2013 ACCF/AHA Guideline for the Management of Heart Failure

Abstract

HomeCirculationVol. 128, No. 162013 ACCF/AHA Guideline for the Management of Heart Failure Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUB2013 ACCF/AHA Guideline for the Management of Heart FailureA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines , Clyde W. Yancy, MD, MSc, FACC, FAHA, Chair, Mariell Jessup, MD, FACC, FAHA, Vice Chair, Biykem Bozkurt, MD, PhD, FACC, FAHA, Javed Butler, MBBS, FACC, FAHA, Donald E. CaseyJr, MD, MPH, MBA, FACP, FAHA, Mark H. Drazner, MD, MSc, FACC, FAHA, Gregg C. Fonarow, MD, FACC, FAHA, Stephen A. Geraci, MD, FACC, FAHA, FCCP, Tamara Horwich, MD, FACC, James L. Januzzi, MD, FACC, Maryl R. Johnson, MD, FACC, FAHA, Edward K. Kasper, MD, FACC, FAHA, Wayne C. Levy, MD, FACC, Frederick A. Masoudi, MD, MSPH, FACC, FAHA, Patrick E. McBride, MD, MPH, FACC, John J.V. McMurray, MD, FACC, Judith E. Mitchell, MD, FACC, FAHA, Pamela N. Peterson, MD, MSPH, FACC, FAHA, Barbara Riegel, DNSc, RN, FAHA, Flora Sam, MD, FACC, FAHA, Lynne W. Stevenson, MD, FACC, W.H. Wilson Tang, MD, FACC, Emily J. Tsai, MD, FACC and Bruce L. Wilkoff, MD, FACC, FHRS Search for more papers by this author , Clyde W. YancyClyde W. Yancy Search for more papers by this author , Mariell JessupMariell Jessup Search for more papers by this author , Biykem BozkurtBiykem Bozkurt Search for more papers by this author , Javed ButlerJaved Butler Search for more papers by this author , Donald E. CaseyJrDonald E. CaseyJr Search for more papers by this author , Mark H. DraznerMark H. Drazner Search for more papers by this author , Gregg C. FonarowGregg C. Fonarow Search for more papers by this author , Stephen A. GeraciStephen A. Geraci Search for more papers by this author , Tamara HorwichTamara Horwich Search for more papers by this author , James L. JanuzziJames L. Januzzi Search for more papers by this author , Maryl R. JohnsonMaryl R. Johnson Search for more papers by this author , Edward K. KasperEdward K. Kasper Search for more papers by this author , Wayne C. LevyWayne C. Levy Search for more papers by this author , Frederick A. MasoudiFrederick A. Masoudi Search for more papers by this author , Patrick E. McBridePatrick E. McBride Search for more papers by this author , John J.V. McMurrayJohn J.V. McMurray Search for more papers by this author , Judith E. MitchellJudith E. Mitchell Search for more papers by this author , Pamela N. PetersonPamela N. Peterson Search for more papers by this author , Barbara RiegelBarbara Riegel Search for more papers by this author , Flora SamFlora Sam Search for more papers by this author , Lynne W. StevensonLynne W. Stevenson Search for more papers by this author , W.H. Wilson TangW.H. Wilson Tang Search for more papers by this author , Emily J. TsaiEmily J. Tsai Search for more papers by this author and Bruce L. WilkoffBruce L. Wilkoff Search for more papers by this author and WRITING COMMITTEE MEMBERS Originally published5 Jun 2013https://doi.org/10.1161/CIR.0b013e31829e8776Circulation. 2013;128:e240–e327Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 Table of ContentsPreamble e2421. Introduction e2451.1. Methodology and Evidence Review e2451.2. Organization of the Writing Committee e2451.3. Document Review and Approval e2451.4. Scope of This Guideline With Reference to Other Relevant Guidelines or Statements e2452. Definition of HF e2462.1. HF With Reduced EF (HFrEF) e2472.2. HF With Preserved EF (HFpEF) e2473. HF Classifications e2474. Epidemiology e2484.1. Mortality e2484.2. Hospitalizations e2484.3. Asymptomatic LV Dysfunction e2484.4. Health-Related Quality of Life and Functional Status e2494.5. Economic Burden of HF e2494.6. Important Risk Factors for HF (Hypertension, Diabetes Mellitus, Metabolic Syndrome, and Atherosclerotic Disease) e2495. Cardiac Structural Abnormalities and Other Causes of HF e2495.1. Dilated Cardiomyopathies e2495.1.1. Definition and Classification of Dilated Cardiomyopathies e2495.1.2. Epidemiology and Natural History of DCM e2505.2. Familial Cardiomyopathies e2505.3. Endocrine and Metabolic Causes of Cardiomyopathy e2505.3.1. Obesity e2505.3.2. Diabetic Cardiomyopathy e2505.3.3. Thyroid Disease e2505.3.4. Acromegaly and Growth Hormone Deficiency e2505.4. Toxic Cardiomyopathy e2515.4.1. Alcoholic Cardiomyopathy e2515.4.2. Cocaine Cardiomyopathy e2515.4.3. Cardiotoxicity Related to Cancer Therapies e2515.4.4. Other Myocardial Toxins and Nutritional Causes of Cardiomyopathy e2515.5. Tachycardia-Induced Cardiomyopathy e2515.6. Myocarditis and Cardiomyopathies Due to Inflammation e2515.6.1. Myocarditis e2515.6.2. Acquired Immunodeficiency Syndrome e2525.6.3. Chagas Disease e2525.7. Inflammation-Induced Cardiomyopathy: Noninfectious Causes e2525.7.1. Hypersensitivity Myocarditis e2525.7.2. Rheumatological/Connective Tissue Disorders e2525.8. Peripartum Cardiomyopathy e2525.9. Cardiomyopathy Caused By Iron Overload e2525.10. Amyloidosis e2525.11. Cardiac Sarcoidosis e2535.12. Stress (Takotsubo) Cardiomyopathy e2536. Initial and Serial Evaluation of the HF Patient e2536.1. Clinical Evaluation e2536.1.1. History and Physical Examination: Recommendations e2536.1.2. Risk Scoring: Recommendation e2536.2. Diagnostic Tests: Recommendations e2536.3. Biomarkers: Recommendations e2556.3.1. Natriuretic Peptides: BNP or NT-proBNP e2566.3.2. Biomarkers of Myocardial Injury: Cardiac Troponin T or I e2566.3.3. Other Emerging Biomarkers e2566.4. Noninvasive Cardiac Imaging: Recommendations e2566.5. Invasive Evaluation: Recommendations e2586.5.1. Right-Heart Catheterization e2596.5.2. Left-Heart Catheterization e2596.5.3. Endomyocardial Biopsy e2607. Treatment of Stages A to D e2607.1. Stage A: Recommendations e2607.1.1. Recognition and Treatment of Elevated Blood Pressure e2607.1.2. Treatment of Dyslipidemia and Vascular Risk e2607.1.3. Obesity and Diabetes Mellitus e2607.1.4. Recognition and Control of Other Conditions That May Lead to HF e2607.2. Stage B: Recommendations e2617.2.1. Management Strategies for Stage B e2627.3. Stage C e2627.3.1. Nonpharmacological Interventions e2627.3.1.1. Education: Recommendation e2627.3.1.2. Social Support e2637.3.1.3. Sodium Restriction: Recommendation e2637.3.1.4. Treatment of Sleep Disorders: Recommendation e2637.3.1.5. Weight Loss e2637.3.1.6. Activity, Exercise Prescription, and Cardiac Rehabilitation: Recommendations e2647.3.2. Pharmacological Treatment for Stage C HFrEF: Recommendations e2647.3.2.1. Diuretics: Recommendation e2657.3.2.2. ACE Inhibitors: Recommendation e2657.3.2.3. ARBs: Recommendations e2677.3.2.4. Beta Blockers: Recommendation e2677.3.2.5. Aldosterone Receptor Antagonists: Recommendations e2687.3.2.6. Hydralazine and Isosorbide Dinitrate: Recommendations e2707.3.2.7. Digoxin: Recommendation e2717.3.2.8. Other Drug Treatment e2717.3.2.8.1. Anticoagulation: Recommendations e2717.3.2.8.2. Statins: Recommendation e2727.3.2.8.3. Omega-3 Fatty Acids: Recommendation e2727.3.2.9. Drugs of Unproven Value or That May Worsen HF: Recommendations e2737.3.2.9.1. Nutritional Supplements and Hormonal Therapies e2737.3.2.9.2. Antiarrhythmic Agents e2737.3.2.9.3. Calcium Channel Blockers: Recommendation e2737.3.2.9.4. Nonsteroidal Anti-Inflammatory Drugs e2747.3.2.9.5. Thiazolidinediones e2747.3.3. Pharmacological Treatment for Stage C HFpEF: Recommendations e2747.3.4. Device Therapy for Stage C HFrEF: Recommendations e2747.3.4.1. Implantable Cardioverter-Defibrillator e2787.3.4.2. Cardiac Resynchronization Therapy e2797.4. Stage D e2807.4.1. Definition of Advanced HF e2807.4.2. Important Considerations in Determining If the Patient Is Refractory e2807.4.3. Water Restriction: Recommendation e2807.4.4. Inotropic Support: Recommendations e2817.4.5. Mechanical Circulatory Support: Recommendations e2827.4.6. Cardiac Transplantation: Recommendation e2838. The Hospitalized Patient e2848.1. Classification of Acute Decompensated HF e2848.2. Precipitating Causes of Decompensated HF: Recommendations e2858.3. Maintenance of GDMT During Hospitalization: Recommendations e2868.4. Diuretics in Hospitalized Patients: Recommendations e2868.5. Renal Replacement Therapy—Ultrafiltration: Recommendations e2878.6. Parenteral Therapy in Hospitalized HF: Recommendation e2878.7. Venous Thromboembolism Prophylaxis in Hospitalized Patients: Recommendation e2888.8. Arginine Vasopressin Antagonists: Recommendation e2888.9. Inpatient and Transitions of Care: Recommendations e2889. Important Comorbidities in HF e2909.1. Atrial Fibrillation e2909.2. Anemia e2939.3. Depression e2939.4. Other Multiple Comorbidities e29310. Surgical/Percutaneous/Transcatheter Interventional Treatments of HF: Recommendations e29311. Coordinating Care for Patients With Chronic HF e29511.1. Coordinating Care for Patients With Chronic HF: Recommendations e29511.2. Systems of Care to Promote Care Coordination for Patients With Chronic HF e29611.3. Palliative Care for Patients With HF e29612. Quality Metrics/Performance Measures: Recommendations e29613. Evidence Gaps and Future Research Directions e299References e299Appendix 1. Author Relationships With Industry and Other Entities (Relevant) e320Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) e323Appendix 3. Abbreviations e327PreambleThe medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist clinicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools.The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly produced guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force), charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, directs and oversees this effort. Writing committees are charged with regularly reviewing and evaluating all available evidence to develop balanced, patient-centric recommendations for clinical practice.Experts in the subject under consideration are selected by the ACCF and AHA to examine subject-specific data and write guidelines in partnership with representatives from other medical organizations and specialty groups. Writing committees are asked to perform a literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and outcomes constitute the primary basis for the recommendations contained herein.In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force.1 The Class of Recommendation (COR) is an estimate of the size of the treatment effect considering risks versus benefits in addition to evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation with the weight of evidence ranked as LOE A, B, or C according to specific definitions that are included in Table 1. Studies are identified as observational, retrospective, prospective, or randomized where appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues for which sparse data are available, a survey of current practice among the clinicians on the writing committee is the basis for LOE C recommendations and no references are cited. The schema for COR and LOE are summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR. A new addition to this methodology is separation of the Class III recommendations to delineate whether the recommendation is determined to be of “no benefit” or is associated with “harm” to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only.Table 1. Applying Classification of Recommendation and Level of EvidenceTable 1. Applying Classification of Recommendation and Level of EvidenceIn view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline–recommended therapies (primarily Class I). This new term, GDMT, will be used herein and throughout all future guidelines.Because the ACCF/AHA practice guidelines address patient populations (and clinicians) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential influence of different practice patterns and patient populations on the treatment effect and relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation.The ACCF/AHA practice guidelines are intended to assist clinicians in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care of a particular patient must be made by the clinician and patient in light of all the circumstances presented by that patient. As a result, situations may arise for which deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas will be identified within each respective guideline when appropriate.Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, clinicians should make every effort to engage the patient’s active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, for which the benefit-to-risk ratio may be lower.The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the members of the writing committee. All writing committee members and peer reviewers of the guideline are required to disclose all current healthcare-related relationships, including those existing 12 months before initiation of the writing effort. In December 2009, the ACCF and AHA implemented a new policy for relationship with industry and other entities (RWI) that requires the writing committee chair plus a minimum of 50% of the writing committee to have no relevant RWI (Appendix 1 includes the ACCF/AHA definition of relevance). These statements are reviewed by the Task Force and all members during each conference call and/or meeting of the writing committee and are updated as changes occur. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the voting members. Members are not permitted to draft or vote on any text or recommendations pertaining to their RWI. Members who recused themselves from voting are indicated in the list of writing committee members, and specific section recusals are noted in Appendix 1. Authors’ and peer reviewers’ RWI pertinent to this guideline are disclosed in Appendixes 1 and 2, respectively. Additionally, to ensure complete transparency, writing committee members’ comprehensive disclosure information—including RWI not pertinent to this document—is available as an online supplement. Comprehensive disclosure information for the Task Force is also available online at http://www.cardiosource.org/en/ACC/About-ACC/Who-We-Are/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The work of writing committees is supported exclusively by the ACCF and AHA without commercial support. Writing committee members volunteered their time for this activity.In an effort to maintain relevance at the point of care for practicing clinicians, the Task Force continues to oversee an ongoing process improvement initiative. As a result, in response to pilot projects, several changes to these guidelines will be apparent, including limited narrative text, a focus on summary and evidence tables (with references linked to abstracts in PubMed), and more liberal use of summary recommendation tables (with references that support LOE) to serve as a quick reference.In April 2011, the Institute of Medicine released 2 reports: Clinical Practice Guidelines We Can Trust and Finding What Works in Health Care: Standards for Systematic Reviews.2,3 It is noteworthy that the ACCF/AHA practice guidelines are cited as being compliant with many of the proposed standards. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated.The recommendations in this guideline are considered current until they are superseded by a focused update or the full-text guideline is revised. Guidelines are official policy of both the ACCF and AHA.Jeffrey L. Anderson, MD, FACC, FAHAChair, ACCF/AHA Task Force on Practice Guidelines1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this document are, whenever possible, evidence based. An extensive evidence review was conducted through October 2011 and includes selected other references through April 2013. Searches were extended to studies, reviews, and other evidence conducted in human subjects and that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected databases relevant to this guideline. Key search words included but were not limited to the following: heart failure, cardiomyopathy, quality of life, mortality, hospitalizations, prevention, biomarkers, hypertension, dyslipidemia, imaging, cardiac catheterization, endomyocardial biopsy, angiotensin-converting enzyme inhibitors, angiotensin-receptor antagonists/blockers, beta blockers, cardiac, cardiac resynchronization therapy, defibrillator, device-based therapy, implantable cardioverter-defibrillator, device implantation, medical therapy, acute decompensated heart failure, preserved ejection fraction, terminal care and transplantation, quality measures, and performance measures. Additionally, the committee reviewed documents related to the subject matter previously published by the ACCF and AHA. References selected and published in this document are representative and not all-inclusive.To provide clinicians with a representative evidence base, whenever deemed appropriate or when published, the absolute risk difference and number needed to treat or harm are provided in the guideline (within tables), along with confidence intervals and data related to the relative treatment effects such as odds ratio, relative risk, hazard ratio, and incidence rate ratio.1.2. Organization of the Writing CommitteeThe committee was composed of physicians and a nurse with broad expertise in the evaluation, care, and management of patients with heart failure (HF). The authors included general cardiologists, HF and transplant specialists, electrophysiologists, general internists, and physicians with methodological expertise. The committee included representatives from the ACCF, AHA, American Academy of Family Physicians, American College of Chest Physicians, American College of Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation.1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers each nominated by both the ACCF and the AHA, as well as 1 to 2 reviewers each from the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation, as well as 32 individual content reviewers (including members of the ACCF Adult Congenital and Pediatric Cardiology Council, ACCF Cardiovascular Team Council, ACCF Council on Cardiovascular Care for Older Adults, ACCF Electrophysiology Committee, ACCF Heart Failure and Transplant Council, ACCF Imaging Council, ACCF Prevention Committee, ACCF Surgeons’ Scientific Council, and ACCF Task Force on Appropriate Use Criteria). All information on reviewers’ RWI was distributed to the writing committee and is published in this document (Appendix 2).This document was approved for publication by the governing bodies of the ACCF and AHA and endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Chest Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation.1.4. Scope of This Guideline With Reference to Other Relevant Guidelines or StatementsThis guideline covers multiple management issues for the adult patient with HF. Although there is an abundance of evidence addressing HF, for many important clinical considerations, this writing committee was unable to identify sufficient data to properly inform a recommendation. The writing committee actively worked to reduce the number of LOE “C” recommendations, especially for Class I−recommended therapies. Despite these limitations, it is apparent that much can be done for HF. Adherence to the clinical practice guidelines herein reproduced should lead to improved patient outcomes.Although of increasing importance, HF in children and congenital heart lesions in adults are not specifically addressed in this guideline. The reader is referred to publically available resources to address questions in these areas. However, this guideline does address HF with preserved ejection fraction (EF) in more detail and similarly revisits hospitalized HF. Additional areas of renewed interest are in stage D HF, palliative care, transition of care, and quality of care for HF. Certain management strategies appropriate for the patient at risk for HF or already affected by HF are also reviewed in numerous relevant clinical practice guidelines and scientific statements published by the ACCF/AHA Task Force on Practice Guidelines, AHA, ACCF Task Force on Appropriate Use Criteria, European Society of Cardiology, Heart Failure Society of America, and the National Heart, Lung, and Blood Institute. The writing committee saw no need to reiterate the recommendations contained in those guidelines and chose to harmonize recommendations when appropriate and eliminate discrepancies. This is especially the case for device-based therapeutics, where complete alignment between the HF guideline and the device-based therapy guideline was deemed imperative.4 Some recommendations from earlier guidelines have been updated as warranted by new evidence or a better understanding of earlier evidence, whereas others that were no longer accurate or relevant or which were overlapping were modified; recommendations from previous guidelines that were similar or redundant were eliminated or consolidated when possible.The present document recommends a combination of lifestyle modifications and medications that constitute GDMT. GDMT is specifically referenced in the recommendations for the treatment of HF (Section 7.3.2). Both for GDMT and other recommended drug treatment regimens, the reader is advised to confirm dosages with product insert material and to evaluate carefully for contraindications and drug-drug interactions. Table 2 is a list of documents deemed pertinent to this effort and is intended for use as a resource; it obviates the need to repeat already extant guideline recommendations. Additional other HF guideline statements are highlighted as well for the purpose of comparison and completeness.Table 2. Associated Guidelines and StatementsTitleOrganizationPublication Year (Reference)Guidelines Guidelines for the Management of Adults With Congenital Heart DiseaseACCF/AHA20085 Guidelines for the Management of Patients With Atrial FibrillationACCF/AHA/HRS20116–8 Guideline for Assessment of Cardiovascular Risk in Asymptomatic AdultsACCF/AHA20109 Guideline for Coronary Artery Bypass Graft SurgeryACCF/AHA201110 Guidelines for Device-Based Therapy of Cardiac Rhythm AbnormalitiesACCF/AHA/HRS20134 Guideline for the Diagnosis and Treatment of Hypertrophic CardiomyopathyACCF/AHA201111 Guideline for Percutaneous Coronary InterventionACCF/AHA/SCAI201112 Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 UpdateAHA/ACCF201113 Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart DiseaseACCF/AHA/ACP/AATS/PCNA/SCAI/STS201214 Guideline for the Management of ST-Elevation Myocardial InfarctionACCF/AHA201315 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial InfarctionACCF/AHA201316 Guidelines for the Management of Patients With Valvular Heart DiseaseACCF/AHA200817 Comprehensive Heart Failure Practice GuidelineHFSA201018 Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart FailureESC201219 Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary CareNICE201020 Antithrombotic Therapy and Prevention of ThrombosisACCP201221 Guidelines for the Care of Heart Transplant RecipientsISHLT201022Statements Contemporary Definitions and Classification of the CardiomyopathiesAHA200623 Genetics and Cardiovascular DiseaseAHA201224 Appropriate Utilization of Cardiovascular Imaging in Heart FailureACCF201325 Appropriate Use Criteria for Coronary Revascularization Focused UpdateACCF201226 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood PressureNHLBI200327 Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III GuidelinesNHLBI200228 Referral, Enrollment, and Delivery of Cardiac Rehabilitation/Secondary Prevention Programs at Clinical Centers and BeyondAHA/AACVPR201129 Decision Making in Advanced Heart FailureAHA201230 Recommendations for the Use of Mechanical Circulatory Support: Device Strategies and Patient SelectionAHA201231 Advanced Chronic Heart FailureESC200732 Oral Antithrombotic Agents for the Prevention of Stroke in Nonvalvular Atrial FibrillationAHA/ASA201233 Third Universal Definition of Myocardial InfarctionESC/ACCF/AHA/WHF201234AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AATS, American Association for Thoracic Surgery; ACCF, American College of Cardiology Foundation; ACCP, American College of Chest Physicians; ACP, American College of Physicians; AHA, American Heart Association; ASA, American Stroke Association; ESC, European Society of Cardiology; HFSA, Heart Failure Society of America; HRS, Heart Rhythm Society; ISHLT, International Society for Heart and Lung Transplantation; NHLBI, National Heart, Lung, and Blood Institute; NICE, National Institute for Health and Clinical Excellence; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; STS, Society of Thoracic Surgeons; and WHF, World Heart Federation.2. Definition of HFHF is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. The cardinal manifestations of HF are dyspnea and fatigue, which may limit exercise tolerance, a