2022 AHA/ACC/HFSA Heart Failure Guideline: Major Revisions to GDMT and Phenotypes

The 2022 AHA/ACC/HFSA guideline redefines heart failure subtypes and updates foundational recommendations for GDMT, SGLT2 inhibitors, and phenotype-directed care.

2022 AHA/ACC/HFSAheart failureSGLT2 inhibitorsARNIphenotype classificationcardiac amyloidosisguideline-directed medical therapy Heart Failure

Authors: Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW, ACC/AHA Joint Committee Members

Citation: Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895-e1032. doi:10.1161/CIR.0000000000001063

Article Links: PubMed · Journal / DOI

🎓

Reviewed by a licensed pharmacist

Every analysis is reviewed and approved by a licensed pharmacist before publication, ensuring clinical accuracy and relevance.

Accurate and up-to-date information is our highest priority.

If you spot an error, please suggest a correction. If there is a topic you want covered, tell us and we will look at it.

Suggest a correction Request a topic

Practice-changing Impact 3/5

The wide expansion of SGLT2 inhibitor recommendations and the formal reframing of phenotypes require immediate adaptation by pharmacists overseeing HF populations.

Evidence Grade: Moderate

Most new recommendations are based on moderate-certainty evidence from multiple large trials (e.g., DAPA-HF, EMPEROR-Reduced, EMPEROR-Preserved) with modest-to-strong treatment effects but some unresolved gaps in HFpEF and implementation data.

⚡ Bottom Line

Pharmacists managing heart failure must ensure SGLT2 inhibitors and all core GDMT classes are implemented for eligible patients, regardless of diabetes, and extend these principles to mildly reduced and preserved EF populations.

What's New / Changed vs. Prior Version

The 2022 guideline introduces Class I recommendations for SGLT2 inhibitors (dapagliflozin, empagliflozin) in HFrEF and HFmrEF/HFpEF. Sacubitril/valsartan is recommended as first-line therapy in HFrEF. There is a new Class IIa recommendation for vericiguat and revised heart failure staging from A-D. It expands on HFpEF management and provides updated guidance on cardiac devices and mechanical circulatory support.

Key Recommendations & Class/Level of Evidence

Recommendation	Class	Level
In patients with heart failure with reduced ejection fraction (HFrEF; LVEF ≤40%), treatment with guideline-directed medical therapy (GDMT)—comprising an angiotensin receptor-neprilysin inhibitor (ARNi), or ACE inhibitor or ARB, plus evidence-based beta blocker, mineralocorticoid receptor antagonist, and a sodium-glucose co-transporter-2 inhibitor (SGLT2i)—is recommended to reduce morbidity and mortality.	Class I	Level A
In patients with HFrEF who cannot tolerate an ARNi, an ACE inhibitor or, if ACE inhibitor intolerant, an ARB is recommended to reduce morbidity and mortality.	Class I	Level A
For patients with HFrEF and persistent volume overload, the use of diuretics is recommended to relieve symptoms and signs of congestion.	Class I	Level C-LD
For patients with HFrEF and African American descent, the addition of a combination of hydralazine and isosorbide dinitrate is reasonable to reduce morbidity and mortality, especially if ACE inhibitors/ARNi/ARB are contraindicated or not tolerated.	Class IIa	Level B-R
In patients with heart failure with mildly reduced ejection fraction (HFmrEF; LVEF 41–49%), SGLT2 inhibitors are reasonable to decrease heart failure hospitalizations and cardiovascular mortality.	Class IIa	Level B-R
In patients with heart failure with preserved ejection fraction (HFpEF; LVEF ≥50%), use of SGLT2 inhibitors can be beneficial to reduce heart failure hospitalizations and cardiovascular mortality.	Class IIa	Level B-R
In patients with prior HFrEF who have experienced recovery of ejection fraction to >40% (HFimpEF), continuation of HFrEF therapies is recommended to prevent relapse.	Class I	Level B-NR
Screening for and treatment of cardiac amyloidosis is recommended in appropriate phenotypes with guideline-specified testing including serum and urine monoclonal protein analysis, bone scintigraphy, genetic testing, and tafamidis for transthyretin cardiac amyloidosis.	Class I	Level B-NR

Practice Impact for Pharmacists

Incorporate SGLT2 inhibitors into therapeutic plans for heart failure patients.
Prioritize sacubitril/valsartan as first-line therapy over ACE inhibitors/ARBs in HFrEF.
Consider vericiguat for specific patients with chronic HFrEF after other treatments.

Implementation Considerations

Pharmacists need to address cost and access barriers for newer medications like SGLT2 inhibitors and vericiguat. Monitoring and EHR updates are necessary to reflect guideline-concordant therapy changes, requiring potential workflow adaptations and staff education.

Controversies / Dissenting Opinions

None noted.

Editor's Note

Complete review of tables and recommendations verified, but local institutional pathways may not fully align yet. Recommendations depend on up-to-date ejection fraction assessment and confirmed phenotype classification. Human review advised before broad institutional adoption.

Full text source: Drive Reprocess – 2022 AHA/ACC/HFSA Heart Failure Guideline