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An update to the heart failure guidelines from the American College of Cardiology (ACC), American Heart Association, and Heart Failure Society of America brought a number of changes in terminology and added SGLT2 inhibitor recommendations.

Stage A heart failure is now "at risk" and stage B heart failure gained the moniker "pre-HF," while symptomatic disease got a new set of classification names:

• HF with reduced ejection fraction (HFrEF): Left ventricular ejection fraction (LVEF) ≤40%

• HF with improved ejection fraction (HFimpEF): LVEF previously ≤40% but >40% on follow-up

• HF with mildly reduced ejection fraction (HFmrEF): LVEF 41-49% and increased LV filling pressures

• HF with preserved ejection fraction (HFpEF): LVEF ≥50% and increased LV filling pressures

These terminology changes were in harmony with the proposed last year in conjunction with the European Society of Cardiology (ESC) and other organizations globally.

Part of the goal of adoption was "to address the evolving role of biomarkers and structural changes for recognition of patients who are at risk of developing HF, who are potential candidates for targeted treatment strategies for the prevention of HF," guideline writing committee chair Paul Heidenreich, MD, of Stanford University in California, and colleagues wrote in the document, released in the and each of the other participating societies' flagship journals in conjunction with the ACC meeting in Washington D.C.

These are "clinically relevant" changes in classifications that will influence management, wrote Michelle Kittleson, MD, PhD, of the Smidt Heart Institute in Los Angeles, in an accompanying the co-publication in the Journal of Cardiac Failure.

For example, the HFimpEF group is clearly different from a patient whose EF is 50-55% on presentation, she noted: "This distinction is important: based on a landmark trial in patients with HFimpEF, there is now a Class I indication that in patients with HFimpEF after treatment, GDMT [guideline-directed medical therapy] should be continued to prevent relapse of HF and left ventricular dysfunction, even in patients who may become asymptomatic."

Congruence in clinical practice guidelines around the world is ideal, wrote Alanna Morris, MD, MSc, of Emory University School of Medicine in Atlanta, and Javed Butler, MD, MPH, MBA, of Baylor University Medical Center in Dallas, in a accompanying the co-publication in Circulation.

"Discordant recommendations for the same disease state based on the same data can cause confusion and/or inaction," Morris and Butler stated.

The guideline update brings concordance with the 2021 ESC guidelines in one key aspect of treatment: adding SGLT-2 inhibitors as a fourth pillar of therapy for symptomatic heart failure, from HFrEF to HFpEF, regardless of diabetes status.

But where there is discordance is that the American guidelines "firmly declare that the ARNI [angiotensin receptor neprilysin inhibitor] should be the preferred renin-angiotensin modulator with a class 1A recommendation; and that the use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers may be used when the use of ARNI is not feasible," Morris and Butler pointed out.

"The ESC guidelines give ARNI a 1B recommendation, stating that ARNI is recommended as a replacement for ACEi in suitable patients who remain symptomatic, although an ARNI can be considered as first-line," they added.

For HFpEF, ESC doesn't give any class or recommendation for either ARNI or mineralocorticoid receptor antagonists (MRAs). In The U.S. guidelines, SGLT2 inhibitors got a 2a recommendation for both HFpEF and HFmrEF, while MRA and ARNI drugs got 2b recommendations.

One thing that didn't change in the U.S. guidelines was the class 1a recommendation for implantable cardioverter defibrillators in primary prevention, whereas the ESC had downgraded the recommendation to 2a for heart failure with ischemic causes.

Why the differences? The disease itself is the same, so it's "more likely to be based on the populations of patients under consideration and the economic conditions of the healthcare systems that provide care for those patients," Morris and Butler wrote.

The U.S. guideline also added recommendations on managing cardiac amyloidosis, cardio-oncology complications, and heart failure comorbidities, while also emphasizing heart failure specialty team care in advanced disease.

Kittleson concluded with some advice: "ask yourself how the contents can help you to take better care of your patients. With patients with an EF of 41%-49%, ask: are they getting better, or worse, and how can management be tailored accordingly? With patients with HFrEF not on optimal GDMT at target doses, ask: why not? With congested patients with HFmrEF of HFpEF, ask: could this be cardiac amyloidosis?"

"And with every patient, ask: what are their barriers to effective self-care and how can they be addressed? Great science alone will not save lives -- for that, we need effective implementation," she said.