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2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America

Originally published28 Apr 2017https://doi.org/10.1161/CIR.0000000000000509Circulation. 2017;136:e137–e161

Table of Contents

Preamblee e138

1. Introduction e139

1.1 Methodology and Evidence Reviewe e140

1.2. Organization of the Writing Group e141

1.3. Document Review and Approval e141

6. Initial and Serial Evaluation of the HF Patient e141

6.3. Biomarkers e141

6.3.1. Biomarkers for Prevention: Recommendation e142

6.3.2. Biomarkers for Diagnosis: Recommendation e142

6.3.3. Biomarkers for Prognosis or Added Risk Stratification: Recommendations e142

7. Treatment of Stages A to D e144

7.3. Stage C e144

7.3.2. Pharmacological Treatment for Stage C HF With Reduced Ejection Fraction: Recommendations e144

7.3.2.10. Renin-Angiotensin System Inhibition With Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker or ARNI: Recommendations e144

7.3.2.11. Ivabradine: Recommendation e145

7.3.3. Pharmacological Treatment for Stage C HFpEF: Recommendations e146

9. Important Comorbidities in HF e147

9.2. Anemia: Recommendations e147

9.5. Hypertension (New Section) e149

9.5.1. Treating Hypertension to Reduce the Incidence of HF: Recommendation e149

9.5.2. Treating Hypertension in Stage C HFrEF: Recommendation e149

9.5.3. Treating Hypertension in Stage C HFpEF: Recommendation e149

9.6. Sleep-Disordered Breathing: Recommendations e149

References e151

Appendix 1. Author Relationships With Industry and Other Entities (Relevant) e156

Appendix 2. Reviewer Relationships With Industry and Other Entities (Comprehensive) e158

Appendix 3. Abbreviations e161

Preamble

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines (guidelines) with recommendations to improve cardiovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a cornerstone for quality cardiovascular care. The ACC and AHA sponsor the development and publication of guidelines without commercial support, and members of each organization volunteer their time to the writing and review efforts. Guidelines are official policy of the ACC and AHA.

Intended Use

Practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations may have a global impact. Although guidelines may be used to inform regulatory or payer decisions, their intent is to improve patients’ quality of care and align with patients’ interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment.

Clinical Implementation

Guideline recommended management is effective only when followed by healthcare providers and patients. Adherence to recommendations can be enhanced by shared decision making between healthcare providers and patients, with patient engagement in selecting interventions based on individual values, preferences, and associated conditions and comorbidities.

Methodology and Modernization

The ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) continuously reviews, updates, and modifies guideline methodology on the basis of published standards from organizations including the Institute of Medicine1,2 and on the basis of internal reevaluation. Similarly, the presentation and delivery of guidelines are reevaluated and modified on the basis of evolving technologies and other factors to facilitate optimal dissemination of information at the point of care to healthcare professionals. Given time constraints of busy healthcare providers and the need to limit text, the current guideline format delineates that each recommendation be supported by limited text (ideally, <250 words) and hyperlinks to supportive evidence summary tables. Ongoing efforts to further limit text are underway. Recognizing the importance of cost-value considerations in certain guidelines, when appropriate and feasible, an analysis of the value of a drug, device, or intervention may be performed in accordance with the ACC/AHA methodology.3

To ensure that guideline recommendations remain current, new data are reviewed on an ongoing basis, with full guideline revisions commissioned in approximately 6-year cycles. Publication of new, potentially practice-changing study results that are relevant to an existing or new drug, device, or management strategy will prompt evaluation by the Task Force, in consultation with the relevant guideline writing committee, to determine whether a focused update should be commissioned. For additional information and policies regarding guideline development, we encourage readers to consult the ACC/AHA guideline methodology manual4 and other methodology articles.5–8

Selection of Writing Committee Members

The Task Force strives to avoid bias by selecting experts from a broad array of backgrounds. Writing committee members represent different geographic regions, sexes, ethnicities, races, intellectual perspectives/biases, and scopes of clinical practice. The Task Force may also invite organizations and professional societies with related interests and expertise to participate as partners, collaborators, or endorsers.

Relationships With Industry and Other Entities

The ACC and AHA have rigorous policies and methods to ensure that guidelines are developed without bias or improper influence. The complete relationships with industry and other entities (RWI) policy can be found online. Appendix 1 of the current document lists writing committee members’ relevant RWI. For the purposes of full transparency, writing committee members’ comprehensive disclosure information is available online. Comprehensive disclosure information for the Task Force is also available online.

Evidence Review and Evidence Review Committees

When developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data.4–7 Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only key references are cited.

An independent evidence review committee (ERC) is commissioned when there are 1 or more questions deemed of utmost clinical importance that merit formal systematic review. This systematic review will strive to determine which patients are most likely to benefit from a drug, device, or treatment strategy and to what degree. Criteria for commissioning an ERC and formal systematic review include: a) the absence of a current authoritative systematic review, b) the feasibility of defining the benefit and risk in a time frame consistent with the writing of a guideline, c) the relevance to a substantial number of patients, and d) the likelihood that the findings can be translated into actionable recommendations. ERC members may include methodologists, epidemiologists, healthcare providers, and biostatisticians. When a formal systematic review has been commissioned, the recommendations developed by the writing committee on the basis of the systematic review are marked with“SR”.

Guideline-Directed Management and Therapy

The term guideline-directed management and therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and pharmacological and procedural treatments. For these and all recommended drug treatment regimens, the reader should confirm the dosage by reviewing product insert material and evaluate the treatment regimen for contraindications and interactions. The recommendations are limited to drugs, devices, and treatments approved for clinical use in the United States.

Class of Recommendation and Level of Evidence

The Class of Recommendation (COR) indicates the strength of the recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates the quality of scientific evidence that supports the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1).4–6

Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)

Table 1.

Glenn N. Levine, MD, FACC, FAHA

Chair, ACC/AHA Task Force on Clinical Practice Guidelines

1. Introduction

The purpose of this focused update is to update the “2013 ACCF/AHA Guideline for the Management of Heart Failure”9 (2013 HF guideline) in areas in which new evidence has emerged since its publication. For this update and future heart failure (HF) guidelines, the Heart Failure Society of America (HFSA) has partnered with the ACC and AHA to provide coordinated guidance on the management of HF.

The scope of the focused update includes revision to the sections on biomarkers; new therapies indicated for stage C HF with reduced ejection fraction (HFrEF); updates on HF with preserved ejection fraction (HFpEF); new data on important comorbidities, including sleep apnea, anemia, and hypertension; and new insights into the prevention of HF.

This focused update represents the second part of a 2-stage publication; with the first part having been published as the “2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure,”10 which introduced guidance on new therapies, specifically for the use of an angiotensin receptor–neprilysin inhibitor (ARNI) (valsartan/sacubitril) and a sinoatrial node modulator (ivabradine). That focused update was published concurrently with the European Society of Cardiology’s complete guideline, “2016 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure.”11

1.1. Methodology and Evidence Review

To identify key data that influence guideline recommendations, the Task Force and members of the 2013 HF guideline writing committee reviewed clinical trials that were presented at the annual scientific meetings of the ACC, AHA, and European Society of Cardiology and other scientific meetings and that were published in peer-reviewed format from April 2013 through November 2016. The evidence is summarized in tables in the Online Data Supplement. All recommendations (new, modified, and unchanged) for each clinical section are included to provide a comprehensive assessment. The text explains new and modified recommendations, whereas recommendations from the previous guideline that have been deleted or superseded no longer appear. Please consult the full-text version of the 2013 HF guideline9 for text and evidence tables supporting the unchanged recommendations and for clinical areas not addressed in this focused update. Individual recommendations in this focused update will be incorporated into the full-text guideline in the future. Recommendations from the prior guideline that remain current have been included for completeness, but the LOE reflects the COR/LOE system used when the recommendations were initially developed. New and modified recommendations in this focused update reflect the latest COR/LOE system, in which LOE B and C are subcategorized for greater specificity.4–6 The section numbers correspond to the full-text guideline sections.

1.2. Organization of the Writing Group

For this focused update, representative members of the 2013 HF guideline writing committee were invited to participate. They were joined by additional invited members to form a new writing group, which is referred to as the 2017 HF focused update writing group. Members were required to disclose all RWI relevant to the data under consideration. The group was composed of experts representing general cardiologists, HF and transplantation specialists, electrophysiologists, pharmacists, and general internists. The 2017 HF focused update writing group included representatives from the ACC, AHA, and HFSA, as well as the American Academy of Family Physicians, American College of Chest Physicians, American College of Physicians, and International Society for Heart and Lung Transplantation.

1.3. Document Review and Approval

The focused update was reviewed by 2 official reviewers each nominated by the ACC, AHA, and HFSA; 1 reviewer each from the American Academy of Family Physicians, American College of Chest Physicians, and International Society for Heart and Lung Transplantation; and 19 individual content reviewers. Reviewers’ RWI information is published in this document (Appendix 2).

This document was approved for publication by the governing bodies of the ACC, AHA, and HFSA.

6. Initial and Serial Evaluation of the HF Patient

6.3. Biomarkers

Assays for BNP (B-type natriuretic peptide) and NT-proBNP (N-terminal pro-B-type natriuretic peptide), which are both natriuretic peptide biomarkers, have been used increasingly to establish the presence and severity of HF. In general, both natriuretic peptide biomarker values track similarly, and either can be used in patient care settings as long as their respective absolute values and cutpoints are not used interchangeably. Notably, BNP, but not NT-proBNP, is a substrate for neprilysin. Therefore, ARNI increases BNP levels12 but not NT-proBNP levels.13 Note that the type of natriuretic peptide assay that has been performed must be considered during interpretation of natriuretic peptide biomarker levels in patients on ARNI. In 2 studies with ARNI, NT-proBNP levels were reduced,12,14 with the reduction in 1 study being associated with improved clinical outcomes.12

A substantial evidence base exists that supports the use of natriuretic peptide biomarkers to assist in the diagnosis or exclusion of HF as a cause of symptoms (eg, dyspnea, weight gain) in the setting of chronic ambulatory HF15–21 or in the setting of acute care with decompensated HF,22–30 especially when the cause of dyspnea is unclear. The role of natriuretic peptide biomarkers in population screening to detect incident HF is emerging.31–37 Elevated plasma levels of natriuretic peptide biomarkers are associated with a wide variety of cardiac and noncardiac causes (Table 2).38–42 Obesity may be associated with lower natriuretic peptide concentrations, and this may modestly reduce diagnostic sensitivity in morbidly obese patients.42

Table 2. Selected Potential Causes of Elevated Natriuretic Peptide Levels38–41

Cardiac
 HF, including RV syndromes
 Acute coronary syndromes
 Heart muscle disease, including LVH
 Valvular heart disease
 Pericardial disease
 Atrial fibrillation
 Myocarditis
 Cardiac surgery
 Cardioversion
 Toxic-metabolic myocardial insults, including cancer chemotherapy
Noncardiac
 Advancing age
 Anemia
 Renal failure
 Pulmonary: obstructive sleep apnea, severe pneumonia
 Pulmonary hypertension
 Critical illness
 Bacterial sepsis
 Severe burns

Modified from Table 8 of the 2013 HF guideline.9

HF, indicates heart failure; LVH, left ventricular hypertrophy; and RV, right ventricular.

Because of the absence of clear and consistent evidence for improvement in mortality and cardiovascular outcomes,43–62 there are insufficient data to inform specific guideline recommendations related to natriuretic peptide–guided therapy or serial measurements of BNP or NT-proBNP levels for the purpose of reducing hospitalization or deaths in the present document.

Like natriuretic peptides, cardiac troponin levels may be elevated in the setting of chronic or acute decompensated HF, suggesting myocyte injury or necrosis.63 Troponins I and T respond similarly for acute coronary syndromes and acute decompensated HF. Elevations in either troponin I or T levels in the setting of acute HF are of prognostic significance and must be interpreted in the clinical context.64

In addition to natriuretic peptides and troponins,65–67 multiple other biomarkers, including those of inflammation, oxidative stress, vascular dysfunction, and myocardial and matrix remodeling, have been implicated in HF.68–71 Biomarkers of myocardial fibrosis, soluble ST2 receptor, and galectin-3 are predictive of hospitalization and death and may provide incremental prognostic value over natriuretic peptide levels in patients with HF.72–74 Strategies that combine multiple biomarkers may ultimately prove beneficial in guiding HF therapy in the future, but multicenter studies with larger derivation and validation cohorts are needed.75,76 Several emerging biomarkers await validation with well-defined outcome measures and prognostic accuracy before they can reach the clinical arena.77–84

This section categorizes the role of biomarkers into prevention, diagnosis, prognosis, and added risk stratification to clarify evidence-based objectives of their use in clinical practice.

6.3.1 Biomarkers for Prevention: Recommendation

Biomarkers: Recommendation for Prevention of HF

6.3.2 Biomarkers for Diagnosis: Recommendation

Biomarkers: Recommendation for Diagnosis

6.3.3 Biomarkers for Prognosis or Added Risk Stratification: Recommendations

Biomarkers: Recommendations for Prognosis

7. Treatment of Stages A to D

7.3. Stage C

7.3.2. Pharmacological Treatment for Stage C HF With Reduced Ejection Fraction: Recommendations

(See Figure 2 and Table 3).

Figure 1.

Figure 1. Biomarkers Indications for Use. Colors correspond to COR in Table 1. *Other biomarkers of injury or fibrosis include soluble ST2 receptor, galectin-3, and high-sensitivity troponin. ACC indicates American College of Cardiology; AHA, American Heart Association; ADHF, acute decompensated heart failure; BNP, B-type natriuretic peptide; COR, Class of Recommendation; ED, emergency department; HF, heart failure; NT-proBNP, N-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association; and pts, patients.

Figure 2.

Figure 2. Treatment of HFrEF Stage C and D. Colors correspond to COR in Table 1. For all medical therapies, dosing should be optimized and serial assessment exercised. *See text for important treatment directions. †Hydral-Nitrates green box: The combination of ISDN/HYD with ARNI has not been robustly tested. BP response should be carefully monitored. ‡See 2013 HF guideline.9 §Participation in investigational studies is also appropriate for stage C, NYHA class II and III HF. ACEI indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor-blocker; ARNI, angiotensin receptor-neprilysin inhibitor; BP, blood pressure; bpm, beats per minute; C/I, contraindication; COR, Class of Recommendation; CrCl, creatinine clearance; CRT-D, cardiac resynchronization therapy–device; Dx, diagnosis; GDMT, guideline-directed management and therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter-defibrillator; ISDN/HYD, isosorbide dinitrate hydral-nitrates; K+, potassium; LBBB, left bundle-branch block; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NSR, normal sinus rhythm; and NYHA, New York Heart Association.

Table 3. Drugs Commonly Used for HFrEF (Stage C HF)

DrugInitial Daily Dose(s)Maximum Doses(s)Mean Doses Achieved in Clinical TrialsReferences
ACE inhibitors
 Captopril6.25 mg TID50 mg TID122.7 mg QD158
 Enalapril2.5 mg BID10–20 mg BID16.6 mg QD129
 Fosinopril5–10 mg QD40 mg QDN/A—
 Lisinopril2.5–5 mg QD20–40 mg QD32.5–35.0 mg QD130
 Perindopril2 mg QD8–16 mg QDN/A—
 Quinapril5 mg BID20 mg BIDN/A—
 Ramipril1.25–2.5 mg QD10 mg QDN/A—
 Trandolapril1 mg QD4 mg QDN/A—
ARBs
 Candesartan4–8 mg QD32 mg QD24 mg QD137
 Losartan25–50 mg QD50–150 mg QD129 mg QD136
 Valsartan20–40 mg BID160 mg BID254 mg QD134
ARNI
 Sacubitril/valsartan49/51 mg BID (sacubitril/valsartan) (therapy may be initiated at 24/26 mg BID)97/103 mg BID (sacubitril/valsartan)375 mg QD; target dose: 24/26 mg, 49/51 mg OR 97/103 mg BID138
If channel inhibitor
 Ivabradine5 mg BID7.5 mg BID6.4 mg BID (at 28 d) 6.5 mg BID (at 1 y)155–157
Aldosterone antagonists
 Spironolactone12.5–25 mg QD25 mg QD or BID26 mg QD142
 Eplerenone25 mg QD50 mg QD42.6 mg QD159
Beta blockers
 Bisoprolol1.25 mg QD10 mg QD8.6 mg QD160
 Carvedilol3.125 mg BID50 mg BID37 mg QD161
 Carvedilol CR10 mg QD80 mg QDN/A—
 Metoprolol succinate extended release (metoprolol CR/XL)12.5–25 mg QD200 mg QD159 mg QD139
Isosorbide dinitrate and hydralazine
 Fixed-dose combination20 mg isosorbide dinitrate/37.5 mg hydralazine TID40 mg isosorbide dinitrate/75 mg hydralazine TID90 mg isosorbide dinitrate/~175 mg hydralazine QD162
 Isosorbide dinitrate and hydralazine20–30 mg isosorbide dinitrate/25–50 mg hydralazine TID or QD40 mg isosorbide dinitrate TID with 100 mg hydralazine TIDN/A163

Modified (Table 15) from the 2013 HF guideline.9

ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor; BID, twice daily; CR, controlled release; CR/XL, controlled release/extended release; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; N/A, not applicable; QD, once daily; and TID, 3 times daily.

7.3.2.10. Renin-Angiotensin System Inhibition With Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker or ARNI: Recommendations

Recommendations for Renin-Angiotensin System Inhibition With ACE Inhibitor or ARB or ARNI

7.3.2.11. Ivabradine: Recommendation

Recommendation for Ivabradine

7.3.3. Pharmacological Treatment for Stage C HFpEF: Recommendations

Recommendations for Stage C HFpEF

9. Important Comorbidities in HF

9.2. Anemia: Recommendations

Recommendations for Anemia

9.5. Hypertension (New Section)

9.5.1. Treating Hypertension to Reduce the Incidence of HF: Recommendation

Recommendation for Prevention

9.5.2. Treating Hypertension in Stage C HFrEF: Recommendation

Recommendation for Hypertension in Stage C HFrEF

9.5.3. Treating Hypertension in Stage C HFpEF: Recommendation

Recommendation for Hypertension in Stage C HFpEF

9.6. Sleep-Disordered Breathing: Recommendations

(Moved from Section 7.3.1.4, Treatment of Sleep Disorders in the 2013 HF guideline.)

Recommendations for Treatment of Sleep Disorders

ACC/AHA Task Force Members

Glenn N. Levine, MD, FACC, FAHA, Chair; Patrick T. O’Gara, MD, FACC, FAHA, Chair-Elect; Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair*; Sana M. Al-Khatib, MD, MHS, FACC, FAHA; Kim K. Birtcher, PharmD, MS, AACC; Biykem Bozkurt, MD, PhD, FACC, FAHA; Ralph G. Brindis, MD, MPH, MACC*; Joaquin E. Cigarroa, MD, FACC; Lesley H. Curtis, PhD, FAHA; Lee A. Fleisher, MD, FACC, FAHA; Federico Gentile, MD, FACC; Samuel Gidding, MD, FAHA; Mark A. Hlatky, MD, FACC; John Ikonomidis, MD, PhD, FAHA; José Joglar, MD, FACC, FAHA; Susan J. Pressler, PhD, RN, FAHA; Duminda N. Wijeysundera, MD, PhD

Presidents and Staff

American College of Cardiology

Mary Norine Walsh, MD, FACC, President

Shalom Jacobovitz, Chief Executive Officer

William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publishing

Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing

American College of Cardiology/American Heart Association

Katherine Sheehan, PhD, Director of Guideline Strategy and Operations

Lisa Bradfield, CAE, Director, Guideline Methodology and Policy

Abdul R. Abdullah, MD, Science and Medicine Advisor

Morgane Cibotti-Sun, MPH, Project Manager, Clinical Practice Guidelines

Sam Shahid, MBBS, MPH, Associate Science and Medicine Advisor

American Heart Association

Steven R. Houser, PhD, FAHA, President

Nancy Brown, Chief Executive Officer

Rose Marie Robertson, MD, FAHA, Chief Science and Medicine Officer

Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations

Jody Hundley, Production Manager, Scientific Publications, Office of Science Operations

* Former Task Force member; current member during the writing effort.

Footnotes

The American Heart Association requests that this document be cited as follows: Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, Drazner MH, Filippatos GS, Fonarow GC, Givertz MM, Hollenberg SM, Lindenfeld J, Masoudi FA, McBride PE, Peterson PN, Stevenson LW, Westlake C. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136:e137–e161. DOI: 10.1161/CIR.0000000000000509.

This document was approved by the American College of Cardiology Clinical Policy Approval Committee, the American Heart Association Science Advisory and Coordinating Committee, the American Heart Association Executive Committee, and the Heart Failure Society of America Executive Committee in April 2017.

The Comprehensive RWI Data Supplement table is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIR.0000000000000509/-/DC1.

The Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIR.0000000000000509/-/DC2.

This article has been copublished in the Journal of the American College of Cardiology and the Journal of Cardiac Failure.

Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (professional.heart.org), and the Heart Failure Society of America (www.hfsa.org). A copy of the document is available at http://professional.heart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843-216-2533 or e-mail .

Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://professional.heart.org/statements and select the “Policies and Development” link.

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page.

Circulation is available at http://circ.ahajournals.org.

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Appendix 1. Author Relationships With Industry and Other Entities (Relevant)—2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure (December 2015)

Committee MemberEmploymentConsultantSpeakers BureauOwnership/Partnership/PrincipalPersonal ResearchInstitutional, Organizational, or Other Financial BenefitExpert WitnessVoting Recusals By Section*
Clyde W. Yancy, ChairNorthwestern University Feinberg School of Medicine, Division of Cardiology—Professor of Medicine and Chief; Diversity and Inclusion—Vice DeanNoneNoneNoneNoneNoneNoneNone
Mariell Jessup, Vice ChairFondation Leducq—Chief Scientific OfficerNoneNoneNoneNoneNoneNoneNone
Biykem BozkurtBaylor College of Medicine, Department of Medicine—Professor of Medicine; Cardiology Section, DeBakey VA Medical Center—Chief; The Mary and Gordon Cain Chair & W.A. “Tex” and Deborah Moncrief, Jr.—Chair; Winters Center for Heart Failure Research—Director; Cardiovascular Research Institute—Associate DirectorNoneNoneNone• NovartisNoneNone7.3.2.10, 7.3.2.11, 7.3.3, and 9.5.
Javed ButlerStony Brook University—Division Chief of Cardiology• Bayer†• Boehringer Ingelheim• CardioCell†• Luitpold• Medtronic• Merck†• Novartis†• Relypsa†• Takeda• Trevena†• Z Pharma• Zensun• Novartis†None• Amgen (DSMB)†NoneNone7.3.2.10, 7.3.2.11, 7.3.3, and 9.5.
Donald E. Casey, JrThomas Jefferson College of Population Health— Faculty; Alvarez & Marsal IPO4Health—Principal and FounderNoneNoneNoneNoneNoneNoneNone
Monica M. ColvinUniversity of Michigan—Associate Professor of Medicine, CardiologyNoneNoneNoneNoneNoneNoneNone
Mark H. DraznerUniversity of Texas Southwestern Medical Center—Professor, Internal MedicineNoneNoneNoneNoneNoneNoneNone
Gerasimos S. FilippatosNational and Kapodistrian University of Athens; Attikon University Hospital, Department of Cardiology, Heart Failure Unit—Professor of CardiologyNoneNoneNone• Bayer†• Bayer (DSMB)• Novartis†• Servier Pharmaceuticals†• ViforNoneNone7.3.2.10, 7.3.2.11, 7.3.3, 9.2, and 9.5.
Gregg C. FonarowAhmanson-UCLA Cardiomyopathy Center—Director; UCLA Division of Cardiology—Co-Chief• Amgen• Janssen Pharmaceuticals• Novartis†NoneNone• Novartis†NoneNone7.3.2.10, 7.3.2.11, 7.3.3, and 9.5.
Michael M. GivertzBrigham and Women's Hospital—Professor of Medicine• Merck• NovartisNoneNoneNoneNoneNone7.3.2.10, 7.3.2.11, 7.3.3, and 9.5.
Steven M. HollenbergCooper University Hospital—Director, Coronary Care Unit, Professor of MedicineNoneNoneNoneNoneNoneNoneNone
JoAnn LindenfeldVanderbilt Heart and Vascular Institute—Director, Advanced Heart Failure and Transplant Section—Professor of Medicine• Abbott• Janssen Pharmaceuticals• Novartis• Relypsa†• ResMed†NoneNone• AstraZeneca• Novartis†NoneNone6.3, 7.3.2.10, 7.3.2.11, 7.3.3, 9.5, and 9.6.
Frederick A. MasoudiUniversity of Colorado, Anschutz Medical Campus—Professor of Medicine, Division of CardiologyNoneNoneNoneNoneNoneNoneNone
Patrick E. McBrideUniversity of Wisconsin School of Medicine and Public Health—Professor of Medicine and Family Medicine; Associate Director, Preventive CardiologyNoneNoneNoneNoneNoneNoneNone
Pamela N. PetersonUniversity of Colorado, Denver Health Medical Center—Associate Professor of Medicine, Division of CardiologyNoneNoneNoneNoneNoneNoneNone
Lynne Warner StevensonBrigham and Women’s Hospital Cardiovascular Division—Director, Cardiomyopathy and Heart Failure ProgramNoneNoneNone• Novartis—PARENT trial (PI)• NHLBI—INTERMACS (Co–PI)NoneNone7.3.2.10, 7.3.2.11, 7.3.3, and 9.5.
Cheryl WestlakeAzusa Pacific University, School of Nursing, Doctoral Programs—ProfessorNoneNoneNoneNoneNoneNoneNone

This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of ≥5% of the voting stock or share of the business entity, or ownership of ≥$5000 of the fair market value of the business entity, or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted.

According to the ACC/AHA, a person has a relevant relationship IF: a) The relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person’s household has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document.

*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply.

†Significant relationship.

ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; DCRI, Duke Clinical Research Institute; DSMB, data safety monitoring board; HFSA, Heart Failure Society of America; NHLBI, National Heart, Lung, and Blood Institute; INTERMACS, Interagency Registry for Mechanically Assisted Circulatory Support; PARENT, Pulmonary artery pressure reduction with entresto; UCLA, University of California, Los Angeles; and VA, Veterans Affairs.

Appendix 2. Reviewer Relationships With Industry and Other Entities (Comprehensive)—2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure (October 2016)

ReviewerRepresentationEmploymentConsultantSpeakers BureauOwnership/Partnership/PrincipalPersonal ResearchInstitutional, Organizational, or Other Financial BenefitExpert Witness
Kim K. BirtcherOfficial Reviewer—ACC/AHA Task Force on Clinical Practice GuidelinesUniversity of Houston College of Pharmacy—Clinical Professor• Jones & Bartlett LearningNoneNoneNoneNoneNone
Akshay S. DesaiOfficial Reviewer—HFSABrigham and Women’s Hospital—Director, Heart Failure Disease Management, Advanced Heart Disease Section, Cardiovascular Division; Associate Professor of Medicine, Harvard Medical School• Medscape Cardiology*• Merck• Novartis*• Relypsa*• St. Jude Medical*NoneNoneNone• Novartis*• ThoratecNone
Anita DeswalOfficial Reviewer—AHAMichael E. DeBakey VA Medical Center—Chief of Cardiology; Director, Heart Failure Program; Baylor College of Medicine—Professor of MedicineNoneNoneNone• NIH*• AHA• AHA (GWTG Steering Committee)†• HFSA†None
Dipti ItchhaporiaOfficial Reviewer—ACC Board of TrusteesNewport Coast Cardiology—Robert and Georgia Roth Endowed Chair for Excellence in Cardiac Care; Director of Disease ManagementNoneNoneNoneNone• St. Jude MedicalNone
Ileana L. PiñaOfficial Reviewer—AHAMontefiore Medical Center—Associate Chief for Academic Affairs, Cardiology; Professor of Medicine & Epidemiology and Population Health—Albert Einstein College of Medicine• RelypsaNoneNoneNoneNoneNone
Geetha RaghuveerOfficial Reviewer—ACC Board of GovernorsUniversity of Missouri-Kansas City School of Medicine—Professor of Pediatrics; Children's Mercy Hospital—Pediatric CardiologyNoneNoneNoneNoneNoneNone
James E. UdelsonOfficial Reviewer—HFSATufts Medical Center—Chief, Division of Cardiology• Lantheus Medical ImagingNoneNone• Gilead (DSMB)• GlaxoSmithKline (DSMB)• NHLBI• Otsuka• Abbott Laboratories• AHA*• Circulation/Circulation: Heart Failure†• HFSA (Executive Council)†• Pfizer/GlaxoSmithKline• Sunshine HeartNone
Mary Norine WalshOfficial Reviewer—ACC Board of TrusteesSt Vincent Heart Center of Indiana—Medical Director, Heart Failure and Cardiac TransplantationNoneNoneNoneNone• Corvia Medical• Otsuka• PCORI• ThoratecNone
David A. BaranOrganizational Reviewer—ISHLTNewark Beth Israel Medical Center—Director of Heart Failure and Transplant Research• Maquet• Otsuka*• NovartisNone• XDx*• NIH*NoneNone
Kenneth CaseyOrganizational Reviewer—CHESTWm. S. Middleton Memorial Veterans Hospital—Director, Sleep MedicineNoneNoneNoneNone• CHESTNone
M. Fuad JanOrganizational Reviewer—CHESTAurora Advanced Healthcare—CardiologistNoneNoneNoneNoneNoneNone
Kenneth W. LinOrganizational Reviewer—AAFPGeorgetown University School of Medicine—Clinician Educator Track, Associate ProfessorNoneNoneNoneNoneNoneNone
Joaquin E. CigarroaContent Reviewer—ACC/AHA Task Force on Clinical Practice GuidelinesOregon Health & Science University—Clinical Professor of MedicineNoneNoneNoneNone• ACC/AHA†• AHA†• ASA†• Catheterization and Cardiovascular Intervention†• NIH• Portland Metro Area AHA (President)†• SCAI Quality Interventional Council†None
Lee A. FleisherContent Reviewer—ACC/AHA Task Force on Clinical Practice GuidelinesUniversity of Pennsylvania Health System—Robert Dunning Dripps Professor of Anesthesiology and Critical Care; Chair, Department of Anesthesiology & Critical Care• Blue Cross/Blue Shield*• NQF†• Yale UniversityNoneNone• Johns Hopkins (DSMB)• Association of University Anesthesiologists†• NIHNone
Samuel S. GiddingContent Reviewer—ACC/AHA Task Force on Clinical Practice GuidelinesNemours/Alfred I. duPont Hospital for Children—Chief, Division of Pediatric Cardiology• FH Foundation†• International FH Foundation†NoneNone• FH Foundation†• NIH*NoneNone
James L. JanuzziContent ReviewerMassachusetts General Hospital—Hutter Family Professor of Medicine in the Field of Cardiology• Critical Diagnostics*• Novartis*• Phillips• Roche Diagnostics*• Sphingotec*NoneNone• Amgen (DSMB)• Boeringer Ingelheim (DSMB)*• Janssen Pharmaceuticals (DSMB)• Prevencio*NoneNone
José A. JoglarContent Reviewer—ACC/AHA Task Force on Clinical Practice GuidelinesUT Southwestern Medical Center—Professor of Internal Medicine; Clinical Cardiac Electrophysiology—Program DirectorNoneNoneNoneNoneNoneNone
Edward K. KasperContent ReviewerJohns Hopkins Cardiology—E. Cowles Andrus Professor in CardiologyNoneNoneNoneNoneNoneNone
Wayne C. LevyContent ReviewerUniversity of Washington—Professor of Medicine• Abbott Laboratories• Biotronik• GE Healthcare• HeartWare• PharminINNoneNone• NIH• Novartis*• St. Jude Medical*• Amgen*• AHA• HeartWare*• Novartis*• Resmed*• ThoratecNone
Judith E. MitchellContent ReviewerSUNY Downstate Medical Center—Director/Heart Failure Center; SUNY Downstate College of Medicine—Associate Professor of MedicineNoneNoneNoneNone• Association of Black Cardiologists†None
Sean P. PinneyContent Reviewer—ACC Heart Failure and Transplant CouncilMount Sinai School of Medicine—Associate Professor of Medicine, Cardiology• Acorda Therapeutics• Thoratec• XDxNoneNone• Thoratec†• NIH†NoneNone
Randall C. StarlingContent Reviewer—ACC Heart Failure and Transplant CouncilCleveland Clinic Department of Cardiovascular Medicine—Vice Chairman, Department of Cardiovascular Medicine; Section Head, Heart Failure & Cardiac Transplant• BioControl• Medtronic• NovartisNoneNone• Medtronic• NIH*• Novartis†• St. Jude Medical†• St. Jude MedicalNone
W.H. Wilson TangContent ReviewerCleveland Clinic Foundation—Assistant Professor of MedicineNoneNoneNone• NIH*• Alnylam Pharmaceuticals• NIH• NHLBI• Roche• Novartis• ThoratecNone
Emily J. TsaiContent ReviewerColumbia University College of Physicians & Surgeons—Assistant Professor of Medicine, Division of CardiologyNoneNoneNone• Bayer†• Bristol-Myers Squib†• NHLBI*NoneNone
Duminda N. WijeysunderaContent Reviewer—ACC/AHA Task Force on Clinical Practice GuidelinesLi Ka Shing Knowledge Institute of St. Michael’s Hospital—Scientist; University of Toronto—Assistant Professor, Department of Anesthesia and Institute of Health Policy Management and EvaluationNoneNoneNone• CIHR (DSMB)†• CIHR*• Heart and Stroke Foundation of Canada*• Ministry of Health & Long-term Care of Ontario*• PCORI DSMB)†NoneNone

This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review, including those not deemed to be relevant to this document. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of ≥5% of the voting stock or share of the business entity, or ownership of ≥$5000 of the fair market value of the business entity, or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review.

American College of Physicians did not provide a peer reviewer for this document.

*Significant relationship.

†No financial benefit.

AAFP indicates American Academy of Family Physicians; ACC, American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; ASA, American Stroke Association; CHEST, American College of Chest Physicians; CIHR, Canadian Institutes of Health Research; DSMB, data safety monitoring board; FH, familial hypercholesterolemia; GWTG, Get With The Guidelines; HFSA, Heart Failure Society of America; ISHLT, International Society for Heart and Lung Transplantation; NIH, National Institutes of Health; NHLBI, National Heart, Lung, and Blood Institute; NQF, National Quality Forum; PCORI, Patient-Centered Outcomes Research Institute; SCAI, Society for Cardiac Angiography and Interventions; SUNY, State University of New York; UT, University of Texas; and VA, Veterans Affairs.

Appendix 3. Abbreviations

ACE = angiotensin-converting enzyme
ARB = angiotensin-receptor blocker
ARNI = angiotensin receptor–neprilysin inhibitor
BNP = B-type natriuretic peptide
BP = blood pressure
COR = Class of Recommendation
CPAP = continuous positive airway pressure
EF = ejection fraction
GDMT = guideline-directed management and therapy
HFpEF = heart failure with preserved ejection fraction
HFrEF = heart failure with reduced ejection fraction
LOE = Level of Evidence
LVEF = left ventricular ejection fraction
NT-proBNP = N-terminal pro-B-type natriuretic peptide
QoL = quality of life
RCT = randomized controlled trial
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