RECOMMENDATION: Treatment Stage C Nonpharmacological Interventions Sodium Restriction
Conditional: Sodium restriction is reasonable for patients with symptomatic HF to reduce congestive symptoms.
    Decision Variable: patients with symptomatic HF Decidable  Y  N
    Action: Sodium restriction is reasonable Executable  Y  N
       
RECOMMENDATION: Treatment Stage C Nonpharmacological Interventions Activity, Exercise Prescription, and Cardiac Rehabilitation
Conditional: Exercise training (or regular physical activity) is recommended as safe and effective for patients with HF who are able to participate to improve functional status. (I-A)
    Decision Variable: patients with HF Decidable  Y  N
    Decision Variable: who are able to participate to improve functional status Decidable  Y  N
    Action: Exercise training (or regular physical activity) is recommended as safe and effective Executable  Y  N
       
RECOMMENDATION: Treatment Stage C Nonpharmacological Interventions Activity, Exercise Prescription, and Cardiac Rehabilitation
Conditional: Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, health-related quality of life (HRQOL), and mortality.
    Decision Variable: clinically stable patients with HF Decidable  Y  N
    Action: Cardiac rehabilitation can be useful Executable  Y  N
       
RECOMMENDATION: Treatment Stage C Pharmacological Treatment for Stage C HFrEF
Conditional: Measures listed as Class I recommendations for patients in stages A and B are recommended where appropriate for patients in stage C. (I-A, I-B, and I-C as appropriate)
    Decision Variable: patients in stage C Decidable  Y  N
    Action: use same measures listed in Class I recommendations for patients in stages A and B Executable  Y  N
       
RECOMMENDATION: Treatment Stage C Pharmacological Treatment for Stage C HFrEF <>
Conditional: GDMT as depicted in Figure 1 should be the mainstay of pharmacological therapy for HFrEF. (I-A) <>
    Action: Executable  Y  N
       
RECOMMENDATION: Treatment of HFrEF Stage C and D (2017)
Conditional: HFrEF NYHA class I–IV (Stage C) ACEI or ARB AND GDMT beta blocker; diuretics as needed (COR I)
    Decision Variable: Stage C patient with HFrEF Decidable  Y  N
    Decision Variable: NYHA class I-IV Decidable  Y  N
    Action: treat with angiotensin-converting enzyme inhibitor or angiotensin receptor-blocker Executable  Y  N
    Action: GDMT beta blocker; Executable  Y  N
    Action: diuretics as needed Executable  Y  N
       
RECOMMENDATION: Treatment of HFrEF Stage C and D (2017)
Conditional: NYHA class II–IV, provided est. CrCl >30 mL/min & K+ <5.0 mEq/L implement Aldosterone antagonist (COR I)
    Decision Variable: patient is NYHA class II–IV Decidable  Y  N
    Decision Variable: provided est. CrCl >30 mL/min Decidable  Y  N
    Decision Variable: K+ <5.0 mEq/L Decidable  Y  N
    Action: implement aldosterone antagonist Executable  Y  N
       
RECOMMENDATION: Treatment of HFrEF Stage C and D (2017)
Conditional: NYHA class II–III HF Adequate BP on ACEI or ARB; No C/I to ARB or sacubitril then Discontinue ACEI or ARB; initiate ARNI
    Decision Variable: NYHA class II–III HF Decidable  Y  N
    Decision Variable: Adequate blood pressure on angiotensin-converting enzyme inhibitor or angiotensin receptor-blocker Decidable  Y  N
    Decision Variable: No contraindication to angiotensin receptor-blocker or sacubitril Decidable  Y  N
    Action: Discontinue ACEI or ARB Executable  Y  N
    Action: initiate ARNI Executable  Y  N
       
RECOMMENDATION: Treatment of HFrEF Stage C and D (2017)
Conditional: NYHA class III–IV, in black patients implment Hydral-Nitrates
    Decision Variable: NYHA class III–IV Decidable  Y  N
    Decision Variable: in black patients Decidable  Y  N
    Action: implement Hydral-Nitrates Executable  Y  N
       
RECOMMENDATION: Treatment of HFrEF Stage C and D (2017)
Conditional: NYHA class II–III, LVEF ≤35%; (caveat: >1 y survival, >40 d post MI) implement implantable cardioverter-defibrillator
    Decision Variable: NYHA class II–III Decidable  Y  N
    Decision Variable: left ventricular ejection fraction ≤35% Decidable  Y  N
    Decision Variable: (caveat: >1 y survival, >40 d post MI) Decidable  Y  N
    Action: implement implantable cardioverter defibrillator Executable  Y  N
       
RECOMMENDATION: Treatment of HFrEF Stage C and D (2017)
Conditional: NYHA class II–IV, LVEF ≤35%, NSR & QRS ≥150 ms with LBBB pattern
    Decision Variable: NYHA class II–IV Decidable  Y  N
    Decision Variable: left ventricular ejection fraction ≤35% Decidable  Y  N
    Decision Variable: normal sinus rhythm and QRS ≥150 ms with left bundle-branch block pattern Decidable  Y  N
    Action: implement cardiac resynchronization therapy Executable  Y  N
    Action: implement cardiac resynchronization therapy–device Executable  Y  N
       
RECOMMENDATION: Treatment of HFrEF Stage C and D (2017)
Conditional: NYHA class II–III, NSR, heart rate ≥70 bpm on maximally tolerated dose beta blocker
    Decision Variable: NYHA class II–III, Decidable  Y  N
    Decision Variable: normal sinus rhythm, Decidable  Y  N
    Decision Variable: heart rate ≥70 bpm on maximally tolerated dose beta blocker Decidable  Y  N
    Action: implement Ivabradine Executable  Y  N
       
RECOMMENDATION: Treatment of HFrEF Stage C and D (2017)
Conditional: patients are Stage D refractory NYHA class III-IV consider additional therapy of palliative care (COR I) or transplant (COR I) or left ventricular assist device (COR IIa) or Investigational studies
    Decision Variable: patients are Stage D refractory NYHA class III-IV Decidable  Y  N
    Action: consider additional therapy of palliative care (COR I) Executable  Y  N
    Action: consider additional therapy of transplant (COR I) Executable  Y  N
    Action: consider additional therapy of left ventricular assist device (COR IIa) Executable  Y  N
    Action: consider investigational studies Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Diuretics
Conditional: Diuretics are recommended in patients with HFrEF with fluid retention
    Decision Variable: patients with HFrEF with fluid retention Decidable  Y  N
    Action: Diuretics are recommended Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF ACE Inhibitors
Conditional: ACE inhibitors are recommended for all patients with HFrEF
    Decision Variable: patients with HFrEF Decidable  Y  N
    Action: ACE inhibitors are recommended Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF ARBs
Conditional: ARBs are recommended in patients with HFrEF who are ACE inhibitor–intolerant
    Decision Variable: patients with HFrEF Decidable  Y  N
    Decision Variable: who are ACE inhibitor–intolerant Decidable  Y  N
    Action: ARBs are recommended Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF ARBs
Conditional: ARBs are reasonable as alternatives to ACE inhibitors as first-line therapy in HFrEF
    Decision Variable: patient with HFrEF Decidable  Y  N
    Decision Variable: first-line therapy Decidable  Y  N
    Action: ARBs are reasonable as alternatives to ACE inhibitors Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF ARBs
Conditional: Addition of an ARB may be considered in persistently symptomatic patients with HFrEF on GDMT
    Decision Variable: persistently symptomatic patients with HFrEF on GDMT Decidable  Y  N
    Action: Addition of an ARB may be considered Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF ARBs
Conditional: Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is potentially harmful for patients with HFrEF.
    Decision Variable: patients with HFrEF Decidable  Y  N
    Action: Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is potentially harmful Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Beta Blockers
Conditional: Use of 1 of the 3 beta blockers proven to reduce mortality is recommended for all stable patients
    Decision Variable: stable patients Decidable  Y  N
    Action: Use of 1 of the 3 beta blockers proven to reduce mortality is recommended Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Aldosterone Receptor Antagonists
Conditional: Aldosterone receptor antagonists are recommended in patients with NYHA class II–IV HF who have LVEF ≤35%
    Decision Variable: patients with NYHA class II–IV HF Decidable  Y  N
    Decision Variable: who have LVEF ≤35% Decidable  Y  N
    Action: Aldosterone receptor antagonists are recommended Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Aldosterone Receptor Antagonists
Conditional: Aldosterone receptor antagonists are recommended to reduce morbidity and mortality following an acute MI in patients who have LVEF of ≤40% who develop symptoms of HF or who have a history of diabetes mellitus, unless contraindicated.
    Decision Variable: patients following an acute MI Decidable  Y  N
    Decision Variable: who have LVEF ≤40% Decidable  Y  N
    Decision Variable: who develop symptoms of HF Decidable  Y  N
    Decision Variable: who have a history of diabetes mellitus Decidable  Y  N
    Action: Aldosterone receptor antagonists are recommended Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Aldosterone Receptor Antagonists
Conditional: Inappropriate use of aldosterone receptor antagonists is potentially harmful because of life-threatening hyperkalemia or renal insufficiency when serum creatinine is >2.5 mg/dL in men or >2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium >5.0 mEq/L.
    Decision Variable: serum creatinine is >2.5 mg/dL in men Decidable  Y  N
    Decision Variable: >2.0 mg/dL in women Decidable  Y  N
    Decision Variable: or estimated glomerular filtration rate <30 mL/min/1.73 m2 Decidable  Y  N
    Decision Variable: and/or potassium >5.0 mEq/L. Decidable  Y  N
    Action: Inappropriate use of aldosterone receptor antagonists is potentially harmful because of life-threatening hyperkalemia or renal insufficiency Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Hydralazine and Isosorbide Dinitrate
Conditional: The combination of hydralazine and isosorbide dinitrate is recommended for African Americans with NYHA class III–IV HFrEF on GDMT
    Decision Variable: African Americans with NYHA class III–IV HFrEF on GDMT Decidable  Y  N
    Action: combination of hydralazine and isosorbide dinitrate is recommended Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Hydralazine and Isosorbide Dinitrate
Conditional: A combination of hydralazine and isosorbide dinitrate can be useful in patients with HFrEF who cannot be given ACE inhibitors or ARBs
    Decision Variable: patients with HFrEF Decidable  Y  N
    Decision Variable: who cannot be given ACE inhibitors or ARBs Decidable  Y  N
    Action: A combination of hydralazine and isosorbide dinitrate can be useful Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Digoxin
Conditional: Digoxin can be beneficial in patients with HFrEF, unless contraindicated, to decrease hospitalizations for HF.
    Decision Variable: patients with HFrEF Decidable  Y  N
    Action: Digoxin can be beneficial, unless contraindicated Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Anticoagulants
Conditional: Patients with chronic HF with permanent/persistent/paroxysmal AF and an additional risk factor for cardioembolic stroke (history of hypertension, diabetes mellitus, previous stroke or transient ischemic attack, or ≥75 years of age) should receive chronic anticoagulant therapy (in the absence of contraindications to anticoagulation).
    Decision Variable: Patients with chronic HF Decidable  Y  N
    Decision Variable: with permanent/persistent/paroxysmal AF Decidable  Y  N
    Decision Variable: an additional risk factor for cardioembolic stroke Decidable  Y  N
    Decision Variable: absence of contraindications to anticoagulation Decidable  Y  N
    Action: should receive chronic anticoagulant therapy Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Anticoagulants
Conditional: The selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal AF should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. (
    Decision Variable: permanent/persistent/paroxysmal AF Decidable  Y  N
    Action: The selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) should be individualized Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Anticoagulants
Conditional: Chronic anticoagulation is reasonable for patients with chronic HF who have permanent/persistent/paroxysmal AF but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). (
    Decision Variable: patients with chronic HF Decidable  Y  N
    Decision Variable: who have permanent/persistent/paroxysmal AF Decidable  Y  N
    Decision Variable: are without an additional risk factor for cardioembolic stroke Decidable  Y  N
    Decision Variable: (in the absence of contraindications to anticoagulation). Decidable  Y  N
    Action: Chronic anticoagulation is reasonable Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Anticoagulants
Conditional: Anticoagulation is NOT recommended in patients with chronic HFrEF without AF, a prior thromboembolic event, or a cardioembolic source
    Decision Variable: patients with chronic HFrEF without AF Decidable  Y  N
    Decision Variable: a prior thromboembolic event Decidable  Y  N
    Decision Variable: a cardioembolic source Decidable  Y  N
    Action: Anticoagulation Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Statins
Conditional: Statins are NOT beneficial as adjunctive therapy when prescribed solely for HF
    Decision Variable: prescribed solely for HF Decidable  Y  N
    Action: Statins are NOT beneficial as adjunctive therapy Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Omega-3 Fatty Acids
Conditional: Omega-3 PUFA supplementation is reasonable to use as adjunctive therapy in HFrEF or HFpEF patients
    Decision Variable: HFrEF patients Decidable  Y  N
    Decision Variable: HFpEF patients Decidable  Y  N
    Action: Omega-3 PUFA supplementation is reasonable to use as adjunctive therapy Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Other
Conditional: Nutritional supplements as treatment for HF are NOT recommended in patients with current or prior symptoms of HFrEF. (
    Decision Variable: patients with current or prior symptoms of HFrEF Decidable  Y  N
    Action: Nutritional supplements as treatment for HF are NOT recommended Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Other
Conditional: Hormonal therapies other than to correct deficiencies are NOT recommended in HFrEF
    Decision Variable: patient with HFrEF Decidable  Y  N
    Action: Hormonal therapies other than to correct deficiencies are NOT recommended Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Other
Conditional: Drugs known to adversely affect the clinical status of patients with current or prior symptoms of HFrEF are potentially harmful and should be avoided or withdrawn whenever possible (eg, most antiarrhythmic drugs, most calcium channel–blocking drugs [except amlodipine], nonsteroidal anti-inflammatory drugs, or thiazolidinediones).
    Decision Variable: patients with current or prior symptoms of HFrEF Decidable  Y  N
    Action: avoided or withdrawn whenever possible (eg, most antiarrhythmic drugs, most calcium channel–blocking drugs [except amlodipine], nonsteroidal anti-inflammatory drugs, or thiazolidinediones). Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Other
Conditional: Long-term use of infused positive inotropic drugs is potentially harmful for patients with HFrEF, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment
    Decision Variable: patients with HFrEF Decidable  Y  N
    Action: Long-term use of infused positive inotropic drugs is potentially harmful Executable  Y  N
       
RECOMMENDATION: Pharmacological Therapy for Management of Stage C HFrEF Calcium Channel Blockers
Conditional: Calcium channel–blocking drugs are NOT recommended as routine treatment in HFrEF
    Decision Variable: patient with HFrEF Decidable  Y  N
    Action: Calcium channel–blocking drugs are NOT recommended as routine treatment Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HF With Reduced Ejection Fraction
Conditional: The clinical strategy of inhibition of the renin-angiotensin system with ACE inhibitors OR ARBs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic HFrEF to reduce morbidity and mortality.
    Decision Variable: patients with chronic HFrEF Decidable  Y  N
    Action: The clinical strategy of inhibition of the renin-angiotensin system with ACE inhibitors OR ARBs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HF With Reduced Ejection Fraction
Conditional: The clinical strategy of inhibition of the renin-angiotensin system with ARNI in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic HFrEF to reduce morbidity and mortality.
    Decision Variable: patients with chronic HFrEF Decidable  Y  N
    Action: The clinical strategy of inhibition of the renin-angiotensin system with ARNI in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HF With Reduced Ejection Fraction
Conditional: The use of ACE inhibitors is beneficial for patients with prior or current symptoms of chronic HFrEF to reduce morbidity and mortality.
    Decision Variable: patients with prior or current symptoms of chronic HFrEF Decidable  Y  N
    Action: The use of ACE inhibitors is beneficial Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HF With Reduced Ejection Fraction
Conditional: The use of ARBs to reduce morbidity and mortality is recommended in patients with prior or current symptoms of chronic HFrEF who are intolerant to ACE inhibitors because of cough or angioedema.
    Decision Variable: patients with prior or current symptoms of chronic HFrEF Decidable  Y  N
    Decision Variable: who are intolerant to ACE inhibitors because of cough or angioedema Decidable  Y  N
    Action: The use of ARBs to reduce morbidity and mortality is recommended Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HF With Reduced Ejection Fraction
Conditional: In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACE inhibitor or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality.
    Decision Variable: In patients with chronic symptomatic HFrEF NYHA class II or III Decidable  Y  N
    Decision Variable: who tolerate an ACE inhibitor or ARB Decidable  Y  N
    Action: replacement by an ARNI is recommended to further reduce morbidity and mortality. Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HF With Reduced Ejection Fraction
Conditional: Angiotensin receptor-neprilysin inhibitor should not be administered concomitantly with ACE inhibitors or within 36 hours of the last dose of an ACE inhibitor.
    Decision Variable: patients with HFrEF Decidable  Y  N
    Action: Angiotensin receptor-neprilysin inhibitor should not be administered concomitantly with ACE inhibitors or within 36 hours of the last dose of an ACE inhibitor. Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HF With Reduced Ejection Fraction
Conditional: Angiotensin receptor-neprilysin inhibitor should not be administered to patients with a history of angioedema.
    Decision Variable: patients with a history of angioedema Decidable  Y  N
    Action: Angiotensin receptor-neprilysin inhibitor should not be administered Executable  Y  N
       
RECOMMENDATION: Ivabradine
Conditional: Ivabradine can be beneficial to reduce HF hospitalization for patients with symptomatic (NYHA class II-III) stable chronic HFrEF (LVEF ≤35%) who are receiving GDEM, including a beta blocker at maximum tolerated dose, and who are in sinus rhythm with a heart rate of ≥70 bpm at rest.
    Decision Variable: patients with symptomatic (NYHA class II-III) stable chronic HFrEF (LVEF ≤35%) Decidable  Y  N
    Decision Variable: who are receiving GDEM, including a beta blocker at maximum tolerated dose, Decidable  Y  N
    Decision Variable: who are in sinus rhythm with a heart rate of ≥70 bpm at rest. Decidable  Y  N
    Action: Ivabradine can be beneficial to reduce HF hospitalization Executable  Y  N
       
RECOMMENDATION: Diuretics (see Table 15)
Conditional: Diuretics are recommended in patients with HFrEF who have evidence of fluid retention, unless contraindicated, to improve symptoms.
    Decision Variable: patients with HFrEF Decidable  Y  N
    Decision Variable: who have evidence of fluid retention Decidable  Y  N
    Decision Variable: not contraindicated Decidable  Y  N
    Action: Diuretics are recommended Executable  Y  N
       
RECOMMENDATION: ACE Inhibitors
Conditional: ACE inhibitors are recommended in patients with HFrEF and current or prior symptoms, unless contraindicated, to reduce morbidity and mortality. (I-A)
    Decision Variable: patients with HFrEF and current or prior symptoms, Decidable  Y  N
    Decision Variable: not contraindicated Decidable  Y  N
    Action: ACE inhibitors are recommended Executable  Y  N
       
RECOMMENDATION: ARBs
Conditional: ARBs are recommended in patients with HFrEF with current or prior symptoms who are ACE inhibitor–intolerant, unless contraindicated, to reduce morbidity and mortality.
    Decision Variable: patients with HFrEF with current or prior symptoms Decidable  Y  N
    Decision Variable: who are ACE inhibitor–intolerant Decidable  Y  N
    Decision Variable: not contraindicated Decidable  Y  N
    Action: ARBs are recommended Executable  Y  N
       
RECOMMENDATION: ARBs
Conditional: ARBs are reasonable to reduce morbidity and mortality as alternatives to ACE inhibitors as first-line therapy for patients with HFrEF, especially for patients already taking ARBs for other indications, unless contraindicated.
    Decision Variable: first-line therapy for patients with HFrEF Decidable  Y  N
    Decision Variable: patients already taking ARBs for other indications Decidable  Y  N
    Decision Variable: not contraindicated Decidable  Y  N
    Action: ARBs are reasonable to reduce morbidity and mortality as alternatives to ACE inhibitors Executable  Y  N
       
RECOMMENDATION: ARBs
Conditional: Addition of an ARB may be considered in persistently symptomatic patients with HFrEF who are already being treated with an ACE inhibitor and a beta blocker in whom an aldosterone antagonist is not indicated or tolerated.
    Decision Variable: persistently symptomatic patients with HFrEF Decidable  Y  N
    Decision Variable: who are already being treated with an ACE inhibitor and a beta blocker i Decidable  Y  N
    Decision Variable: an aldosterone antagonist is not indicated or tolerated. Decidable  Y  N
    Action: Addition of an ARB Executable  Y  N
       
RECOMMENDATION: ARBs
Conditional: Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is potentially harmful for patients with HFrEF.
    Decision Variable: patients with HFrEF Decidable  Y  N
    Action: Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is potentially harmful Executable  Y  N
       
RECOMMENDATION: Beta Blockers
Conditional: Use of 1 of the 3 beta blockers proven to reduce mortality (ie, bisoprolol, carvedilol, and sustained-release metoprolol succinate) is recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality.
    Decision Variable: for all patients with current or prior symptoms of HFrEF, Decidable  Y  N
    Decision Variable: unless contraindicated Decidable  Y  N
    Action: Use of 1 of the 3 beta blockers proven to reduce mortality (ie, bisoprolol, carvedilol, and sustained-release metoprolol succinate) Executable  Y  N
       
RECOMMENDATION: Aldosterone Receptor Antagonists (see Table 17)
Conditional: Aldosterone receptor antagonists (or mineralocorticoid receptor antagonists) are recommended in patients with NYHA class II–IV and who have LVEF of ≤35%, unless contraindicated, to reduce morbidity and mortality. Patients with NYHA class II should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists. Creatinine levels should be ≤2.5 mg/dL in men or ≤2.0 mg/dL in women (or estimated glomerular filtration rate >30 mL/min/1.73 m2) 2) and potassium levels should be <5.0 mEq/L. Careful monitoring of potassium levels, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyperkalemia and renal insufficiency.
    Decision Variable: patients with NYHA class II–IV Decidable  Y  N
    Decision Variable: and who have LVEF of ≤35% Decidable  Y  N
    Decision Variable: unless contraindicated Decidable  Y  N
    Decision Variable: Patients with NYHA class II should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists. Decidable  Y  N
    Decision Variable: Creatinine levels should be ≤2.5 mg/dL in men or ≤2.0 mg/dL in women (or estimated glomerular filtration rate >30 mL/min/1.73 m2) 2) Decidable  Y  N
    Decision Variable: and potassium levels should be <5.0 mEq/L. Decidable  Y  N
    Action: Aldosterone receptor antagonists (or mineralocorticoid receptor antagonists) Executable  Y  N
    Action: Careful monitoring of potassium levels, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyperkalemia and renal insufficiency. Executable  Y  N
       
RECOMMENDATION: Aldosterone Receptor Antagonists (see Table 17)
Conditional: Aldosterone receptor antagonists are recommended to reduce morbidity and mortality following an acute MI in patients who have LVEF of ≤40% who develop symptoms of HF or who have a history of diabetes mellitus, unless contraindicated.
    Decision Variable: following an acute MI in patients Decidable  Y  N
    Decision Variable: who have LVEF of ≤40% Decidable  Y  N
    Decision Variable: who develop symptoms of HF Decidable  Y  N
    Decision Variable: or who have a history of diabetes mellitus Decidable  Y  N
    Decision Variable: unless contraindicated Decidable  Y  N
    Action: Aldosterone receptor antagonists Executable  Y  N
       
RECOMMENDATION: Aldosterone Receptor Antagonists (see Table 17)
Conditional: Inappropriate use of aldosterone receptor antagonists is potentially harmful because of life-threatening hyperkalemia or renal insufficiency when serum creatinine is >2.5 mg/dL in men or >2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium >5.0 mEq/L.
    Decision Variable: patients with HFrEF Decidable  Y  N
    Decision Variable: serum creatinine is >2.5 mg/dL in men Decidable  Y  N
    Decision Variable: >2.0 mg/dL in women Decidable  Y  N
    Decision Variable: estimated glomerular filtration rate <30 mL/min/1.73 m2 Decidable  Y  N
    Decision Variable: potassium >5.0 mEq/L Decidable  Y  N
    Action: Inappropriate use of aldosterone receptor antagonists is potentially harmful Executable  Y  N
       
RECOMMENDATION: Hydralazine and Isosorbide Dinitrate
Conditional: The combination of hydralazine and isosorbide dinitrate is recommended to reduce morbidity and mortality for patients selfdescribed as African Americans with NYHA class III–IV HFrEF receiving optimal therapy with ACE inhibitors and beta blockers, unless contraindicated.
    Decision Variable: patients self-described as African Americans with NYHA class III–IV HFrEF Decidable  Y  N
    Decision Variable: receiving optimal therapy with ACE inhibitors and beta blockers Decidable  Y  N
    Decision Variable: unless contraindicated Decidable  Y  N
    Action: The combination of hydralazine and isosorbide dinitrate is recommended Executable  Y  N
       
RECOMMENDATION: Hydralazine and Isosorbide Dinitrate
Conditional: A combination of hydralazine and isosorbide dinitrate can be useful to reduce morbidity or mortality in patients with current or prior symptomatic HFrEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency, unless contraindicated.
    Decision Variable: patients with current or prior symptomatic HFrEF Decidable  Y  N
    Decision Variable: who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency, Decidable  Y  N
    Decision Variable: unless contraindicated Decidable  Y  N
    Action: A combination of hydralazine and isosorbide dinitrate can be useful Executable  Y  N
       
RECOMMENDATION: Digoxin
Conditional: Digoxin can be beneficial in patients with HFrEF, unless contraindicated, to decrease hospitalizations for HF.
    Decision Variable: patients with HFrEF Decidable  Y  N
    Decision Variable: unless contraindicated Decidable  Y  N
    Action: Digoxin can be beneficial Executable  Y  N
       
RECOMMENDATION: Anticoagulation
Conditional: Patients with chronic HF with permanent/persistent/paroxysmal AF and an additional risk factor for cardioembolic stroke (history of hypertension, diabetes mellitus, previous stroke or transient ischemic attack, or ≥75 years of age) should receive chronic anticoagulant therapy (in the absence of contraindications to anticoagulation).
    Decision Variable: Patients with chronic HF Decidable  Y  N
    Decision Variable: with permanent/persistent/paroxysmal AF Decidable  Y  N
    Decision Variable: and an additional risk factor for cardioembolic stroke (history of hypertension, diabetes mellitus, previous stroke or transient ischemic attack, or ≥75 years of age) Decidable  Y  N
    Decision Variable: (in the absence of contraindications to anticoagulation). Decidable  Y  N
    Action: should receive chronic anticoagulant therapy (in the absence of contraindications to anticoagulation). Executable  Y  N
       
RECOMMENDATION: Anticoagulation
Conditional: The selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal AF should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin.
    Decision Variable: on the basis of risk factors Decidable  Y  N
    Decision Variable: cost Decidable  Y  N
    Decision Variable: tolerability Decidable  Y  N
    Decision Variable: patient preference Decidable  Y  N
    Decision Variable: potential for drug interactions Decidable  Y  N
    Decision Variable: other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin Decidable  Y  N
    Action: individualize the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal AF Executable  Y  N
       
RECOMMENDATION: Anticoagulation
Conditional: Chronic anticoagulation is reasonable for patients with chronic HF who have permanent/persistent/paroxysmal AF but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation).
    Decision Variable: patients with chronic HF Decidable  Y  N
    Decision Variable: who have permanent/persistent/paroxysmal AF Decidable  Y  N
    Decision Variable: but are without an additional risk factor for cardioembolic stroke Decidable  Y  N
    Decision Variable: in the absence of contraindications to anticoagulation Decidable  Y  N
    Action: Chronic anticoagulation is reasonable Executable  Y  N
       
RECOMMENDATION: Anticoagulation
Conditional: Anticoagulation is NOT recommended in patients with chronic HFrEF without AF, a prior thromboembolic event, or a cardioembolic source. (III-B: No Benefit)
    Decision Variable: patients with chronic HFrEF without AF Decidable  Y  N
    Decision Variable: a prior thromboembolic event Decidable  Y  N
    Decision Variable: a cardioembolic source Decidable  Y  N
    Action: Anticoagulation is NOT recommended Executable  Y  N
       
RECOMMENDATION: Statins
Conditional: Statins are NOT beneficial as adjunctive therapy when prescribed solely for the diagnosis of HF in the absence of other indications for their use.
    Decision Variable: Statins are prescribed solely for the diagnosis of HF in the absence of other indications for their use Decidable  Y  N
    Action: Statins are NOT beneficial as adjunctive therapy Executable  Y  N
       
RECOMMENDATION: Omega-3 Fatty Acids
Conditional: Omega-3 polyunsaturated fatty acid (PUFA) supplementation is reasonable to use as adjunctive therapy in patients with NYHA class II–IV symptoms and HFrEF or HFpEF, unless contraindicated, to reduce mortality and cardiovascular hospitalizations.
    Decision Variable: patients with NYHA class II–IV symptoms Decidable  Y  N
    Decision Variable: HFrEF Decidable  Y  N
    Decision Variable: or HFpEF Decidable  Y  N
    Decision Variable: unless contraindicated, Decidable  Y  N
    Action: Omega-3 polyunsaturated fatty acid (PUFA) supplementation is reasonable to use as adjunctive therapy Executable  Y  N
       
RECOMMENDATION: Drugs of Unproven Value or That May Worsen HF
Conditional: Nutritional supplements as treatment for HF are NOT recommended in patients with current or prior symptoms of HFrEF.
    Decision Variable: patients with current or prior symptoms of HFrEF Decidable  Y  N
    Action: Nutritional supplements as treatment for HF are NOT recommended Executable  Y  N
       
RECOMMENDATION: Drugs of Unproven Value or That May Worsen HF
Conditional: Hormonal therapies other than to correct deficiencies are NOT recommended for patients with current or prior symptoms of HFrEF.
    Decision Variable: patients with current or prior symptoms of HFrEF Decidable  Y  N
    Action: Hormonal therapies other than to correct deficiencies are NOT recommended Executable  Y  N
       
RECOMMENDATION: Drugs of Unproven Value or That May Worsen HF
Conditional: Drugs known to adversely affect the clinical status of patients with current or prior symptoms of HFrEF are potentially harmful and should be avoided or withdrawn whenever possible (eg, most antiarrhythmic drugs, most calcium channel–blocking drugs [except amlodipine], nonsteroidal anti-inflammatory drugs, or thiazolidinediones).
    Decision Variable: patients with current or prior symptoms of HFrEF Decidable  Y  N
    Action: Drugs known to adversely affect the clinical status are potentially harmful and should be avoided or withdrawn whenever possible Executable  Y  N
       
RECOMMENDATION: Drugs of Unproven Value or That May Worsen HF
Conditional: Long-term use of infused positive inotropic drugs is potentially harmful for patients with HFrEF, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage D starting on page 34).
    Decision Variable: patients with HFrEF Decidable  Y  N
    Action: Long-term use of infused positive inotropic drugs is potentially harmful except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment Executable  Y  N
       
RECOMMENDATION: Calcium Channel Blockers
Conditional: Calcium channel–blocking drugs are NOT recommended as routine treatment for patients with HFrEF.
    Decision Variable: patients with HFrEF. Decidable  Y  N
    Action: Calcium channel–blocking drugs are NOT recommended as routine treatment Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HFpEF: Recommendations (2017)
Conditional: Systolic and diastolic blood pressure should be controlled in patients with HFpEF in accordance with published clinical practice guidelines to prevent morbidity.
    Decision Variable: patients with HFpEF Decidable  Y  N
    Action: Systolic and diastolic blood pressure should be controlled Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HFpEF: Recommendations (2017)
Conditional: Diuretics should be used for relief of symptoms due to volume overload in patients with HFpEF.
    Decision Variable: patients with HFpEF Decidable  Y  N
    Action: Diuretics should be used for relief of symptoms due to volume overload Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HFpEF: Recommendations (2017)
Conditional: Coronary revascularization is reasonable in patient with CAD in whom symptoms (angina) or demonstrable myocardial ischemia is judged to be having an adverse effect on symptomatic HFpEF despite GDMT.
    Decision Variable: patient with CAD in whom symptoms (angina) or demonstrable myocardial ischemia is judged to be having an adverse effect on symptomatic HFpEF despite GDMT Decidable  Y  N
    Action: Coronary revascularization is reasonable Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HFpEF: Recommendations (2017)
Conditional: Management of AF according to published clinical practice guidelines in patients with HFpEF is reasonable to improve symptomatic HF.
    Decision Variable: patients with HFpEF Decidable  Y  N
    Action: Management of AF according to published clinical practice guidelines is reasonable to improve symptomatic HF Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HFpEF: Recommendations (2017)
Conditional: The use of beta-blocking agents, ACE inhibitors, and ARBs in patients with hypertension is reasonable to control blood pressure in patients with HFpEF.
    Decision Variable: patients with hypertension Decidable  Y  N
    Decision Variable: patients with HFpEF Decidable  Y  N
    Action: use beta-blocking agents Executable  Y  N
    Action: use ACE inhibitors Executable  Y  N
    Action: use ARBs Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HFpEF: Recommendations (2017)
Conditional: In appropriately selected patients with HFpEF (with EF ≥45%, elevated BNP levels or HF admission within 1 year, estimated glomerular filtration rate >30 mL/min, creatinine <2.5 mg/dL, potassium <5.0 mEq/L), aldosterone receptor antagonists might be considered to decrease hospitalizations.
    Decision Variable: In appropriately selected patients Decidable  Y  N
    Decision Variable: with EF ≥45% Decidable  Y  N
    Decision Variable: , elevated BNP levels Decidable  Y  N
    Decision Variable: or HF admission within 1 year Decidable  Y  N
    Decision Variable: , estimated glomerular filtration rate >30 mL/min, Decidable  Y  N
    Decision Variable: creatinine <2.5 mg/dL, potassium <5.0 mEq/L), Decidable  Y  N
    Action: aldosterone receptor antagonists might be considered to decrease hospitalizations. Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HFpEF: Recommendations (2017)
Conditional: The use of ARBs might be considered to decrease hospitalizations for patients with HFpEF.
    Decision Variable: for patients with HFpEF Decidable  Y  N
    Action: use of ARBs might be considered to decrease hospitalizations Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HFpEF: Recommendations (2017)
Conditional: Routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or QoL in patients with HFpEF is ineffective.
    Decision Variable: patients with HFpEF Decidable  Y  N
    Action: Routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or QoL is ineffective Executable  Y  N
       
RECOMMENDATION: Pharmacological Treatment for Stage C HFpEF: Recommendations (2017)
Conditional: Routine use of nutritional supplements is not recommended for patients with HFpEF.
    Decision Variable: patients with HFpEF Decidable  Y  N
    Action: Routine use of nutritional supplements is not recommended Executable  Y  N
       
RECOMMENDATION: Device Therapy for Stage C HFrEF (see Table 20)
Conditional: ICD therapy is recommended for primary prevention of sudden cardiac death (SCD) to reduce total mortality in selected patients with nonischemic DCM or ischemic heart disease ≥40 days post-MI with LVEF of ≤35% and NYHA class II or III symptoms on chronic GDMT, who have a reasonable expectation of meaningful survival for >1 year.a .a (I-A)
    Decision Variable: selected patients with nonischemic DCM Decidable  Y  N
    Decision Variable: or ischemic heart disease ≥40 days Decidable  Y  N
    Decision Variable: post-MI Decidable  Y  N
    Decision Variable: with LVEF of ≤35% Decidable  Y  N
    Decision Variable: and NYHA class II or III symptoms Decidable  Y  N
    Decision Variable: on chronic GDMT Decidable  Y  N
    Decision Variable: , who have a reasonable expectation of meaningful survival for >1 year Decidable  Y  N
    Action: ICD therapy is recommended for primary prevention of sudden cardiac death to reduce total mortality Executable  Y  N
       
RECOMMENDATION: Device Therapy for Stage C HFrEF (see Table 20)
Conditional: Cardiac resynchronization therapy is indicated for patients who have LVEF of 35% or less, sinus rhythm, left bundle-branch block (LBBB) with a QRS duration of 150 ms or greater, and NYHA class II, III, or ambulatory class IV symptoms on GDMT.
    Decision Variable: patients who have LVEF of 35% or less Decidable  Y  N
    Decision Variable: sinus rhythm Decidable  Y  N
    Decision Variable: left bundle-branch block with a QRS duration of 150 ms or greater Decidable  Y  N
    Decision Variable: NYHA class II, III, or ambulatory class IV symptoms Decidable  Y  N
    Decision Variable: on GDMT Decidable  Y  N
    Action: Cardiac resynchronization therapy Executable  Y  N
       
RECOMMENDATION: Device Therapy for Stage C HFrEF (see Table 20)
Conditional: ICD therapy is recommended for primary prevention of SCD to reduce total mortality in selected patients at least 40 days post-MI with LVEF of 30% or less and NYHA class I symptoms while receiving GDMT, who have a reasonable expectation of meaningful survival for more than 1 year.
    Decision Variable: selected patients at least 40 days post-MI Decidable  Y  N
    Decision Variable: with LVEF of 30% or less Decidable  Y  N
    Decision Variable: NYHA class I symptoms while receiving GDMT Decidable  Y  N
    Decision Variable: who have a reasonable expectation of meaningful survival for more than 1 year Decidable  Y  N
    Action: ICD therapy is recommended for primary prevention of SCD to reduce total mortality Executable  Y  N
       
RECOMMENDATION: Device Therapy for Stage C HFrEF (see Table 20)
Conditional: CRT can be useful for patients who have LVEF of ≤35% , sinus rhythm, a non-LBBB pattern with a QRS duration of ≥150 ms, and NYHA class III/ambulatory class IV symptoms on GDMT.
    Decision Variable: patients who have LVEF of ≤35% Decidable  Y  N
    Decision Variable: sinus rhythm Decidable  Y  N
    Decision Variable: a non-LBBB pattern with a QRS duration of ≥150 ms Decidable  Y  N
    Decision Variable: NYHA class III/ambulatory class IV symptoms on GDMT Decidable  Y  N
    Action: CRT can be useful Executable  Y  N
       
RECOMMENDATION: Device Therapy for Stage C HFrEF (see Table 20)
Conditional: CRT can be useful for patients who have LVEF of ≤35%, sinus rhythm, LBBB with a QRS duration of 120–149 ms, and NYHA class II, III, or ambulatory class IV symptoms on GDMT.
    Decision Variable: patients who have LVEF of ≤35% Decidable  Y  N
    Decision Variable: sinus rhythm Decidable  Y  N
    Decision Variable: LBBB with a QRS duration of 120–149 ms Decidable  Y  N
    Decision Variable: NYHA class II, III, or ambulatory class IV symptoms on GDMT Decidable  Y  N
    Action: CRT can be useful Executable  Y  N
       
RECOMMENDATION: Device Therapy for Stage C HFrEF (see Table 20)
Conditional: CRT can be useful in patients with AF and LVEF of ≤35% on GDMT 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.
    Decision Variable: patients with AF and LVEF of ≤35% on GDMT Decidable  Y  N
    Decision Variable: patient requires ventricular pacing or otherwise meets CRT criteria Decidable  Y  N
    Decision Variable: atrioventricular nodal ablation or pharmacological rate control will allow near 100% ventricular pacing with CRT Decidable  Y  N
    Action: CRT can be useful Executable  Y  N
       
RECOMMENDATION: Device Therapy for Stage C HFrEF (see Table 20)
Conditional: CRT can be useful for patients on GDMT who have LVEF of ≤35% and are undergoing placement of a new or replacement device with anticipated requirement for significant (>40%) ventricular pacing.
    Decision Variable: patients on GDMT Decidable  Y  N
    Decision Variable: who have LVEF of ≤35% Decidable  Y  N
    Decision Variable: undergoing placement of a new or replacement device with anticipated requirement for significant (>40%) ventricular pacing. Decidable  Y  N
    Action: CRT can be useful Executable  Y  N
       
RECOMMENDATION: Device Therapy for Stage C HFrEF (see Table 20)
Conditional: The usefulness of implantation of an ICD is of uncertain benefit to prolong meaningful survival in patients with a high risk of nonsudden death as predicted by frequent hospitalizations, advanced frailty, or comorbidities such as systemic malignancy or severe renal dysfunction.
    Decision Variable: patients with a high risk of nonsudden death as predicted by frequent hospitalizations, advanced frailty, or comorbidities such as systemic malignancy or severe renal dysfunction. Decidable  Y  N
    Action: The usefulness of implantation of an ICD is of uncertain benefit to prolong meaningful survival Executable  Y  N
       
RECOMMENDATION: Device Therapy for Stage C HFrEF (see Table 20)
Conditional: CRT may be considered for patients who have LVEF of ≤35%, sinus rhythm, a non-LBBB pattern with a QRS duration of 120–149 ms, and NYHA class III/ambulatory class IV on GDMT.
    Decision Variable: patients who have LVEF of ≤35% Decidable  Y  N
    Decision Variable: sinus rhythm Decidable  Y  N
    Decision Variable: a non-LBBB pattern with a QRS duration of 120–149 ms Decidable  Y  N
    Decision Variable: and NYHA class III/ambulatory class IV on GDMT Decidable  Y  N
    Action: CRT may be considered Executable  Y  N
       
RECOMMENDATION: Device Therapy for Stage C HFrEF (see Table 20)
Conditional: CRT may be considered for patients who have LVEF of ≤35%, sinus rhythm, a non-LBBB pattern with a QRS duration of ≥150 ms, and NYHA class II symptoms on GDMT.
    Decision Variable: patients who have LVEF of ≤35% Decidable  Y  N
    Decision Variable: sinus rhythm Decidable  Y  N
    Decision Variable: a non-LBBB pattern with a QRS duration of ≥150 ms Decidable  Y  N
    Decision Variable: NYHA class II symptoms on GDMT Decidable  Y  N
    Action: CRT may be considered Executable  Y  N
       
RECOMMENDATION: Device Therapy for Stage C HFrEF (see Table 20)
Conditional: CRT may be considered for patients who have LVEF of ≤30%, ischemic etiology of HF, sinus rhythm, LBBB with a QRS duration of ≥150 ms, and NYHA class I symptoms on GDMT.
    Decision Variable: patients who have LVEF of ≤30% Decidable  Y  N
    Decision Variable: ischemic etiology of HF Decidable  Y  N
    Decision Variable: sinus rhythm Decidable  Y  N
    Decision Variable: LBBB with a QRS duration of ≥150 ms Decidable  Y  N
    Decision Variable: NYHA class I symptoms on GDMT Decidable  Y  N
    Action: CRT may be considered Executable  Y  N
       
RECOMMENDATION: Device Therapy for Stage C HFrEF (see Table 20)
Conditional: CRT is NOT recommended for patients with NYHA class I or II symptoms and non-LBBB pattern with a QRS duration of <150 ms.
    Decision Variable: patients with NYHA class I or II symptoms Decidable  Y  N
    Decision Variable: non-LBBB pattern with a QRS duration of <150 ms Decidable  Y  N
    Action: CRT is NOT recommended Executable  Y  N
       
RECOMMENDATION: Device Therapy for Stage C HFrEF (see Table 20)
Conditional: CRT is NOT indicated for patients whose comorbidities and/or frailty limit survival with good functional capacity to <1 year.
    Decision Variable: patients whose comorbidities and/or frailty limit survival with good functional capacity to <1 year Decidable  Y  N
    Action: CRT is NOT indicated Executable  Y  N
       
RECOMMENDATION: Water Restriction
Conditional: Fluid restriction (1.5–2 L/d) is reasonable in stage D, especially in patients with hyponatremia, to reduce congestive symptoms.
    Decision Variable: especially in patients with hyponatremia Decidable  Y  N
    Decision Variable: in stage D Decidable  Y  N
    Action: Fluid restriction (1.5–2 L/d) is reasonable to reduce congestive symptoms Executable  Y  N
       
RECOMMENDATION: Inotropic Support (see Tables 23 and 24)
Conditional: Until definitive therapy (eg, coronary revascularization, MCS, heart transplantation) or resolution of the acute precipitating problem, patients with cardiogenic shock should receive temporary intravenous inotropic support to maintain systemic perfusion and preserve endorgan performance.
    Decision Variable: Until definitive therapy (eg, coronary revascularization, MCS, heart transplantation) Decidable  Y  N
    Decision Variable: or resolution of the acute precipitating problem, Decidable  Y  N
    Decision Variable: patients with cardiogenic shock Decidable  Y  N
    Action: should receive temporary intravenous inotropic support Executable  Y  N
       
RECOMMENDATION: Inotropic Support (see Tables 23 and 24)
Conditional: Continuous intravenous inotropic support is reasonable as “bridge therapy” in patients with stage D HF refractory to GDMT and device therapy who are eligible for and awaiting MCS or cardiac transplantation.
    Decision Variable: patients with stage D HF Decidable  Y  N
    Decision Variable: refractory to GDMT and device therapy Decidable  Y  N
    Decision Variable: who are eligible for and awaiting MCS or cardiac transplantation. Decidable  Y  N
    Action: Continuous intravenous inotropic support is reasonable as “bridge therapy” Executable  Y  N
       
RECOMMENDATION: Inotropic Support (see Tables 23 and 24)
Conditional: Short-term, continuous intravenous inotropic support may be reasonable in those hospitalized patients presenting with documented severe systolic dysfunction who present with low blood pressure and significantly depressed cardiac output to maintain systemic perfusion and preserve end-organ performance.
    Decision Variable: hospitalized patients Decidable  Y  N
    Decision Variable: presenting with documented severe systolic dysfunction Decidable  Y  N
    Decision Variable: who present with low blood pressure Decidable  Y  N
    Decision Variable: significantly depressed cardiac output to maintain systemic perfusion and preserve end-organ performance Decidable  Y  N
    Action: Short-term, continuous intravenous inotropic support may be reasonable Executable  Y  N
       
RECOMMENDATION: Inotropic Support (see Tables 23 and 24)
Conditional: Long-term, continuous intravenous inotropic support may be considered as palliative therapy for symptom control in select patients with stage D HF despite optimal GDMT and device therapy who are not eligible for either MCS or cardiac transplantation.
    Decision Variable: select patients with stage D HF despite optimal GDMT and device therapy Decidable  Y  N
    Decision Variable: who are not eligible for either MCS or cardiac transplantation. Decidable  Y  N
    Action: Long-term, continuous intravenous inotropic support may be considered as palliative therapy for symptom control Executable  Y  N
       
RECOMMENDATION: Inotropic Support (see Tables 23 and 24)
Conditional: Long-term use of either continuous or intermittent, intravenous parenteral positive inotropic agents, in the absence of specific indications or for reasons other than palliative care, is potentially harmful in the patient with HF.
    Decision Variable: patient with HF Decidable  Y  N
    Decision Variable: in the absence of specific indications or for reasons other than palliative care Decidable  Y  N
    Action: Long-term use of either continuous or intermittent, intravenous parenteral positive inotropic agents is potentially harmful Executable  Y  N
       
RECOMMENDATION: Inotropic Support (see Tables 23 and 24)
Conditional: Use of parenteral inotropic agents in hospitalized patients without documented severe systolic dysfunction, low blood pressure, or impaired perfusion, and evidence of significantly depressed cardiac output, with or without congestion, is potentially harmful.
    Decision Variable: hospitalized patients Decidable  Y  N
    Decision Variable: without documented severe systolic dysfunction, Decidable  Y  N
    Decision Variable: low blood pressure Decidable  Y  N
    Decision Variable: or impaired perfusion Decidable  Y  N
    Decision Variable: and evidence of significantly depressed cardiac output, with or without congestion Decidable  Y  N
    Action: Use of parenteral inotropic agents is potentially harmful Executable  Y  N
       
RECOMMENDATION: Mechanical Circulatory Support
Conditional: MCS is beneficial in carefully selected patients with stage D HFrEF in whom definitive management (eg, cardiac transplantation) or cardiac recovery is anticipated or planned.
    Decision Variable: carefully selected patients with stage D HFrEF Decidable  Y  N
    Decision Variable: in whom definitive management (eg, cardiac transplantation) or cardiac recovery is anticipated or planned Decidable  Y  N
    Action: MCS is beneficial Executable  Y  N
       
RECOMMENDATION: Mechanical Circulatory Support
Conditional: Nondurable MCS, including the use of percutaneous and extracorporeal ventricular assist devices, is reasonable as a “bridge to recovery” or a “bridge to decision” for carefully selecteda HFrEF a H patients with acute, profound hemodynamic compromise.
    Decision Variable: carefully selected HFrEF patients Decidable  Y  N
    Decision Variable: with acute, profound hemodynamic compromise Decidable  Y  N
    Action: Nondurable MCS, including the use of percutaneous and extracorporeal ventricular assist devices, is reasonable as a “bridge to recovery” or a “bridge to decision” Executable  Y  N
       
RECOMMENDATION: Mechanical Circulatory Support
Conditional: Durable MCS is reasonable to prolong survival for carefully selecteda a patients with stage D HFrEF.
    Decision Variable: carefully selected a patients with stage D HFrEF Decidable  Y  N
    Action: Durable MCS is reasonable Executable  Y  N
       
RECOMMENDATION: Cardiac Transplantation
Conditional: Evaluation for cardiac transplantation is indicated for carefully selected patients with stage D HF despite GDMT, device, and surgical management.
    Decision Variable: carefully selected patients Decidable  Y  N
    Decision Variable: with stage D HF Decidable  Y  N
    Decision Variable: GDMT Decidable  Y  N
    Decision Variable: device management Decidable  Y  N
    Decision Variable: surgical management Decidable  Y  N
    Action: Evaluation for cardiac transplantation is indicated Executable  Y  N
       
RECOMMENDATION: Precipitating Causes of Decompensated HF
Conditional: ACS precipitating acute HF decompensation should be promptly identified by ECG and serum biomarkers, including cardiac troponin testing, and treated optimally as appropriate to the overall condition and prognosis of the patient.
    Decision Variable: patient with ACS precipitating acute HF decompensation Decidable  Y  N
    Action: should be promptly identified by ECG and serum biomarkers, including cardiac troponin testing, Executable  Y  N
    Action: and treated optimally as appropriate to the overall condition and prognosis of the patient. Executable  Y  N
       
RECOMMENDATION: Precipitating Causes of Decompensated HF
Conditional: Common precipitating factors for acute HF should be considered during initial evaluation, as recognition of these conditions is critical to guide appropriate therapy.
    Decision Variable: during initial evaluation Decidable  Y  N
    Action: common precipitating factors for acute HF should be considered Executable  Y  N
       
RECOMMENDATION: Maintenance of GDMT During Hospitalization
Conditional: In patients with HFrEF experiencing a symptomatic exacerbation of HF requiring hospitalization during chronic maintenance treatment with GDMT, it is recommended that GDMT be continued in the absence of hemodynamic instability or contraindications.
    Decision Variable: In patients with HFrEF Decidable  Y  N
    Decision Variable: experiencing a symptomatic exacerbation of HF requiring hospitalization during chronic maintenance treatment with GDMT Decidable  Y  N
    Action: it is recommended that GDMT be continued in the absence of hemodynamic instability or contraindications. Executable  Y  N
       
RECOMMENDATION: Maintenance of GDMT During Hospitalization
Conditional: Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents. Beta-blocker therapy should be initiated at a low dose and only in stable patients.
    Decision Variable: after optimization of volume status Decidable  Y  N
    Decision Variable: successful discontinuation of intravenous diuretics Decidable  Y  N
    Decision Variable: successful discontinuation of vasodilators Decidable  Y  N
    Decision Variable: successful discontinuation of inotropic agents Decidable  Y  N
    Decision Variable: only in stable patient Decidable  Y  N
    Action: Initiation of beta-blocker therapy at a low dose is recommended Executable  Y  N
Conditional: Caution should be used when initiating the use of beta blockers in patients who have required inotropes during their hospital course.
    Decision Variable: patients who have required inotropes during their hospital course. Decidable  Y  N
    Action: Caution should be used when initiating the use of beta blockers Executable  Y  N
       
RECOMMENDATION: Diuretics in Hospitalized Patients: Recommendations
Conditional: Patients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity.
    Decision Variable: Patients with HF Decidable  Y  N
    Decision Variable: admitted with evidence of significant fluid overload Decidable  Y  N
    Action: should be promptly treated with intravenous loop diuretics Executable  Y  N
       
RECOMMENDATION: Diuretics in Hospitalized Patients: Recommendations
Conditional: If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose
    Decision Variable: patients are receiving loop diuretic therapy Decidable  Y  N
    Action: the initial intravenous dose should equal or exceed their chronic oral daily dose Executable  Y  N
    Action: should be given as either intermittent boluses or continuous infusion. Executable  Y  N
    Action: Urine output and signs and symptoms of congestion should be serially assessed, Executable  Y  N
    Action: and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension. Executable  Y  N
       
RECOMMENDATION: Diuretics in Hospitalized Patients: Recommendations
Conditional: The effect of HF treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of HF medications.
    Decision Variable: patients with HF Decidable  Y  N
    Action: The effect of HF treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion Executable  Y  N
    Action: Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of HF medications. Executable  Y  N
       
RECOMMENDATION: Diuretics in Hospitalized Patients: Recommendations
Conditional: When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: a. Higher doses of intravenous loop diuretics (IIa-B), or b. Addition of a second (eg, thiazide) diuretic (IIa-B).
    Decision Variable: When diuresis is inadequate to relieve symptoms Decidable  Y  N
    Action: it is reasonable to intensify the diuretic regimen using higher doses of intravenous loop diuretics Executable  Y  N
    Action: it is reasonable to intensify the diuretic regimen using addition of a second (eg, thiazide) diuretic Executable  Y  N
       
RECOMMENDATION: Diuretics in Hospitalized Patients: Recommendations
Conditional: Low-dose dopamine infusion may be considered in addition to loop diuretic therapy to improve diuresis and better preserve renal functio and renal blood flow.
    Decision Variable: improve diuresis and better preserve renal functio and renal blood flow Decidable  Y  N
    Action: Low-dose dopamine infusion may be considered in addition to loop diuretic therapy Executable  Y  N
       
RECOMMENDATION: Renal Replacement Therapy—Ultrafiltration
Conditional: Ultrafiltration may be considered for patients with obvious volume overload to alleviate congestive symptoms and fluid weight.
    Decision Variable: patients with obvious volume overload Decidable  Y  N
    Action: Ultrafiltration may be considered to alleviate congestive symptoms and fluid weight Executable  Y  N
       
RECOMMENDATION: Renal Replacement Therapy—Ultrafiltration
Conditional: Ultrafiltration may be considered for patients with refractory congestion not responding to medical therapy.
    Decision Variable: patients with refractory congestion not responding to medical therapy. Decidable  Y  N
    Action: Ultrafiltration may be considered Executable  Y  N
       
RECOMMENDATION: Parenteral Therapy in Hospitalized HF
Conditional: If symptomatic hypotension is absent, intravenous nitroglycerin, nitroprusside, or nesiritide may be considered as an adjuvant to diuretic therapy for relief of dyspnea in patients admitted with acute decompensated HF.
    Decision Variable: symptomatic hypotension is absent Decidable  Y  N
    Decision Variable: patients admitted with acute decompensated HF Decidable  Y  N
    Action: intravenous nitroglycerin, nitroprusside, or nesiritide may be considered as an adjuvant to diuretic therapy for relief of dyspnea Executable  Y  N
       
RECOMMENDATION: Venous Thromboembolism Prophylaxis in Hospitalized Patients
Conditional: A patient admitted to the hospital with decompensated HF should receive venous thromboembolism prophylaxis with an anticoagulant medication if the risk–benefit ratio is favorable.
    Decision Variable: A patient admitted to the hospital with decompensated HF Decidable  Y  N
    Action: should receive venous thromboembolism prophylaxis with an anticoagulant medication Executable  Y  N
       
RECOMMENDATION: Arginine Vasopressin Antagonists
Conditional: In patients hospitalized with volume overload, including HF, who have persistent severe hyponatremia and are at risk for or having active cognitive symptoms despite water restriction and maximization of GDMT, vasopressin antagonists may be considered in the short term to improve serum sodium concentration in hypervolemic, hyponatremic states with either a V2 receptor–selective or a nonselective vasopressin antagonist.
    Decision Variable: patients hospitalized with volume overload, including HF Decidable  Y  N
    Decision Variable: who have persistent severe hyponatremia Decidable  Y  N
    Decision Variable: are at risk for or having active cognitive symptoms despite water restriction and maximization of GDMT Decidable  Y  N
    Action: vasopressin antagonists may be considered in the short term to improve serum sodium concentration in hypervolemic, hyponatremic states with either a V2 receptor–selective or a nonselective vasopressin antagonist Executable  Y  N
       
RECOMMENDATION: Inpatient and Transitions of Care
Conditional: The use of performance improvement systems and/or evidence-based systems of care is recommended in the hospital and early postdischarge outpatient setting to identify appropriate HF patients for GDMT, provide clinicians with useful reminders to advance GDMT, and assess the clinical response.
    Decision Variable: identify appropriate HF patients for GDMT Decidable  Y  N
    Decision Variable: provide clinicians with useful reminders to advance GDMT Decidable  Y  N
    Decision Variable: assess the clinical response Decidable  Y  N
    Action: The use of performance improvement systems and/or evidence-based systems of care is recommended Executable  Y  N
       
RECOMMENDATION: Inpatient and Transitions of Care
Conditional: Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed (I-B): a. Initiation of GDMT if not previously established and not contraindicated b. Precipitant causes of HF, barriers to optimal care transitions, and limitations in postdischarge support c. Assessment of volume status and supine/upright hypotension with adjustment of HF therapy, as appropriate d. Titration and optimization of chronic oral HF therapy e. Assessment of renal function and electrolytes, where appropriate f. Assessment and management of comorbid conditions g. Reinforcement of HF education, self-care, emergency plans, and need for adherence h. Consideration for palliative care or hospice care in selected patients
    Decision Variable: Throughout the hospitalization as appropriate, Decidable  Y  N
    Decision Variable: before hospital discharge, Decidable  Y  N
    Decision Variable: at the first postdischarge visit Decidable  Y  N
    Decision Variable: in subsequent follow-up visits Decidable  Y  N
    Action: Initiation of GDMT if not previously established and not contraindicated b. Executable  Y  N
    Action: Precipitant causes of HF, barriers to optimal care transitions, and limitations in postdischarge support c. Executable  Y  N
    Action: Assessment of volume status and supine/upright hypotension with adjustment of HF therapy, as appropriate Executable  Y  N
    Action: Titration and optimization of chronic oral HF therapy Executable  Y  N
    Action: Assessment of renal function and electrolytes, where appropriate Executable  Y  N
    Action: Assessment and management of comorbid conditions Executable  Y  N
    Action: Reinforcement of HF education, self-care, emergency plans, and need for adherence Executable  Y  N
    Action: Consideration for palliative care or hospice care in selected patients Executable  Y  N
       
RECOMMENDATION: Inpatient and Transitions of Care
Conditional: Multidisciplinary HF disease-management programs are recommended for patients at high risk for hospital readmission, to facilitate the implementation of GDMT, to address different barriers to behavioral change, and to reduce the risk of subsequent rehospitalization for HF.
    Decision Variable: for patients at high risk for hospital readmission Decidable  Y  N
    Action: Multidisciplinary HF disease-management programs are recommended Executable  Y  N
       
RECOMMENDATION: Inpatient and Transitions of Care
Conditional: Scheduling an early follow-up visit (within 7–14 days) and early telephone follow-up (within 3 days) of hospital discharge is reasonable.
    Decision Variable: (within 3 days) of hospital discharge Decidable  Y  N
    Action: Scheduling an early follow-up visit (within 7–14 days) and early telephone follow-up Executable  Y  N
       
RECOMMENDATION: Inpatient and Transitions of Care
Conditional: Use of clinical risk-prediction tools and/or biomarkers to identify patients at higher risk for postdischarge clinical events is reasonable.
    Decision Variable: identify patients at higher risk for postdischarge clinical events Decidable  Y  N
    Action: Use of clinical risk-prediction tools and/or biomarkers Executable  Y  N
       
RECOMMENDATION: Table 28. Anemia: Recommendations (2017)
Conditional: In patients with NYHA class II and III HF and iron deficiency (ferritin <100 ng/mL or 100–300 ng/mL if transferrin saturation is <20%), intravenous iron replacement might be reasonable to improve functional status and QoL.
    Decision Variable: patients with NYHA class II and III HF and iron deficiency (ferritin <100 ng/mL or 100–300 ng/mL if transferrin saturation is <20%) Decidable  Y  N
    Action: intravenous iron replacement might be reasonable to improve functional status and QoL Executable  Y  N
       
RECOMMENDATION: Table 28. Anemia: Recommendations (2017)
Conditional: In patients with HF and anemia, erythropoietin-stimulating agents should not be used to improve morbidity and mortality.
    Decision Variable: patients with HF and anemia Decidable  Y  N
    Action: erythropoietin-stimulating agents should not be used to improve morbidity and mortality Executable  Y  N
       
RECOMMENDATION: Table 30. Treating Hypertension to Reduce the Incidence of HF: Recommendation (2017)
Conditional: In patients at increased risk, stage A HF, the optimal blood pressure in those with hypertension should be <130/80 mm Hg.
    Decision Variable: In patients at increased risk, stage A HF Decidable  Y  N
    Decision Variable: in those with hypertension Decidable  Y  N
    Action: the optimal blood pressure should be <130/80 mm Hg. Executable  Y  N
       
RECOMMENDATION: Table 31. Recommendation for Hypertension in Stage C HFrEF (2017)
Conditional: Patients with HFrEF and hypertension should be prescribed GDMT titrated to attain systolic blood pressure <130 mm Hg.
    Decision Variable: Patients with HFrEF Decidable  Y  N
    Decision Variable: and hypertension Decidable  Y  N
    Action: should be prescribed GDMT titrated to attain systolic blood pressure <130 mm Hg. Executable  Y  N
       
RECOMMENDATION: Table 32. Treating Hypertension in Stage C HFpEF: Recommendation (2017)
Conditional: Patients with HFpEF and persistent hypertension after management of volume overload should be prescribed GDMT titrated to attain systolic blood pressure <130 mm Hg
    Decision Variable: Patients with HFpEF Decidable  Y  N
    Decision Variable: persistent hypertension after management of volume overload Decidable  Y  N
    Action: should be prescribed GDMT titrated to attain systolic blood pressure <130 mm Hg Executable  Y  N
       
RECOMMENDATION: Table 33. Sleep Disordered Breathing: Recommendations (2017)
Conditional: In patients with NYHA class II–IV HF and suspicion of sleep disordered breathing or excessive daytime sleepiness, a formal sleep assessment is reasonable
    Decision Variable: In patients with NYHA class II–IV HF Decidable  Y  N
    Decision Variable: and suspicion of sleep disordered breathing Decidable  Y  N
    Decision Variable: or excessive daytime sleepiness, Decidable  Y  N
    Action: a formal sleep assessment is reasonable Executable  Y  N
       
RECOMMENDATION: Table 33. Sleep Disordered Breathing: Recommendations (2017)
Conditional: In patients with cardiovascular disease and obstructive sleep apnea, CPAP may be reasonable to improve sleep quality and daytime sleepiness
    Decision Variable: In patients with cardiovascular disease Decidable  Y  N
    Decision Variable: obstructive sleep apnea Decidable  Y  N
    Action: continuous positive airway pressure may be reasonable Executable  Y  N
       
RECOMMENDATION: Table 33. Sleep Disordered Breathing: Recommendations (2017)
Conditional: In patients with NYHA class II–IV HFrEF and central sleep apnea, adaptive servo-ventilation causes harm
    Decision Variable: In patients with NYHA class II–IV HFrEF Decidable  Y  N
    Decision Variable: central sleep apnea Decidable  Y  N
    Action: adaptive servo-ventilation causes harm Executable  Y  N
       
RECOMMENDATION: Surgical/Percutaneous/Transcatheter Interventional Treatments of HF
Conditional: Coronary artery revascularization via coronary artery bypass graft (CABG) or percutaneous intervention is indicated for patients (HFpEF and HFrEF) on GDMT with angina and suitable coronary anatomy, especially for a left main stenosis (>50%) or left main–equivalent disease. (I-C)
    Decision Variable: patients (HFpEF and HFrEF) on GDMT Decidable  Y  N
    Decision Variable: with angina Decidable  Y  N
    Decision Variable: suitable coronary anatomy, especially for a left main stenosis (>50%) or left main–equivalent disease Decidable  Y  N
    Action: Coronary artery revascularization via coronary artery bypass graft Executable  Y  N
    Action: or percutaneous intervention Executable  Y  N
       
RECOMMENDATION: Surgical/Percutaneous/Transcatheter Interventional Treatments of HF
Conditional: Coronary artery revascularization via coronary artery bypass graft to improve survival is reasonable in patients with mild to moderate LV systolic dysfunction (EF 35%–50%) and significant (≥70% diameter stenosis) multivessel CAD or proximal left anterior descending (LAD) coronary artery stenosis when viable myocardium is present in the region of intended revascularization. (IIa-B)
    Decision Variable: patients with mild to moderate LV systolic dysfunction (EF 35%–50%) Decidable  Y  N
    Decision Variable: and significant (≥70% diameter stenosis) multivessel coronary artery disease Decidable  Y  N
    Decision Variable: or proximal left anterior descending coronary artery stenosis when viable myocardium is present in the region of intended revascularization. Decidable  Y  N
    Action: Coronary artery revascularization via coronary artery bypass graft to improve survival is reasonable Executable  Y  N
       
RECOMMENDATION: Surgical/Percutaneous/Transcatheter Interventional Treatments of HF
Conditional: CABG or medical therapy is reasonable to improve morbidity and cardiovascular mortality for patients with severe LV dysfunction (EF <35%), HF, and significant CAD.
    Decision Variable: patients with severe LV dysfunction (EF <35%) Decidable  Y  N
    Decision Variable: heart failure Decidable  Y  N
    Decision Variable: significant coronary artery disease Decidable  Y  N
    Action: coronary artery bypass graft Executable  Y  N
    Action: medical therapy Executable  Y  N
       
RECOMMENDATION: Surgical/Percutaneous/Transcatheter Interventional Treatments of HF
Conditional: Surgical aortic valve replacement is reasonable for patients with critical aortic stenosis and a predicted surgical mortality of <10%. (IIa-B)
    Decision Variable: patients with critical aortic stenosis Decidable  Y  N
    Decision Variable: and a predicted surgical mortality of <10%. Decidable  Y  N
    Action: Surgical aortic valve replacement is reasonable Executable  Y  N
       
RECOMMENDATION: Surgical/Percutaneous/Transcatheter Interventional Treatments of HF
Conditional: Transcatheter aortic valve replacement after careful candidate consideration is reasonable for patients with critical aortic stenosis who are deemed inoperable. (IIa-B)
    Decision Variable: patients with critical aortic stenosis Decidable  Y  N
    Decision Variable: who are deemed inoperable Decidable  Y  N
    Action: Transcatheter aortic valve replacement after careful candidate consideration is reasonable Executable  Y  N
       
RECOMMENDATION: Surgical/Percutaneous/Transcatheter Interventional Treatments of HF
Conditional: CABG may be considered with the intent of improving survival in patients with ischemic heart disease with severe LV systolic dysfunction (EF <35%) and operable coronary anatomy whether or not viable myocardium is present. (IIb-B)
    Decision Variable: patients with ischemic heart disease with severe LV systolic dysfunction (EF <35%) Decidable  Y  N
    Decision Variable: and operable coronary anatomy whether or not viable myocardium is present. Decidable  Y  N
    Action: coronary artery bypass graft may be considered Executable  Y  N
       
RECOMMENDATION: Surgical/Percutaneous/Transcatheter Interventional Treatments of HF
Conditional: Transcatheter mitral valve repair or mitral valve surgery for functional mitral insufficiency is of uncertain benefit and should only be considered after careful candidate selection and with a background of GDMT.
    Decision Variable: after careful candidate selection Decidable  Y  N
    Decision Variable: and with a background of GDMT. Decidable  Y  N
    Action: Transcatheter mitral valve repair or mitral valve surgery for functional mitral insufficiency is of uncertain benefit and should only be considered Executable  Y  N
       
RECOMMENDATION: Surgical/Percutaneous/Transcatheter Interventional Treatments of HF
Conditional: Surgical reverse remodeling or LV aneurysmectomy may be considered in carefully selected patients with HFrEF for specific indications including intractable HF and ventricular arrhythmias.
    Decision Variable: carefully selected patients with HFrEF for specific indications including intractable HF and ventricular arrhythmias. Decidable  Y  N
    Action: Surgical reverse remodeling Executable  Y  N
    Action: or LV aneurysmectomy may be considered Executable  Y  N
       
RECOMMENDATION: Coordinating Care for Patients With Chronic HF
Conditional: Effective systems of care coordination with special attention to care transitions should be deployed for every patient with chronic HF that facilitate and ensure effective care that is designed to achieve GDMT and prevent hospitalization.
    Decision Variable: every patient with chronic HF that facilitate and ensure effective care that is designed to achieve GDMT and prevent hospitalization Decidable  Y  N
    Action: Effective systems of care coordination with special attention to care transitions should be deployed Executable  Y  N
       
RECOMMENDATION: Coordinating Care for Patients With Chronic HF
Conditional: Every patient with HF should have a clear, detailed, and evidencebased plan of care that ensures the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease. This plan of care should be updated regularly and made readily available to all members of each patient’s healthcare team. (I-C)
    Decision Variable: patient with HF Decidable  Y  N
    Action: should have a clear, detailed, and evidencebased plan of care Executable  Y  N
    Action: should be updated regularly a Executable  Y  N
    Action: made readily available to all members of each patient’s healthcare team Executable  Y  N
       
RECOMMENDATION: Coordinating Care for Patients With Chronic HF
Conditional: Palliative and supportive care is effective for patients with symptomatic advanced HF to improve quality of life. (I-B)
    Decision Variable: patients with symptomatic advanced HF Decidable  Y  N
    Action: Palliative and supportive care is effective Executable  Y  N
       
RECOMMENDATION: Quality Metrics/Performance Measures
Conditional: Performance measures based on professionally developed clinical practice guidelines should be used with the goal of improving quality of care for HF.
    Decision Variable: patient with HF Decidable  Y  N
    Action: Performance measures based on professionally developed clinical practice guidelines should be used with the goal of improving quality of care . Executable  Y  N
       
RECOMMENDATION: Quality Metrics/Performance Measures
Conditional: Participation in quality improvement programs and patient registries based on nationally endorsed, clinical practice guideline–based quality and performance measures can be beneficial in improving quality of HF care.
    Decision Variable: in improving quality of HF care. Decidable  Y  N
    Action: Participation in quality improvement programs and patient registries based on nationally endorsed, clinical practice guideline–based quality and performance measures can be beneficial Executable  Y  N