ACC/AHA/HFSA 2022 and ESC 2021 guidelines on heart failure comparison

Abstract

The 2022 American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) and the 2021 European Society of Cardiology (ESC) both provide evidence‐based guides for the diagnosis and treatment of heart failure (HF). In this review, we aimed to compare recommendations suggested by these guidelines highlighting the differences and latest evidence mentioned in each of the guidelines. While the staging of HF depends on left ventricular ejection fraction, the Universal Definition of HF, suggested in 2021, is described in 2022 ACC/AHA/HFSA guidelines. Both guidelines recommend invasive and non‐invasive tests to diagnose. Despite being identical in the backbone, some differences exist in medical therapy and devices, which can be partially attributed to the recent trials published that are presented in the American guidelines. The recommendation of implantable cardioverter defibrillator for prevention in HF with reduced ejection fraction (HFrEF) patients, made by ACC/AHA/HFSA guidelines, is among the bold differences. It seems that ACC/AHA/HFSA guidelines emphasize the quality of life, cost‐effectiveness, and optimization of care given to patients. On the other hand, the ESC guidelines provide recommendations for certain comorbidities. This comparison can guide clinicians in choosing the proper approach for their own settings and the writing committees in addressing the differences in order to have better consistency in future guidelines.

Introduction

Heart failure (HF) is defined as any structural and/or functional impairment of cardiac blood ejection resulting in a complex clinical syndrome with typical symptoms and clinical signs. ¹ The increasing age of the world population, in addition to changes in lifestyle, has led to a higher incidence of cardiovascular diseases (CVDs) worldwide, and HF is not an exception. In the United States, HF incidence decreased from 35.7 per 1000 in 2011 to 26.5 per 1000 in 2016 among Medicare beneficiaries. ² The number of annual deaths from HF also increased in the country by about 13% from 2009 to 2014. ³ In Europe, the prevalence of HF was reported to be 1%–2%, ⁴ , ⁵ while its incidence was about 5/1000 person‐years in adults. ⁶ , ⁷ A large part of the world population has risk factors for HF. Coronary artery disease (CAD), hypertension, valve diseases, and arrhythmias are common causes of HF. ¹ , ⁸ Hypertension, obesity, atherosclerotic CVD, prediabetes, and diabetes are also major risk factors with high relative risk and high prevalence. ¹ , ⁹ In developing countries, there may be some additional aetiologies for HF, including valve disease and infective diseases (such as Chagas disease, Lyme disease, and HIV‐AIDS). Management of the aforementioned risk factors can play a crucial role in preventing and treating CVDs that lead to HF.

HF guidelines have been designed and used for several years in the United States and in Europe, intended to provide healthcare workers, especially physicians, with the newest literature regarding HF management and help them in decision making via the most up‐to‐date evidence. The European Society of Cardiology (ESC) guidelines published in 2021 and the American College of Cardiology/American Heart Association/Heart Failure Association of America (ACC/AHA/HFSA) guidelines published in 2022 are the latest evidence‐based clinical guidelines for the management of patients with HF. ¹ , ⁸ In this report, we aimed to compare these two guidelines and evaluate their consistencies and differences. The sections of interest for the present report embrace staging, evaluation and diagnosis, prevention, treatment of HF with reduced ejection fraction (HFrEF), treatment of HF with mildly reduced EF (HFmrEF), treatment of HF with preserved EF (HFpEF), advanced HF, acute HF, comorbidities, and special populations.

Staging

ACC/AHA/HFSA guidelines suggest four stages of HF based on the Universal Definition of HF. ¹⁰ As this was suggested after the release of the 2021 ESC guidelines, they lack this universal definition. Stage A refers to patients ‘at risk for HF’ without any symptoms, structural heart disease, or increased cardiac biomarkers of stretch or injury who have CVD risk factors such as hypertension, atherosclerosis, diabetes, metabolic syndrome, or obesity. Stage B is considered ‘pre‐HF’, which means that no symptoms or signs of HF are available, but one of the followings is present: (1) structural heart disease; (2) evidence for increased filling pressures; (3) patients with risk factors and increased levels of B‐type natriuretic peptide (BNP) or persistently elevated cardiac troponin. Patients with structural heart disease with current or previous symptoms of HF are known as ‘symptomatic HF’ and Stage C. ‘Advanced HF’ refers to patients with marked HF symptoms with recurrent hospitalizations despite their medical therapy, and their symptoms interfere with their daily lives. These patients are categorized as stage D.

Left ventricular ejection fraction (LVEF) was classically used to categorize patients diagnosed with HF. Based on both guidelines, HF can be classified into HFrEF, HFmrEF, and HFpEF. In the latest ACC/AHA/HFSA guidelines, HF with improved LVEF (HFimpEF) has been added to the list. Criteria for the classification of HF are available in Table 1 .

Table 1.

Heart failure classification criteria

Type of HF	ACC/AHA/HFSA criteria	ESC criteria
HFrEF	LVEF ≤ 40%	LVEF ≤ 40%
HFimpEF	Previous LVEF ≤ 40% and follow‐up LVEF > 40%	N/A
HFmrEF	LVEF 41%–49% and evidence of spontaneous or provokable increased LV filling pressures	LVEF 41%–49%
HFpEF	LVEF ≥ 50% and evidence of spontaneous or provokable increased LV filling pressures	LVEF ≥ 50% and objective evidence of cardiac structural and/or functional abnormalities consistent with the presence of LV diastolic dysfunction/raised LV filling pressures, including raised natriuretic peptides

HF, heart failure; HFimpEF, heart failure with improved ejection fraction; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LV, left ventricular; LVEF, left ventricular ejection fraction; N/A, not available.

Evaluation and diagnosis

The diagnostic approach is the same between ACC/AHA/HFSA 2022 and ESC 2021 guidelines with the clinical assessment, followed by natriuretic peptide measurement, echocardiography, staging, and treatment initiation (Figure  1 ). The diagnosis of HF is based on clinical signs and symptoms in addition to para‐clinical evaluations. History and physical examination still play a significant role in the diagnosis and provide information regarding the underlying mechanism for HF, including known cardiomyopathy with or without a positive family history, prior myocardial infarction, CAD, alcohol misuse, known cancer with cardiotoxic chemotherapy, chronic kidney disease (CKD), and diabetes mellitus; however, reduced accuracy of history and physical examination is seen when used alone. ¹¹ , ¹² The main signs observed are those related to congestion, such as jugular vein distension, orthopnoea, oedema, third heart sound, and hepatojugular reflex, in addition to symptoms including breathlessness, fatigue, and paroxysmal nocturnal dyspnea. ¹³ , ¹⁴

Figure 1.

Diagnostic algorithm for patients with suspected HF; ECG, electrocardiography; BNP, brain natriuretic factor; HFimpEF, heart failure with improved ejection fraction; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction.

A summary of the comparison between the guidelines' diagnostic evaluation methods is illustrated in Table 2 . Both guidelines emphasize the role of a thorough history and physical examination. Three‐generation family history for patients with cardiomyopathy, comprehensive history for finding specific causes of HF, and evaluation of the New York Heart Association (NYHA) class are among them. Both guidelines have similar requirements for 12‐lead electrocardiogram (ECG) and laboratory testing to rule out arrhythmias and myocardial injury. Chest X‐ray and transthoracic echocardiography (TTE) are recommended with the highest class of recommendation (CoR) in both ESC 2021 and ACC/AHA/HFSA 2022 guidelines. TTE is used to classify HF to HFrEF, HFmrEF, and HFpEF, as mentioned.

Table 2.

The comparison between guidelines diagnostic evaluation methods

Recommendation	AHA 2022	ESC 2021
History and physical examination	1	1
12‐lead ECG	1	1
Transthoracic echocardiography (TTE)	1	1
Repeating TTE in case of significant clinical change, or receiving GDMT	1
Chest X‐ray	1	1
Blood test	1	1
BNP/NT‐proBNP
Patients with dyspnoea for diagnosis or exclusion	1	1
Risk stratification and disease severity	1
Prognosis on HF admission	1
Preventing new‐onset HF in patients at risk via screening	2a
Pre‐discharge prognosis on admission	2a
Genetic screening in first‐degree relatives of patients with inherited cardiomyopathy	1
Genetic counselling in family of patients with non‐ischaemic cardiomyopathy	2a
CMR in patients with poor echocardiogram	1	1
CMR for tissue characterization		1
CMR to distinguish ischaemic or non‐ischaemic myocardial damage		2a
CMR for diagnosis or management	2a
CTCA in patients with low to intermediate pre‐test probability of CAD to rule out coronary stenosis		2a
Noninvasive stress imaging (stress echocardiography, single‐photon emission CT [SPECT], CMR, or positron emission tomography [PET]) for detection of ischaemia	2b	2b
Invasive coronary angiography in patients with angina despite pharmacological treatment		1
Invasive coronary angiography in patients with HFrEF with intermediate to high probability of CAD and ischaemia in non‐invasive stress test		2b
Endomyocardial Biopsy in patients with progressive symptoms or suspecting a specific diagnosis	2a	2a
Endomyocardial Biopsy in routine evaluation of HF	3
Assessment and documentation of NYHA classification for eligibility of treatment	1
Cardiopulmonary exercise testing (CPET) for evaluation for advanced treatment or heart transplant	1	1
Cardiopulmonary exercise testing (CPET) for assessment of functional capacity or prescribing training	2a	2a
Cardiopulmonary exercise testing (CPET) for identification of cause of dyspnoea	2a	2a
Right heart catheterization in severe HF for evaluation of heart transplant or mechanical circulatory support		1
Right heart catheterization in HF due to constrictive pericarditis, restrictive cardiomyopathy, congenital heart disease, and high output states.		2a
Right heart catheterization in patients with probable pulmonary hypertension for confirmation of diagnosis		2a
Right heart catheterization in HFpEF for confirmation of diagnosis		2b
Routine right heart haemodynamic monitoring for HF patients	3
Validated multivariable risk scores to predict risk of mortality	2a

AHA, American heart association; BNP, brain natriuretic peptide; CAD, coronary artery disease; CMR, cardiovascular magnetic resonance imaging; computed tomography coronary angiography; ECG, electrocardiogram; ESC, European society of cardiology; GDMT, guideline‐directed medical therapy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; NT, N‐terminal; NYHA, New York heart association.

The importance of BNP/NT‐proBNP is reported in both guidelines. They have high sensitivity in the emergency setting, thus ruling out HF. However, various cardiac and non‐cardiac causes can lead to their increase, such as acute coronary syndrome (ACS), myocarditis, valvular heart disease, anaemia, kidney disease, and pulmonary embolism. ¹⁵ , ¹⁶ The ACC/AHA/HFSA 2022 guidelines also recommend its measurement for risk stratification and establishment of prognosis. Genetic screening in first‐degree relatives of patients with inherited cardiomyopathy is advised in both guidelines; however, the ACC/AHA/HFSA 2022 guidelines recommended it with the highest CoR.

Cardiac magnetic resonance (CMR) imaging is highly recommended by both guidelines in situations where TTE is inadequate or of poor quality. However, the application of CMR is not confined to this in the ESC guidelines. Characterization of myocardial tissue morphology in suspected infiltrative disease, Fabry disease, and myocarditis, in addition to distinguishing ischaemic and non‐ischaemic myocardial damage in dilated cardiomyopathy (DCM), are other applications of CMR recommended by the ESC HF guidelines. ¹⁷ Computed tomography (CT) coronary angiography can be used in patients with angina despite pharmacological treatment, according to the ESC guidelines with CoR of IIa. However, non‐invasive stress imaging such as stress echocardiography, single‐photon emission CT (SPECT), and positron emission tomography (PET) are not strictly recommended and may be used for patients with CAD.

The ESC guidelines mainly describe invasive angiography for its application in patients with angina episodes and without clinical improvement after the administration of pharmacological treatment. Cardiopulmonary exercise testing (CPET) for evaluation of advanced treatment of HF or heart transplant is recommended with the highest CoR in both guidelines. At the same time, it may help to determine the cause of dyspnoea (IIa). Finally, although the ACC/AHA/HFSA 2022 guidelines indicate the likely effectiveness of endomyocardial biopsy in patients with progressive symptoms, just like the ESC guidelines, it questions its use as a routine diagnostic evaluation in patients with suspected HF, mainly due to its complications such as perforation, tamponade, and thrombus formation while providing not much additional value. ¹⁸ , ¹⁹

In summary, in terms of the diagnostic approach, the backbones of both guidelines are similar with regard to history taking and physical examination, natriuretic peptide testing, TTE, ECG, and routine blood tests. However, minor differences in particular situations with a concurrent disorder such as CAD are highlighted.

Prevention of patients at risk and pre‐HF

The ACC/AHA/HFSA guidelines suggest pharmacological and non‐pharmacological recommendations for patients at risk for HF and pre‐HF with different classes of recommendation; however, the ESC guidelines only provided preventive strategies as potential corrective actions in patients with risk factors for developing HF.

For the general population without risk factors of HF being present, ACC/AHA/HFSA and ESC suggested regular physical activity, healthy diet, maintaining a normal weight, smoking cessation, no/light alcohol intake, and influenza vaccination as primary strategies for preventing HF. In the ACC/AHA/HFSA guidelines and for the general population, validated multivariable risk scores, including Framingham Heart Failure Risk Score, ²⁰ Health ABC Heart Failure Score, ²¹ ARIC Risk Score, ²² and PCP‐HF ²³ are suggested as valuable tools to estimate the risk of HF incidence with a CoR of IIa.

The ACC/AHA/HFSA and ESC guidelines recommend strategies for populations with specific risk factors for HF, which are summarized in Table 3 . In a population in contact with infectious microorganisms, early diagnosis and use of antimicrobial therapy for the prevention and/or treatment are recommended in the ESC guidelines. Moreover, cardiac function assessment, side effect monitoring, and dose adaptation are recommended preventive strategies in populations using cardiotoxic drugs such as anthracyclines or chest radiation. ⁸ Hypertension as a risk factor for the incidence of HF should be controlled by lifestyle changes and antihypertensive therapy suggested by both guidelines (CoR of I in the ACC/AHA/HFSA guidelines). Physical activity, a healthy diet, and sodium‐glucose co‐transporter 2 (SGLT2) inhibitors are recommended for all patients with diabetes mellitus in the ESC guidelines. On the other hand, ACC/AHA/HFSA suggests the mentioned recommendations for patients with type 2 diabetes and either established CVD or high cardiovascular risk (CoR: I). The ACC/AHA/HFSA 2022 guidelines suggested natriuretic peptide biomarker screening and validated multivariable risk scores for patients at risk for HF (CoR: IIa). ESC recommends statin therapy, a healthy diet, and lifestyle changes for patients with dyslipidaemia or CAD.

Table 3.

Recommended strategies for populations with specific risk factors for heart failure

Risk factor	Recommendation	CoR
ACC/AHA/HFSA 2022
Hypertension	Optimal control of BP	1
Type 2 diabetes and CVD or high risk for CVD	SGLT2 inhibitors	1
CVDs	Optimal management of CVD	1
Exposure to cardiotoxic agents	Multidisciplinary evaluation for management	1
Cardiomyopathies in first‐degree relatives	Genetic screening and counselling	1
Patients at risk for HF	Natriuretic peptide biomarker screening	2a
Patients at risk for HF	Validated multivariable risk scores	2a
ESC 2021
Sedentary habit	Regular physical activity	NR
Smoking	Smoking cessation	NR
Obesity	Healthy diet and physical activity	NR
Excessive alcohol intake	Abstain from alcohol in patients with alcohol‐induced CMP and no/light intake in general population	NR
Influenza	Vaccination	NR
Microbes	Early diagnosis and antimicrobial therapy for either prevention and/or treatment	NR
Cardiotoxic drugs	Cardiac function and side effect monitoring, dose adaptation, and change of chemotherapy	NR
Chest radiation	Cardiac function and side effect monitoring, dose adaptation	NR
Hypertension	Lifestyle changes and anti‐hypertensive therapy	NR
Dyslipidaemia	Healthy diets and statin	NR
Diabetes mellitus	Physical activity, healthy diet, and SGLT2 inhibitors	NR
CAD	Lifestyle changes and statin	NR

AHA, American heart association; BP, blood pressure; CAD, coronary artery disease; CVD, cardiovascular disease; ESC, European society of cardiology; HF, heart failure; SGLT2, sodium‐glucose cotransporter‐2; NR, not reported.

Preventing the syndrome of clinical HF in patients with pre‐HF is discussed only in the ACC/AHA/HFSA guidelines. ACC/AHA/HFSA categorizes patients based on their LVEF, recent or remote (>40 days) MI or ACS history, and expected survival. Angiotensin‐converting enzyme inhibitors (ACEis) and beta‐blockers should be used to prevent symptomatic HF and reduce mortality in patients with LVEF ≤ 40%. In patients who are intolerant of ACEi, have a history of MI, and have an LVEF ≤ 40%, angiotensin (II) receptor blockers (ARBs) should be used. Other situations and relevant recommendations are available in Table 4 .

Table 4.

Recommendations for patients with pre heart failure

Recommendation	AHA 2022
ACE inhibitors in patients with LVEF ≤40% to prevent HF and reduce mortality	1
Statins in patients with history of MI or ACS to prevent HF and adverse cardiovascular events	1
ARB in patients with recent MI, LVEF ≤40%, and intolerant to ACE inhibitors to prevent HF and reduce mortality	1
Beta blockers in patients with history of MI or ACS, and LVEF ≤40% to reduce mortality	1
ICD for primary prevention of sudden cardiac death in patients have a history of remote MI (>40 days), LVEF ≤30%, NYHA class I while receiving GDMT and expected survival >1 year to reduce mortality	1
Beta blockers in patients with LVEF ≤40% to prevent HF	1
Avoid to use thiazolidinediones in patients with LVEF <50% because they increase the risk of HF and hospitalization.	3 (H)
Nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful in patients with LVEF <50%	3 (H)

AHA, American heart association; ACE, angiotensin‐converting enzyme; LVEF, left ventricular ejection fraction; ARB, angiotensin receptor blocker; ASC, acute coronary syndrome; ICD, implantable cardioverter‐defibrillator; GDMT, guideline‐directed medical therapy; HF, heart failure; MI, myocardial infarction; NYHA, New York heart association; H, harm.

HFrEF treatment

Pharmacological therapy is the backbone of HFrEF treatment. The overall structure of pharmacological treatment is almost the same in both guidelines, presenting commonly prescribed medical agents for HF patients. These findings are mainly based on large‐scale clinical trials conducted in patients with HFrEF.

The summary of CoR for medications suggested for HF is illustrated in Table 5 . Loop diuretics can be used for patients with symptoms of congestion, while the ACC/AHA/HFSA 2022 guidelines indicate the addition of thiazide diuretics to loop diuretics in case of non‐response. Similarly, the ESC guidelines mentioned the synergistic effect of the combination of thiazide and loop diuretics for HFrEF patients with diuretic resistance.

Table 5.

Summary of CoR for medications suggested for HFrEF

Recommendation	AHA 2022	ESC 2021
Diuretics for patients with fluid retention in order to relieve congestion and improve symptoms	1	1
Addition of thiazide to a loop diuretic with decreased response to moderate or high‐dose loop diuretics	1
ARNi in patients to reduce mortality and morbidity (in ESC in replacement of ACEi)	1	1
ACEi to reduce HFrEF hospitalization and death (in AHA when ARNi not possible)	1	1
ARB for patients who cannot tolerate ACEi (cough or angioedema) or ARNi in order to reduce mortality and morbidity	1	1
ARNi to replace ACEi or ARB to further reduce mortality and morbidity	1	1
One of three beta‐blockers (bisoprolol, carvedilol and sustained release succinate) to reduce mortality	1
A beta‐blocker to reduce risk of HF hospitalization and death		1
MRA in patients with HFrEF to reduce hospitalization and death	1	1
MRA is not indicated in patients whose serum potassium cannot be maintained <5.5 meq/L	3
SGLT2 inhibitors to reduce hospitalization and death related to HF, irrespective of presence of type 2 diabetes	1	1
Hydralazine and isosorbide dinitrate in African American patients with NYHA III/IV who are receiving optimal therapy to reduce mortality and morbidity	1	2a
Hydralazine and isosorbide dinitrate in patients with intolerance to ACEi, ARB or ARNi to reduce death rate	2b	2b
PUFA supplementation in HF patients with NYHA II/IV as adjunctive therapy to reduce mortality and hospitalization	2b
Potassium binders (patiromer, sodium zirconium cyclosilicate) in HF patients with hyperkalaemia while taking RAAS inhibitor	2b
Anticoagulation in patients with HFrEF without specific indication	3 (NB)
Dihydropyridine CCB for HFrEF	3 (NB)
Vitamins, nutritional supplements and hormonal therapy other than deficiencies	3 (NB)
Ivabridine for HF patients with HR ≥ 70 bpm at rest despite beta‐blockers, ACEi and MRA to reduce mortality and morbidity	2a	2a
Ivabridine for HF patients with contraindications for beta blockers and resting HR ≥ 70 bpm to reduce CV hospitalization and death, ACEi and MRA should still be used	2a
Digoxin for patients with sinus rhythm to reduce HF hospitalizations	2b	2b
Vericiguat for patients with NYHA II‐IV with worsening symptoms HF despite treatment with an ACEi or ARNi, a bet‐blocker and MRA to reduce the risk of CV mortality	2b	2b

ACEi, angiotensin‐converting enzyme inhibitor; AHA, American heart association; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor‐neprilysin inhibitor; CCB, calcium channel blockers; CV, cardiovascular; ESC, European society of cardiology; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; HR, heart rate; MRA, mineralocorticoid receptor antagonists; NB, no benefit; NYHA, New York heart association; PUFA, polyunsaturated fatty acids; RAAS, renin‐angiotensin‐aldosterone system; SGLT2, sodium‐glucose cotransporter‐2.

While being massively used by physicians, ACEis are recommended by the ESC as the first line. This is also advised by ACC/AHA/HFSA as an alternative for angiotensin receptor–neprilysin inhibitor (ARNi) when not possible. The use and efficacy of ARNis have increased in HF management, compared with previous guidelines. ²⁴ , ²⁵ Additional benefits of ARNis are mentioned in ESC guidelines, including improvement of quality of life, reduction of diabetes incidence, slowing down the drop in eGFR, and reduced rate of hyperkalaemia. ²⁶ , ²⁷ , ²⁸ , ²⁹ The only currently available ARNi is composed of the ARB valsartan and the inhibitor of neprilysin sacubitril, as in the large trial of PARADIGM‐HF, its efficacy was reported to be higher than that of enalapril. ²⁶ ARBs also can be used as a substitute for ACEis and ARNIs. Beta‐blockers, specifically bisoprolol, carvedilol, and sustained‐release metoprolol succinate, can be prescribed to reduce HF hospitalization and mortality in HFrEF patients. The addition of mineralocorticoid receptor antagonists (MRAs) such as spironolactone and eplerenone is mentioned in both guidelines; however, caution should be exercised in patients with impaired renal function and hyperkalaemia (K > 5 meq/L). SGLT2 inhibitors, first used as anti‐diabetic medications, have proven to have beneficial effects on cardiovascular death and HF irrespective of the presence of diabetes. ³⁰ , ³¹ They are highly recommended in both ESC and ACC/AHA/HFSA guidelines. The ACC/AHA/HFSA guidelines emphasize using hydralazine and isosorbide dinitrate in African American patients with NYHIII/IV who receive optimal therapy to reduce mortality and morbidity (CoR: I). On the other hand, according to the ESC guidelines, it also should be considered in this population with lower CoR (IIa).

Omega‐3 polyunsaturated fatty acid (PUFA) supplementation and potassium binders are only mentioned in the American guidelines and might be helpful for HFrEF patients (CoR: IIb). Ivabradine, an I_f channel blocker in the sinoatrial node whose use results in heart rate reduction, is recommended with a CoR of IIa in patients with LVEF ≤35% and a resting heart rate ≥70 bpm despite high‐dose beta‐blocker therapy. Finally, digoxin might benefit HFrEF patients with normal sinus rhythm despite optimal therapy (CoR of IIb in both guidelines).

The titration of guideline‐directed medical therapy (GDMT) to achieve target doses is recommended by the ACC/AHA/HFSA guidelines for HF (CoR: I), while there is also a recommendation for up‐titration to the dose recommended by clinical trials in the ESC guidelines. In contrast, its more frequent dose management should be considered every 1 to 2 weeks (CoR: IIa). It should be noted that in GDMT, the target dose should be achieved even if improved symptoms are observed already at lower doses.

Implantable cardioverter‐defibrillators (ICDs) are indicated in HFrEF patients with ischaemic heart disease, LVEF≤35%, and NYHA II/III with an expected survival of >1 year, due to both guidelines. In ACC/AHA/HFSA criteria, ICDs are suggested for patients with NYHA I class, at least 40‐days post‐MI and LVEF ≤30% with the same expected survival of >1 year to reduce the risk of sudden cardiac death and overall mortality. However, the ESC guidelines mention ICD implantation for patients recovering from ventricular arrhythmia and causing haemodynamic instability. For better clarification, all indications for ICD implantation based on both criteria and their comparison are summarized in Table 6 .

Table 6.

Indications for ICD and CRT based on both criteria and their comparison

Recommendation	AHA 2022	ESC 2021
ICD therapy for non‐ischaemic DCM or ischaemic heart disease, LVEF ≤35% and NYHA III/IV with expected good functional survival of >1 year to reduce SCD and mortality	1	1
ICD for patients at least 40‐days post MI, LVEF ≤30% and NYHA I with expected good functional survival of >1 year to reduce SCD and mortality	1
ICD for patients recovering from a ventricular arrhythmia causing haemodynamic instability with expected good functional survival of >1 year to reduce SCD and mortality, unless arrhythmia occurred <48 h after MI		1
ICD for patients with arrhythmogenic cardiomyopathy with high risk of SCD and LVEF ≤45%, to reduce SCD	2a
ICD for patients with symptomatic HF of a non‐ischaemic aetiology and LVEF ≤35% with expected good functional survival of >1 year to reduce SCD and mortality		2a
Wearable ICD in patients at risk of SCD as a bridge to an implanted device		2b
ICD for patients within 40 days of MI does not improve prognosis		3
ICD for HF patients with NYHA IV with severe symptoms refractory to pharmacological therapy		3
ICD is not recommended for patients whose comorbidities or frailty limit survival with good functional capacity to <1 year	3
CRT for patients who have LVEF ≤35%, sinus rhythm, left bundle branch block (LBBB) with a QRS duration ≥150 ms, and NYHA class II, III, or ambulatory IV symptoms to reduce mortality, hospitalization and improve symptoms	1	1
CRT rather than RV pacing is recommended for patients with HFrEF regardless of NYHA class or QRS width who have an indication for ventricular pacing for high degree AV block in order to reduce morbidity, including patients with AF	2a	1
CRT in patients with high‐degree or complete heart block and LVEF between 36% and 50% to reduce mortality, hospitalization and improve symptoms	2a
CRT for patients who have LVEF ≤35%, sinus rhythm, non‐left bundle branch block (LBBB) QRS morphology, QRS duration ≥150 ms, and NYHA class II, III, or ambulatory IV symptoms to reduce mortality and morbidity	2a	2a
CRT for HF patients with LVEF ≤35%, sinus rhythm, LBBB with a QRS duration of 120 to 149 ms, and NYHA class II, III, or ambulatory IV symptoms to reduce mortality, hospitalization and improve symptoms and QoL	2a	2a
CRT who has LVEF ≤35% and are undergoing placement of a new or replacement device implantation with anticipated requirement for significant (>40%) ventricular pacing, CRT can be useful to reduce total mortality, reduce hospitalizations, and improve symptoms and QoL	2a	2a
CRT for HF patients with LVEF ≤35%, sinus rhythm, non‐LBBB pattern with a QRS duration of 120 to 149 ms, and NYHA class II, III, or ambulatory IV symptoms to reduce mortality, hospitalization and improve symptoms and QoL	2b	2b
CRT for patients who have LVEF ≤30%, ischaemic cause of HF, sinus rhythm, LBBB with a QRS duration ≥150 ms, and NYHA class I symptoms to reduce symptoms and decrease hospitalization rate	2b
CRT is not recommended for patients with QRS duration of <120 ms	3 (NB)
CRT is not recommended in patients with a QRS duration <130 ms who do not have an indication for pacing due to high degree AV block		3
CRT is not recommended for patients with NYHA class I or II symptoms and non‐LBBB pattern with QRS duration <150 ms	3 (NB)
CRT is not recommended for patients whose comorbidities or frailty limit survival with good functional capacity to <1 year	3 (NB)

AHA, American heart association; AV, atrioventricular; CRT, cardiac resynchronization therapy; DCM, dilated cardiomyopathy; ESC, European society of cardiology; ICD, implantable cardioverter‐defibrillator; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NB, no benefit; NYHA, New York heart association; QoL, quality of life; QRS, HFrEF, heart failure with reduced ejection fraction; RV, right ventricle; SCD, sickle cell disease.

Cardiac resynchronization therapy (CRT) is strongly advised by both guidelines in cases of LVEF ≤35%, left bundle branch block (LBBB), QRS duration of more than 150 ms, and in the presence of sinus rhythm. The ESC guidelines emphasize the administration of CRT for patients requiring right ventricular pacing, while CoR in ACC/AHA/HFSA is IIa. In cases with a non‐LBBB pattern and QRS duration >150 ms or LBBB with QRS duration of 120 to 149, CRT should be considered, similarly in both guidelines. The cut‐off for QRS duration for not indicating CRT is <120 ms in the ACC/AHA/HFSA guidelines and <130 ms in the ESC guidelines.

Non‐pharmacological management of HFrEF is extensively described in the ACC/AHA/HFSA guidelines. Affected patients should receive care from multidisciplinary teams to facilitate the implementation of GDMT, in addition to specific education and support to facilitate HF self‐care (CoR: I). Moreover, vaccination against respiratory illnesses and screening for depression, social isolation, frailty, and low literacy should be considered (CoR: IIa). ACC/AHA/HFSA recommends dietary sodium restriction of <2300 mg/day to reduce congestion. ³² However, it is mentioned that currently, there is no trial to support this level. ³³ Finally, exercise is strongly suggested in patients who can participate, while cardiac rehabilitation can be helpful for them (CoR: IIa). There is a thorough discussion in the ESC guidelines, as well. Multidisciplinary HF management programmes, self‐management strategies, and exercise to improve quality of life were all recommended as CoR I. Influenza and pneumococcal vaccines and supervised exercise‐based cardiac rehabilitation programmes are also highly suggested by the European guidelines (CoR: IIa).

HFmrEF treatment

HF with mildly reduced EF (HFmrEF) is diagnosed in the presence of HF signs and symptoms and/or mildly reduced LVEF (41%–49%), while elevated natriuretic peptides (NPs), and other evidence of structural heart disease make the diagnosis more probable based on the ESC guidelines definition. Up to now, there are no prospective RCTs to evaluate treatment and prognosis specifically in patients with HFmrEF; however, subset and post‐hoc analyses from previous high‐quality studies gathered required data in these patients. HFmrEF is more similar, especially in lower LVEF (near 41%), to HFrEF than HFpEF. Thus, the management of HFmrEF is very similar to HFrEF even though the evidence base for the recommendations is less robust.

The summary of recommendations and CoR for HFmrEF is available in Table 7 . ACC/AHA/HFSA and ESC recommend diuretics as needed to alleviate symptoms and signs (CoR: I). SGLT2 inhibitors are recommended in ACC/AHA/HFSA with CoR of IIa, without being mentioned in the ESC guidelines. As both guidelines suggest, an ACEi, ARB, beta‐blocker, MRA, or ARNI may reduce the risk of HF hospitalization and death (CoR: IIb).

Table 7.

Summary of recommendations and CoR for HFmrEF

Recommendation	AHA 2022	ESC 2021
Diuretics are recommended in patients with congestion to alleviate symptoms and signs	1	1
SGLT2 inhibitors are recommended to decrease the risk of hospitalizations and cardiovascular mortality	2a
ACE inhibitors are recommended to reduce risk of hospitalizations and death	2b	2b
ARBs are recommended to reduce risk of hospitalizations and death	2b	2b
ARN inhibitors (sacubitril/valsartan) are recommended to reduce the risk of hospitalizations and death	2b	2b
MRAs are recommended to reduce the risk of hospitalizations and death	2b	2b
Beta‐blockers are recommended to reduce the risk of hospitalizations and death	2b	2b

ACE, angiotensin‐converting‐enzyme; AHA, American Heart Association; ARB, angiotensin II receptor blocker; ARN, angiotensin receptor neprilysin; ESC, European Society of Cardiology; MRA, mineralocorticoid receptor antagonists; SGLT2, sodium‐glucose cotransporter‐2.

As the term HFimpEF was only defined in ACC/AHA/HFSA guidelines, the only recommendation for these patients is continuing GDMT in order to prevent relapse of HF and LV dysfunction (CoR: I). This should be performed even if the patient becomes asymptomatic, while in the ones without improvement, GDMT should be optimized.

HFpEF treatment

The management of this group of patients is limited as there is no definite pharmacological therapy, and the medication therapy is mainly based on symptom management. Both guidelines highly recommend the management of hypertension according to guidelines to reach blood pressure targets (CoR: I). Screening and treatment of both cardiovascular and non‐cardiovascular (CV) comorbidities are mentioned in the ESC guidelines because these are more common in patients with HFpEF than in HFrEF. ³⁴ These include atrial fibrillation (AF), CKD, and non‐CV comorbidities, among which the ESC guidelines emphasize the consideration of AF treatment with anticoagulation treatment with the highest CoR. Diuretics are also indicated to reduce congestion, as suggested by both guidelines. The case for SGLT2 inhibitors is quite interesting. While the ACC/AHA/HFSA guidelines recommend considering SGLT2 inhibitors in all HF patients (CoR: IIa), ESC only suggests their administration in diabetic HF patients (CoR: I). However, the ESC guidelines was published only shortly after the publication of the results of the EMPEROR‐Preserved trial (empagliflozin vs. placebo in patients with HFpEF) ³⁵ ; thus, the usage of this publication fell just outside the review timeframe to be considered for guideline recommendations by the ESC.

Statin therapy for patients at high risk of CV disease is the other mentioned recommendation for HFpEF patients. MRAs, ARBs, and ARNIs may be beneficial for patients in the lower spectrum of LVEF to reduce hospitalization, according to the ACC/AHA/HFSA 2022 guidelines. Finally, as the ACC/AHA/HFSA guidelines suggest, although nitrates seem to benefit patients with HFrEF by reducing pulmonary congestion and improving exercise tolerance, no such evidence of efficacy was observed in HFpEF patients. ³⁶ The same is true for phosphodiesterase‐5 inhibitors, which showed no improvement in oxygen consumption or exercise tolerance in this population. ³⁷ The summary of CoR for medications suggested for HFpEF is illustrated in Table 8 .

Table 8.

The summary of CoR for medications suggested for HFpEF

Recommendation	AHA 2022	ESC 2021
Hypertension management to achieve blood pressure targets in clinical practice guidelines	1	1
Screening, and treatment of aetiologies and cardiovascular and non‐cardiovascular comorbidities		1
Diuretics in congested patients	1	1
SGLT2 inhibitors in diabetic patients for decreasing HF hospitalizations		1
SGLT2 inhibitors for decreasing HF hospitalizations and CV mortality	2a
Statins for patients at high risk of CV disease		1
AF treatment in order to improve symptoms	2a
MRAs to reduce hospitalization, particularly among patients with lower LVEF	2b
ARBs to reduce hospitalization, particularly among patients with lower LVEF	2b
ARNIs to reduce hospitalization, particularly among patients with lower LVEF	2b
Routine use of nitrates or phosphodiesterase‐5 inhibitors to increase activity	3

AF, atrial fibrillation; AHA, American Heart Association; ARB, angiotensin II receptor blocker; ARN, angiotensin receptor neprilysin; CV, cardiovascular; ESC, European Society of Cardiology; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonists; SGLT2, sodium‐glucose cotransporter‐2.

Advanced heart failure

According to the definition proposed by ESC in 2018, the main focus for diagnosing advanced HF is refractory symptoms despite maximal therapy, not necessarily reduced LVEF. In addition, other organ failure may also be present, but this is not mandatory. ³⁸ Seven profiles were defined by the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) for the stratification of patients with advanced HF. ³⁹ As described in both guidelines, these profiles can be used to assess the prognosis of the patients undergoing urgent heart transplantation or LV assist device (LVAD) implantation. ⁴⁰ , ⁴¹ The most critical point in this population is identifying warning signs, as they often refer to medical care late. ⁴² The summary of recommended management points according to both guidelines is illustrated in Table 9 .

Table 9.

Advanced heart failure management

Recommendation	AHA 2022	ESC 2021
Heart transplantation for advanced HF, refractory to medical/device therapy and without contraindication	1	1
Good compliance and appropriate capacity for device handling and psychosocial support for patients being considered for long‐term MCS		1
Long‐term MCS in advanced HF patients to improve functional class and reduce mortality	2a	2a
MCS in advanced HF patients to be considered as a bridge to cardiac transplantation or to improve symptoms	2a	2a
Renal replacement therapy		2b
Fluid restriction in patients with advanced HF and hyponatremia	2b
Inotropes and vasopressors as a bridge to MCS or heart transplantation	2a	2a
Inotropes and vasopressors as a palliative therapy in ineligible patients for MCS or cardiac transplantation	2b

AHA, American Heart Association; ESC, European Society of Cardiology; HF, heart failure; MCS, mechanical circulatory support;

Acute heart failure

Acute HF (AHF) is a sudden or gradual onset of symptoms severe enough for patients to seek urgent medical attention. AHF can be a sign of new‐onset HF or acute chronic HF decompensation. Diagnostic tools available are ECG, echocardiography, and plasma NPs. Normal concentrations of NPs with no signs on ECG and imaging can rule out AHF. The most common presentations with which patients can refer to the medical team are acute decompensated HF, acute pulmonary oedema, isolated right ventricular failure, and cardiogenic shock. ⁸

Diuretics for congestion resolution and thromboembolism prophylaxis are highly recommended by both guidelines (CoR: I), while vasodilators may be beneficial (CoR: IIa). One of the main differences among them may be the administration of intravenous inotropic agents, considered the first line in cardiogenic shock patients according to ACC/AHA/HFSA guidelines to maintain systemic perfusion and preserve end‐organ performance. However, ESC recommends possible beneficial effects of it in patients not responding to the fluid challenge and after it (CoR: IIa). Short‐term mechanical circulatory support (MCS) should be considered, as suggested by both guidelines (CoR: IIa), as a bridge treatment and to support the end‐organ perfusion. ⁴³ The ACC/AHA/HFSA guidelines emphasize maintenance and optimization of GDMT in affected patients at least after discharge or reaching a stable state. Similarly, the European guidelines suggest the up‐titration of optimal medical therapy. At last, the ESC guidelines recommend that patients' oral treatment be modified to lower the risk of 30‐day readmission episodes, as proven by different studies. ⁴⁴ , ⁴⁵ Table 10 illustrates all recommended management recommendations for patients with AHF.

Table 10.

Acute heart failure management

Recommendation	AHA 2022	ESC 2021
Diuretics for patients with acute HF with the evidence of fluid overload	1	1
Diuretics in addition to guideline‐directed medical therapy to reduce congestion	1
Diuretics and adjustment of treatment for patients discharging from the hospital in order to resolve congestion	1	1
Second diuretic (thiazide) or higher doses of loop diuretics for patients with inadequate response to normal diuretic regimen during hospitalization	2a	2a
Vasodilators such as venous nitroglycerin or nitroprusside to reduce congestion	2b	2b
Thromboembolism prophylaxis with anticoagulant agents (e.g., LMWH) to reduce deep venous thrombosis and pulmonary embolism	1	1
Inotropic agents for patients with sign of cardiogenic shock	1
Inotropic agents for patients with SBP < 90 mmHg and evidence of hypoperfusion refractory to fluid challenge		2b
Inotropic agents should not be routinely used unless symptomatic hypotension		3
Short term MCS in cardiogenic shock patients as a bridge	2a	2a
Temporary MCS in cases where there is no initial rapid response to shock MCS may be considered	2b
Multidisciplinary management of cardiogenic shock	2a
Intra‐aortic Balloon Pump in cardiogenic shock patients as a bridge		2b
Intra‐aortic Balloon Pump is not routinely recommended in post‐MI cardiogenic shock		3
PA line for patients with cardiogenic shock in order to define haemodynamic subsets and management strategies	2b
Vasopressors, preferably norepinephrine, may be considered in patients with cardiogenic shock to increase blood pressure		2b
Opiates should not be routinely recommended unless in patients with severe pain or anxiety		3
Oxygen for patients with SpO2 < 90%		1
Intubation in progressive respiratory failure despite oxygen administration		1
Non‐invasive positive pressure ventilation in patients with respiratory distress		2a
GDMT should be retained and further optimized	1
Referral to multidisciplinary HF disease management programmes for those with HFrEF particularly those with recurrent hospitalization for HF	1
Patient‐centred discharge instructions with a clear plan for transitional care before discharge	1
Early follow‐up visits are recommended at 1–2 weeks after discharge		1
Ferric carboxymaltose for patients with iron deficiency		1

AHA, American Heart Association; ESC, European society of cardiology; GDMT, guideline‐directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LMWH, low molecular weight heparin; MI, myocardial infarction; PA, pulmonary artery; SBP, systolic blood pressure; SpO₂, oxygen saturation.

Comorbidities

Both cardiac and non‐cardiac comorbidities are well established in the ESC 2021 guidelines, while ACC/AHA/HFSA mainly focuses on CV comorbidities. Hypertension is the most frequent comorbidity in all adults, as discussed in the ACC/AHA/HFSA 2022 guidelines (84.2% in age ≥65 and 80.7 in age <65). ischaemic heart disease, hyperlipidaemia, anaemia, diabetes, and arthritis are the most common comorbidities after hypertension.

There are several CV comorbidities known in patients with HF. Arrhythmias and conduction disturbances, chronic coronary syndromes, valvular heart disease, and stroke are major comorbidities that frequently coexist with HF. In patients with AF and HF, in addition to a CHA₂DS₂‐VASc score ≥2 in men and ≥3 in women, chronic anticoagulant therapy is suggested as the main therapy with CoR I in both guidelines. Moreover, DOACs are preferred over warfarin in eligible patients (CoR: I). Beta‐blockers and digoxin are highly recommended by the European guidelines (CoR: IIa) for rate control in AF patients. With the support of trials, both guidelines suggest AF catheter ablation in case of a clear association between AF and worsening HF and tolerance to medical therapy. ⁴⁶ , ⁴⁷ , ⁴⁸

The ACC/AHA/HFSA 2022 guidelines suggested surgical revascularization for HF patients with CAD and LVEF ≤35% and suitable coronary anatomy (CoR: I). Similarly, the ESC 2021 guidelines considered CABG as the first‐choice therapy in all patients eligible for surgery, especially if they have a multi‐vessel disease or are diabetic (CoR: IIa).

Valvular heart disease (VHD) comorbidities are described in both guidelines, more specifically in the ESC guidelines. First, GDMT applies to all HFrEF patients, with or without VHD. ACC/AHA/HFSA specifically addresses multidisciplinary management of VHD to prevent HF worsening and adverse clinical outcomes (CoR: I). According to the American guidelines, secondary mitral regurgitation also should be treated by optimization of GDMT before any intervention targeting it. On the contrary, the European guidelines suggest percutaneous edge‐to‐edge mitral valve repair in case of not eligible for surgery and not needing coronary revascularization (CoR: IIa). Aortic stenosis was also suggested to be managed via transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR), based on shared decision making, indications, and assessment, in patients with HF and severe high‐gradient aortic stenosis (CoR: I in ESC guidelines).

Up‐titration of GDMT to the maximally tolerated dose was recommended by the ACC/AHA/HFSA for hypertensive patients with HFrEF. The ESC 2021 guidelines suggest the same treatment strategy for hypertension in HFrEF and HFpEF. This strategy includes neurohormonal antagonists, diuretics, and lifestyle modification, including weight loss, reduced sodium intake, and physical activity. Finally, stroke was described as frequent comorbidity in the ESC 2021 guidelines due to the overlap of shared risk factors.

Diabetes, cancer, iron deficiency and anaemia, and sleep‐disordered breathing are mentioned as non‐cardiac comorbidities of HF in the ACC/AHA/HFSA 2022 guidelines. The ESC 2021 guidelines mention thyroid disorders, obesity, cachexia, sarcopenia, frailty, kidney dysfunction, electrolyte disorders, hyperlipidaemia, gout and arthritis, erectile dysfunction, depression, and infection. Both guidelines suggest SGLT2i in diabetic patients to manage hyperglycaemia (CoR: I). The ACC/AHA/HFSA 2022 guidelines recommend multidisciplinary management for cancer comorbidity, while the ESC mentions anthracycline chemotherapy, HER2‐targeted therapies, vascular endothelial growth factor (VEGF) inhibitors, multi‐targeted kinase inhibitors, proteasome inhibitors, immunomodulatory drugs, combination RAF and MEK inhibitors, androgen deprivation therapies, and immune checkpoint inhibitors as potential cancer drugs causing LV dysfunction or HF due to their cardiotoxic potential. ESC recommends that all patients with HF be screened periodically for anaemia and iron deficiency (CoR: I). Both guidelines suggest intravenous iron supplements for iron‐deficient HFrEF patients, with the ESC guidelines specifically mentioning ferric carboxymaltose (CoR: IIa). Moreover, ACC/AHA/HFSA suggests avoidance of erythropoietin‐stimulating agents in patients with HF and anaemia (CoR: III; harm). They also suggest a formal sleep study in patients with HF and suspicion of sleep‐disordered breathing (CoR: IIa) and continuous positive airway pressure (CPAP) for patients diagnosed with obstructive sleep apnoea (CoR: IIa). Other comorbidities mentioned in the ESC 2021 guidelines should be treated the same as in a non‐HF population.

Special populations

Descriptions of the management of HF in special populations are provided in both guidelines. The ACC/AHA/HFSA guidelines emphasize HF risk assessment and multidisciplinary management strategies to reduce outcome disparities when a specific population is at risk for health disparity, such as Black and Hispanic patients, women, the elderly, Asian populations, Native American populations, and patients with lower socioeconomic status (CoR: I).

The next special population discussed in the guidelines includes cardio‐oncology cases. In patients developing cancer therapy‐related cardiomyopathies, the multidisciplinary discussion about cancer therapy interruption, discontinuation, or continuation options is highly recommended. In addition, cancer‐related cardiomyopathies can be treated with ARB, ACEis, and beta‐blockers to prevent HF (CoR: IIa according to both guidelines). In patients with CV risk factors that may be the subject of cardiotoxic anticancer therapy, evaluation of baseline cardiac function and identification of drug‐induced cardiomyopathies should be considered (CoR: IIa, similar in both guidelines). Moreover, the ESC guidelines highly recommend CV evaluation of these patients at increased risk before cancer therapy (CoR: I).

HF can considerably complicate pregnancy as women with pre‐existing HF are at higher risk of CV problems during the course of their pregnancy. ⁴⁹ , ⁵⁰ First, in these populations, patient‐centred counselling regarding contraception, and all the risks should be provided, as suggested by the ACC/AHA/HFSA guidelines (CoR: I). Second, all ACEi, ARB, ARNi, MRA, SGLT2i, ivabradine, and vericiguat medications are highly contraindicated by both guidelines during pregnancy due to their teratogenic potential. However, beta‐blockers can be continued, preferably a beta‐1‐selective one such as bisoprolol or metoprolol. Third, as pregnancy is a hypercoagulable state, patients with concurrent AF should be given low‐molecular‐weight heparin in the first and last trimesters. The ACC/AHA/HFSA guidelines also recommend (CoR: IIb) anticoagulation until 6–8 weeks postpartum, although the efficacy and safety are not established well.

Other mentioned populations described in the ESC guidelines are those with cardiomyopathies, left ventricular non‐compaction, atrial disease, myocarditis, and amyloidosis. The diagnosis and treatment of cardiac amyloidosis as restrictive cardiomyopathy is discussed in the ACC/AHA/HFSA in more detail. Namely, serum and urine screening, bone scintigraphy, and genetic testing are the main diagnostic tools available. Treatment with transthyretin tetramer stabilizer therapy (tafamidis) for reduction of cardiovascular mortality and morbidity is recommended by CoR of I in the ACC/AHA/HFSA guidelines. Moreover, anticoagulation is also recommended to reduce the risk of stroke (CoR: IIa).

Conclusions

Both ACC/AHA/HFSA 2022 and ESC 2021 HF guidelines provide valuable guidance for clinicians and help in clinical management and decision making, with the support of large trials. While mainly having the same structure and points of emphasis, in some cases, each of the guidelines may have elaborated more on a specific topic, which should be considered in these conditions. These differences may stem from the timing of the publication of these two guidelines, for which the American guidelines include newer evidence and trials. Universal Definition of HF ¹⁰ and the recently published EMPEROR‐Preserved trial are among them. Also, the point of view in the US and Europe can contribute to these differences, as the American guidelines give more value to the quality of life, cost‐effectiveness, and quality of care provided for the patients and the ESC guidelines emphasize more specific suggestions such as the exact management for certain comorbidities and special populations. Finally, further consistency between guidelines in some classes of recommendations is warranted by highlighting the differences.

Conflict of interest

Stephan von Haehling has been a paid consultant for and/or received honoraria payments from AstraZeneca, Bayer, Boehringer Ingelheim, BRAHMS, Chugai, Grünenthal, Helsinn, Hexal, Novartis, Pharmacosmos, Respicardia, Roche, Servier, Sorin, and Vifor. Stephan von Haehling reports research support from Amgen, Boehringer Ingelheim, IMI, and the German Center for Cardiovascular Research (DZHK).

Behnoush, A. H. , Khalaji, A. , Naderi, N. , Ashraf, H. , and von Haehling, S. (2023) ACC/AHA/HFSA 2022 and ESC 2021 guidelines on heart failure comparison. ESC Heart Failure, 10: 1531–1544. 10.1002/ehf2.14255.