STAGE A
At high risk for HF but without
structural heart disease or
symptoms of HF
STAGE B
Structural heart disease but
without signs or symptoms
of HF
STAGE C
Structural heart disease with
prior or current symptoms
of HF
STAGE D
Refractory HF
e.g., Patients with:
• Previous MI
• LV remodeling including LV
Hand low EF
• Asymptomatic valvular
disease
e.g., Patients with:
• Known structural heart
disease and
• HF signs and symptoms
e.g., Patients with:
• Marked HF symptoms at
rest
• Recurrent hospitalizations
despite GDMT
THERAPY
Goals
• Control symptoms
• Improve HRQOL
• Patient education
• Prevent hospitalization
• Prevent mortality
Strategies
• Identification of comorbidities
Treatment
• Diuresis to relieve symptoms
of congestion
• Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
• Revascularization or valvular
surgery as appropriate
THERAPY
Goals
• Control symptoms
• Improve HRQOL
• Patient education
• Prevent hospitalization
• Prevent mortality
Drugs for routine use
• Diuretics for fluid retention
• ACEI or ARB
• ARNI
• Beta blockers
• Aldosterone antagonists
Drugs for use in selected
patients
• Hydralazine/isosorbide dinitrate
• ACEI and ARB
• Ivabradine
• Digoxin
Inselected patients
• CRT
• ICD
• Revascularization or valvular
surgery as appropriate
HFpEF HFrEF
THERAPY
Goals
• Prevent HF symptoms
• Prevent further cardiac
remodeling
Drugs
• ACEI or ARB as appropriate
• Beta blockers as
appropriate
In selected patients
• ICD
• Revascularization or
valvular surgery as
appropriate
THERAPY
Goals
• Control symptoms
• Improve HRQOL
• Reduce hospital
readmissions
• Establish patient’s end-of-
life goals
Options
• Advanced care measures
• Heart transplant
• Chronic inotropes
• Temporary or permanent
MCS
• Experimental surgery or
drugs
• Palliative care and hospice
• ICD deactivation
e.g., Patients with:
• HTN
• Atherosclerotic disease
• DM
• Obesity
• Metabolic syndrome
OR
Patients
• Using cardiotoxins
• With family history of
cardiomyopathy
THERAPY
Goals
• Heart healthy lifestyle
• Prevent vascular, coronary
disease
• Prevent LV structural
abnormalities
Drugs
• ACEI or ARB in appropriate
patients for vascular
disease or DM
• Statins as appropriate
Development
of symptoms
of HF
Refractory
symptoms
of HF at rest,
despite GDMT
Structural
heart disease
Stages in the development of HF and recommended therapy by stage. ACEI indicates angiotensin-converting
enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin-receptor blocker; CAD, coronary artery disease;
CRT, cardiac resynchronization therapy; DM, diabetes mellitus; EF, ejection fraction; GDMT, guideline-
directed medical therapy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF,
heart failure with reduced ejection fraction; HRQOL, health-related quality of life; HTN, hypertension; ICD,
implantable cardioverter-defibrillator; LV, left ventricular; LVH, left ventricular hypertrophy; MCS, mechanical
circulatory support; and MI, myocardial infarction. Adapted from Hunt et al.3
Yancy CW et al., ACCF/AHA Guideline for the Management of Heart Failure, Circulation, 10/15/13.
Yancy CW et al., 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management
of Heart Failure, Circulation, 08/08/2017.
AT RISK FOR HEART FAILURE HEART FAILURE
