The American College of Cardiology (ACC), in collaboration with the American Heart Association (AHA), is renowned for its extensive publication of cardiology-related clinical practice guidelines. Alongside these guidelines, the ACC also produces Expert Consensus Decision Pathways (ECDPs), which are consensus-based documents aimed at providing valuable insights and recommendations in the field of cardiology.
In this edition of our Guidelines Timelines Series, we will be reviewing the ACC ECDP for Optimization of Heart Failure Treatment, and more specifically, the recommendations for Heart Failure with Reduced Ejection Fraction (HFrEF). Originally published in 2017, the ECDP was developed to expand upon the information found within the joint ACC/AHA Heart Failure Guidelines. The ACC ECDP has gone through a number of iterations, as well as a “splitting” of sorts into multiple separate ECDP updates. While we won’t cover everything included across all of these Heart Failure Pathways, we will cover some of the highlights, especially those focusing on HFrEF. Without further ado, we’ll go ahead and dive in!
Overview of ACC Heart Failure ECDPs In This Timeline
- 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment (January 2018)
- 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment (January 2021)
- Management of Heart Failure With Preserved Ejection Fraction (April 2023)
- Treatment of Heart Failure With Reduced Ejection Fraction (March 2024)
The 2017 iteration of the HF ECDP was a “full” Pathway document, covering both heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). However, in 2021, the publication was split. The 2021 ECDP focused mainly on HFrEF. The 2023 ECDP updated specifically for HFpEF. And in 2024, like in 2021, the ECDP updates only for the HFrEF portion. As a result, even though we technically have four separate ECDPs to compare along our timeline, there were only actually three iterations of the recommendations for HFrEF, and two iterations of the recommendations for HFpEF.
Major HFrEF Changes: from 2017 to 2021
- Between the 2017 and 2021 ECDPs, new therapies for HFrEF were approved that broadened the treatment options available for patients. Notably, the development of angiotensin receptor-neprilysin inhibitors (ARNIs), sodium-glucose cotransporter-2 (SGLT2) inhibitors, and percutaneous therapy for mitral regurgitation (MR) mark significant advancements in the management of HFrEF.
- Update to Table 1: Starting and Target Doses of Select GDMT and Novel Therapies for HF
- Revisions to Table 6: Potential Infrastructure Components to Support Team-Based HF Care
- Updates to Table 10: Ten Considerations to Improve Adherence
- Identify NYHA functional class added to Table 13: Helpful Information for Completion of Prior Authorization Forms
- Additional to Table 15: Common Cardiovascular and Noncardiovascular Comorbidities Encountered in Patients With HFrEF
- And more
Major HFrEF Changes: from 2021 to 2024
- Since publication of the 2021 ECDP, new data emerged that triggered an update to the ECDP for HFrEF, including publication of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
- Table 1: Starting and Target Doses of GDMT for HF was updated
- Attention to the clinical, social, and financial barriers to achieving GDMT should be prioritized.
- Updates to Figure 2: Treatment for Guideline-Directed Medical Therapy Including Novel Therapies
- Updates to Figure 3: GDMT, Including Newer Therapies, in the ECDP for Chronic HF, including the addition of Sotagliflozin and Vericiguat
- Movement away from SGLT2i class to more broad SGLTi class after approval of Sotagliflozin
- Indications for Use of an SGLT Inhibitor in HFrEF
- Table 4: Contraindications and Cautions for Sacubitril/Valsartan, Ivabradine, SGLT Inhibitors, and Vericiguat
- Updates to Table 6: Triggers for HF Patient Referral to a Specialist/Program
- Updates to Table 9: Reasons for Nonadherence (World Health Organization)
- Updates to Table 10: Ten Considerations to Improve Adherence
- And more
Comparing Treatment Algorithm for HFrEF Stage C Initial Treatment from 2017-2024
| Medication | 2024 ECDP | 2021 ECDP | 2017 ECDP |
| ACE/ARB | Not included in recommendations | Optional 1sr line, but ARNI preferred | 1st line |
| ARNIs | Optional 1st line | Preferred 1st line | 2nd line switch for patients stable on ACEi/ARB NYHA class II-III |
| SGLT2is | Optional 1st line | Optional 2nd line addition for patients meeting eGFR criteria NYHA class II-IV | Not included in recommendations |
| Ivabradine | Optional 2nd line addition for patients with resting heart rate ≥70, on maximally tolerated betablocker, dose in sinus rhythm, NYHA class II–II | Optional 2nd line addition for patients with resting HR ≥70, on maximally tolerated beta-blocker dose in sinus rhythm, NYHA class II–III | Optional 2nd line addition for patients with resting HR ≥70, on maximally tolerated beta-blocker dose in sinus rhythm, NYHA class II–III |
| Sotagliflozin | Optional 1st line | Not included in recommendations | Not included in recommendations |
| Vericiguat | Optional 2nd line addition for high-risk patients already on optimal GDMT with worsening HF as evidenced by a HF hospitalization or requirement for intravenous diuretics | Not included in recommendations | Not included in recommendations |
| Diuretics | Optional 2nd line titrate for patients with persistent volume overload, NYHA class II-IV | Optional 2nd line titrate for patients with persistent volume overload, NYHA class II-IV | Optional 2nd line titrate for patients with persistent volume overload, NYHA class II-IV |
| Hydralazine + isosorbide dinitrate | Optional 2nd line addition for persistently symptomatic African Americans NYHA class III-IV, despite ARNI/beta-blocker-aldosterone antagonist/SGLTi | Optional 2nd line addition for persistently symptomatic African Americans NYHA class III-IV, despite ARNI/beta-blocker-aldosterone antagonist/SGLTi | Optional 2nd line addition for persistently symptomatic African Americans NYHA class III-IV |
| Aldosterone antagonist | Not included in recommendations | Optional 2nd line addition for patients with eGFR ≥30 mL/min/1.73 m2 or creatinine ≤2.5 mg/dL in males or ≤2.0 mg/dL in females or K+ ≤5.0 mEq/L, NYHA Class II–IV | Optional 2nd line addition for patients with eGFR ≥30 mL/min/1.73 m2 or K+ ≤5.0 mEq/L, NYHA Class II–IV |
Looking ahead, we do expect ACC to release another heart failure related Expert Consensus Decision Pathway, however this one will be an update to Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized with Heart Failure. That ECDP is currently scheduled for release sometime between July-September 2024.
This concludes our Guidelines Timelines Series on the American College of Cardiology Expert Consensus Pathways for Heart Failure with Reduced Ejection Fraction (HFrEF). Let us know if you would like to see us build upon this with another edition, but this time focusing instead upon the key changes surrounding HFpEF. Either way, thanks for visiting, and make sure to sign up for alerts and stay informed on the latest published guidelines and articles.
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