Table 1.
Summary of guideline recommendations for heart failure with preserved ejection fraction management
| Organization society | National Institute for Health and Care Excellence (NICE)14,15 | American Heart Association/American College of Cardiology/Heart Failure Society of America (AHA/ACC/HFSA)16 | European Society of Cardiology (ESC)17,18 | Canadian Cardiovascular Society/Canadian Heart Failure Society (CCS/CHFS)19 | Saudi Heart Association (SHA)20,21 | National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHFA/CSANZ)22 | Japanese Circulation Society/Japanese Heart Failure Society (JCS/JHFS)23,24 |
|---|---|---|---|---|---|---|---|
| Document type | Clinical practice guidelines | Clinical practice guidelines | Clinical practice guidelines | Clinical practice guidelines | Clinical practice guidelines | Clinical practice guidelines | Clinical practice guidelines |
| Region applied | United Kingdom | United States of America | Europe | Canada | Saudi Arabia | Australia and New Zealand | Japan |
| Year | 2018 (update 2023) | 2022 | 2021 (update 2023) | 2017 (update 2020) | 2019 (update 2022) | 2018 | 2017 (update 2021) |
| AGREE II rigour score, % | 88 | 85 | 72 | 69 | 68 | 66 | 55 |
| Conflict of interest | EI, SCIa,b | EI, SCIa,b | EI, SCIa | Declaration no longer available | SCIa | SCIa,b | EI, SCIa |
| Methods used to evaluate evidence | Systematic review | Systematic review | Systematic review | Systematic review | Systematic review | Systematic review | Not specified |
| Methods used to formulate recommendations | Formal consensus | Formal consensus | Formal consensus | Formal consensus | Formal consensus | Formal consensus | Formal consensus |
| Consideration of costs | Cost considered in strength of recommendation | Information from studies on cost considered where available | Not reported | Not reported | Information from studies on cost considered where available | Information from studies on cost considered where available | Information from studies on cost considered where available |
| Definition of HFpEF | 1. Symptoms of HF 2. LVEF ≥50% 3. Cardiac structure or function abnormalities and/or raised levels of NPs |
1. Clinical signs and symptoms of HF 2. LVEF ≥50% 3. Evidence of spontaneous or provokable increased LV filling pressures including raised NPs, non-invasive and invasive hemodynamic measurements |
1. Symptoms and signs of HF 2. LVEF ≥50% 3. Evidence of structural and/or functional cardiac abnormalities consistent with LV diastolic dysfunction/raised LV filling pressures, including raised NPs |
1. Clinical symptoms and signs of reduced cardiac output and/or congestion at rest or with stress due to heart function 2. LVEF ≥50% |
1. Evidence of congestive HF 2. LVEF ≥50% 3. LV diastolic dysfunction 4. Elevated NPs |
1. Symptoms +/− signs of HF 2. LVEF ≥50% 3. Objective evidence of relevant structural heart disease and/or diastolic dysfunction with high filling pressures identified by either catheterization, TTE or elevated NPs |
1. Clinical symptoms of HF 2. LVEF ≥50% 3. LV diastolic dysfunction |
| Key diagnostic tests | NT-proBNP—>400 ng/L TTE—assess diastolic function (no parameters or cut-offs provided) |
NT-proBNP ≥125 pg/mL BNP ≥35 pg/mL Higher cut-offs recommended for AF or CKD TTE—parameters indicating raised LV filling pressures/structural heart disease: • Average E/e’ ≥15 • Septal e’ <7 cm/s • Lateral e’ <10 cm/s • TR velocity >2.8 m/s • PA systolic pressure >35 mmHg • LA volume index ≥29 mL/m2 • LV mass index >116 (male) or >95 (female) g/m2 • Relative wall thickness >0.42 • LV wall thickness ≥12 mm |
NT-proBNP—>125 (SR) or >365 (AF) pg/mL BNP—>35 (SR) or >105 (AF) pg/mL Resting TTE—parameters indicating LV diastolic dysfunction/raised LV filling pressures: • LV mass index ≥95 (female) or ≥115 g/m2 (male) • LV relative wall thickness >0.42 • LA volume index >34 (SR) or >40 mL/m2 (AF) • E/e’ ratio at rest >9 • PA systolic pressure >35 mmHg • TR velocity at rest >2.8 m/s |
NT-proBNP—>125 (ambulatory) or >300 (acute) pg/mL BNP—>50 (ambulatory) or >100 (acute) pg/mL TTE—include diastolic parameters e.g. transmitral and pulmonary venous flow patterns, or mitral annulus velocities (no cut-offs provided) |
NT-proBNP—>125 pg/mL BNP—>35 pg/mL TTE—parameters to assess (no cut-offs provided): • LA volume index • LV mass index • LV wall thickness • Transmitral and tissue doppler indices • Longitudinal strain patterns • TR velocity • RV systolic function • TAPSE • RV systolic pressure |
NT-proBNP—>450 (age <50 years) or > 900 (age 50–75 years) or >1800 (age >75 years) ng/L BNP—>400 ng/L Resting TTE—parameters indicating structural heart disease: • LV mass index >115 g/m2 (men) or >95 g/m2 (women) • LA volume index >34 mL/m2 OR diastolic dysfunction (≥3 abnormal suggestive): • Septal e’ <7 cm/s or lateral e’ <10 cm/s • Average E/e’ ratio >14 • LA volume index >34 mL/m2 • TR velocity >2.8 m/s |
NT-proBNP—≥400 pg/mL BNP—≥100 pg/mL Mild HF cannot be ruled out if NT-proBNP 125–400 pg/mL or BNP 40–100 pg/mL Resting TTE—parameters of LV diastolic dysfunction (≥3 abnormal suggestive): • Average E/e’ >14 (septal E/e’ >15 or lateral E/e’ >13) • Septal e’ <7 cm/s or lateral e’ <10 cm/s • TR velocity >2.8 m/s • LA volume index >34 mL/m2 |
| Other tests | Alternative imaging e.g. CMR, TOE or radionuclide angiography—consider if poor TTE images | CPET—delineate aetiology of dyspnoea, assess functional capacity and may guide prognosis (1 C-LD) Alternative imaging e.g. CMR, cardiac CT, radionuclide imaging—if TTE inadequate for LVEF assessment (1 C-LD) CMR—can be useful for diagnosis or management if known HF or cardiomyopathy (2a B-NR) Right heart catheterization—consider if persistent symptoms despite treatment (2a C-EO) Endomyocardial biopsy—consider if suspect specific cause for HF that would influence therapy (2a B-NR) Genetic screening and counselling—if genetic or inherited cardiomyopathy suspected (1 B-NR) |
CPET—confirm reduction in exercise capacity and help differentiate cause of dyspnoea (IIa C) CMR—assess cardiac structure and function if TTE inadequate or further investigate aetiology (I C) Diastolic stress test—if equivocal resting TTE and laboratory markers (IIb C) Right heart catheterization—invasively measured PCWP ≥15 (at rest) or ≥25 (with exercise) mmHg or LVEDP ≥16 mmHg (at rest) are considered diagnostic (IIb C) Endomyocardial biopsy—consider in rapidly progressive HF where biopsy can detect suspected diagnosis (IIa C) |
CMR—consider when TTE non-diagnostic or to help elucidate aetiology (I LQE) | CPET or stress echocardiography—consider in select cases to identify cause of dyspnoea (IIb) CMR—assess cardiac structure and function if TTE inadequate or further investigate aetiology (I) Right heart catheterization—workup for transplant if advanced HF (I) Endomyocardial biopsy—consider if suspect specific diagnosis that would influence therapy (IIb) Genetic testing—if familial cardiomyopathy suspected (I–IIa depending on suspected diagnosis) |
CMR with LGE—consider to identify inflammatory and infiltrative cardiomyopathies if HF with increased and unexplained LV wall thickness (I LQE) PET or bone scintigraphy—consider to identify infiltrative cardiomyopathies if HF with increased and unexplained LV wall thickness (II LQE) |
CPET—if cause of symptoms unclear or in workup to advanced treatments (I B) CMR—provides information on cardiac structure, function and aetiology if cannot assess with TTE (I C) ECG-gated SPECT—assess LV volume and LVEF if cannot assess with TTE (IIa C) Right heart catheterization—pulmonary artery pressure monitoring in select patients (I C) Endomyocardial biopsy—confirm specific diagnosis that affects HF treatment strategies (IIa C) |
| Prevention | Correct risk factors: • Salt and fluid restriction—not routinely advised; if needed, restrict fluids if dilutional hyponatraemia or reduce intake if high levels of salt and/or fluid consumption. Avoid salt substitutes containing potassium • Refer to dietetics if BMI <18.5 kg/m2 or weight loss advice if >30 kg/m2 |
Correct risk factors: • Healthy lifestyle modifications including physical activity, maintaining healthy weight, healthy diet and smoking cessation (1 B-NR) • Control hypertension—aim for <130/80 mmHg (1 A) • Statin if history of ACS (1 A) • SGLT2 inhibitors in patients with T2DM (1 A) Screening: • Population screening through NP monitoring (2a B-R) and risk scores (2a B-NR) |
Correct risk factors: • Counselling against sedentary habit, obesity, cigarette smoking, and alcohol abuse (I C) • Treatment of hypertension (I A) • Treatment with statins in patients at high risk of CVD or with CVD (I A) • SGLT2 inhibitors in patients with diabetes at high risk of CVD or with CVD (I A) • SGLT2 inhibitors in patients with T2DM and CKD (I A) • Finerenone in patients with T2DM and CKD (I A) |
Correct risk factors: • Healthy lifestyle modifications e.g. increased physical activity and healthy weight maintenance (I MQE) • Control hypertension—aim <140/90 mmHg, or SBP <130 mmHg in diabetes or high risk of CV event (I MQE) • Manage T2DM (I MQE)—metformin first line (II MQE); consider empagliflozin if concurrent T2DM and established CVD (II LQE) |
Correct risk factors: • Smoking cessation and treatment for those with alcohol excess (I) • Treatment of hypertension (I) • Treatment of obesity (I) • Statins if CVD or at risk of CVD (I) • SGLT2 inhibitor if T2DM with CVD or at high risk of CVD (I) |
Correct risk factors: • Smoking cessation (I LQE) • Avoid excess alcohol (I VLQE) • Weight reduction (I LQE) • Regular physical activity (I LQE) • Treatment of hypertension and hyperlipidaemia (I HQE) • SGLT2 inhibitors in T2DM and CVD with insufficient glycaemic control (I HQE) |
Correct risk factors: • Weight reduction and increased physical activity (I A) • Smoking cessation (I C) • Alcohol control (IIa C) • Treat hypertension with lifestyle changes and thiazide diuretic (I A) • Statin if CAD (I A) • SGLT2 inhibitor in T2DM and CAD (I A) |
| Acute treatment | IV diuretics—either bolus or infusion. Consider higher dose than admission IV nitrates—not for routine use Non-invasive ventilation—consider if there is severe dyspnoea and acidaemia, or if despite treatment the patient has respiratory failure, reduced consciousness or physical exhaustion Invasive ventilation—consider if respiratory failure or reduced consciousness or physical exhaustion despite treatment Inotropes or vasopressors—consider if potentially reversible cardiogenic shock |
Treat identifiable precipitating factors or aetiology (1 C-LD) IV loop diuretics—improve symptoms and reduce morbidity (1 B-NR); reasonable to use higher dose of loop diuretic or add second diuretic i.e. thiazide or MRA if inadequate decongestion from diuresis (2a B-NR) IV nitroglycerin or nitroprusside—consider as adjunct to diuretics for relief of dyspnoea in absence of hypotension (2b B-NR) VTE prophylaxis—if not already anticoagulated to prevent venous thromboembolic disease (1 B-R) |
Diuretics—IV loop diuretics if fluid overload to improve symptoms (I C); consider combination of loop diuretic with thiazide diuretic if resistant oedema not responsive to increase in loop diuretic doses (IIa B) Vasodilators—consider if SBP >110 mmHg to improve symptoms and reduce congestion (IIb B) Oxygen—if SpO2 <90% or PaO2 <60 mmHg (I C) Ventilatory support—intubation if progressive respiratory failure persisting despite oxygen or non-invasive ventilation (I C); consider non-invasive positive pressure ventilation if respiratory distress (respiratory rate >25 breaths/min, SpO2 <90%) (IIa B) |
IV diuretics—treat pulmonary or peripheral congestion (I LQE); preference for high dose loop diuretic +/− thiazide or MRA Tolvaptan—consider if volume overload and symptomatic hyponatraemia (II MQE) IV vasodilators—for relief of dyspnoea if SBP >100 mmHg; nitroglycerin (II MQE), nesiritide (II HQE) or nitroprusside (II VLQE) Oxygen—if hypoxic, target SpO2 >90% (I MQE) Non-invasive ventilation—not for routine use (I MQE) Inotropes—not for routine use if haemodynamically stable (I HQE) |
IV loop diuretics—bolus or infusion to improve symptoms of congestion (I); consider adding thiazide or acetazolamide in resistant fluid overload (IIb) IV vasodilators—if SBP >110 mmHg for symptomatic relief (II) Oxygen—if SpO2 <90% or PaO2 <60 mmHg (I) Non-invasive ventilation—consider if respiratory rate >25 and SpO2 <90% (IIa) Intubation—if respiratory failure causing hypoxia, hypercapnia and acidosis which cannot be managed non-invasively (I) VTE prophylaxis—if not already anticoagulated (I) |
Treat precipitating factors or aetiology (I LQE) IV loop diuretics—for fluid overload; if resistant consider adding thiazide or MRA (I LQE) IV vasodilators—consider to relieve congestive symptoms if SBP >90 mmHg (II LQE) Oxygen—if hypoxic, target SpO2 <94% (I VLQE) Non-invasive ventilation—if remain hypoxic and tachypnoeic despite oxygen therapy (I HQE) IV inotropes—consider in peripheral hypoperfusion and congestion refractory to other treatment (II VLQE) |
Loop diuretics—for fluid retention (I C); if poor response to bolus injections for continuous infusion (IIa B) or combination with thiazide or MRA (IIb C) Tolvaptan—if poor response to loop diuretic (IIa A) or in fluid retention with hyponatraemia (IIa C) Vasodilators—treat pulmonary congestion; nitrates (I B), carperitide (IIa B) or nicorandil (IIb C) Oxygen—if hypoxic, target SpO2 >90% (I C) Non-invasive ventilation—if dyspnoea and respiratory rate >25 and SpO2 <90% (I A) |
| Opiates—not for routine use Ultrafiltration—consider if confirmed diuretic resistance |
Cardiogenic shock: • IV inotropes -maintain systemic perfusion (1 B-NR) • Temporary MCS—reasonable to support cardiac function if pharmacological methods insufficient (2a B-NR); consider transfer to temporary MCS centre (2b C-LD) • PA line placement—consider to define haemodynamics and guide further management (2b B-NR) |
Vasopressors and/or inotropes—consider if cardiogenic shock unresponsive to standard treatment (IIb B) Opiates—routine use not advised unless in selected patients with severe/intractable pain or anxiety (III C) Other drugs—thromboembolism prophylaxis (e.g. with low-molecular-weight heparin) if not already anticoagulated and no contraindications (I A) |
Morphine—not for routine use (I MQE) | Inotropes—if SBP <110 mmHg and hypoperfusion not responding to treatment (IIb) Vasopressors—consider if poor response to inotropes (IIb) Renal replacement therapy—if refractory fluid overload and acute kidney injury (IIa) Ultrafiltration—if refractory congestion unresponsive to diuretics (IIb) |
Tracheal intubation—if remains hypoxaemic (PaO2 <60 mmHg), hypercapnic (PaCO2 >50 mmHg) and acidotic (pH <7.35) despite above measures (I C) Cardiogenic shock: • Inotropes/vasopressors—increase cardiac output/maintain systolic blood pressure if persistent peripheral hypoperfusion (IIa B) • MCS—consider short-term use (IIb C); transfer to ICU/CCU where MCS available (I C) • Swan-Ganz catheterization—determine haemodynamics if unresponsive to appropriate treatment (I C) Haemofiltration/haemodialysis/haemodiafiltration—if severe fluid retention refractory to drug therapies (IIb B) |
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| Chronic treatment | Treatment of any causes, comorbidities and precipitating factors Loop diuretics—for fluid retention SGLT2 inhibitor—dapagliflozin or empagliflozin Fluid/salt restriction—only if high levels of intake; requires regular review Multidisciplinary interventions: • Specialist HF multidisciplinary team to deliver care • Education on self-care advice and managing HF • Influenza (annual) and pneumococcal disease (once-only) vaccinations Exercise rehabilitation: • Personalised exercise-based rehabilitation program |
Treatment of comorbidities—e.g. hypertension (1 C-LD) or AF (2a C-EO) and any known aetiology such as amyloidosis (1 B-NR) Diuretics—for fluid retention; loop diuretic +/− thiazide diuretic if hypertensive or refractory oedema (1 B-NR) SGLT2 inhibitor (2a B-R) MRA, ARB or ARNI—consider in select patients, especially if LVEF on lower end of spectrum (2b B-R) Dietary sodium restriction—reduce congestive symptoms (2a C-LD) Multidisciplinary interventions: • Multidisciplinary team care • Education and support to facilitate HF self-care and exercise (1 B-R) • Respiratory illness vaccinations (2a B-NR) Exercise rehabilitation: • Exercise training (1 A) or cardiac rehabilitation program to improve quality of life (2a B-NR) |
Treatment for aetiology, CV and non-CV comorbidities—e.g. hypertension, CAD, amyloidosis, AF, valvular heart disease (I C) Diuretics—for fluid retention; loop diuretics preferred, although thiazide diuretics may be useful for managing hypertension (I C) SGLT2 inhibitor—dapagliflozin or empagliflozin (I A) Multidisciplinary interventions: • Multidisciplinary HF management programme (I A) • Self-management strategies (I A) • Home-based and/or clinic-based programmes (I A) • Consider influenza and pneumococcal vaccinations (IIa B) Exercise rehabilitation: • Exercise if able (I A) • Consider a supervised, exercise-based, cardiac rehabilitation programme in patients with more severe disease, frailty, or with comorbidities (IIa C) |
Treatment of comorbidities and aetiology—e.g. hypertension and amyloidosis (I HQE) Loop diuretics—to manage peripheral oedema (I MQE) Candesartan—consider to reduce HF hospitalizations (II MQE) MRA—consider if serum potassium <5.0 mmol/L and eGFR >30 mL/min (II MQE) Sodium (2-3 g/d) and fluid (max 2 L/d) restriction—consider if fluid retention or congestion not easily controlled with diuretics (II LQE) Multidisciplinary interventions: • Referral to HF disease management program if recurrent hospitalizations (I HQE) Exercise rehabilitation: • Regular exercise (I MQE) |
Screen and treat CV and non-CV comorbidities (I) Diuretics—for fluid overload (I) SGLT2 inhibitors—dapagliflozin or empagliflozin (I) ARNI, ARB, beta-blocker, MRA—consider in select patients to reduce risk of HF hospitalization and death (IIb) Multidisciplinary interventions: • Enrolment into multidisciplinary team HF management program (I) • Self-management strategies (I) • Influenza and pneumococcal vaccinations (IIa) Exercise rehabilitation: • Regular exercise (I) • Cardiac rehabilitation programme (IIa) |
Treatment of comorbidities and aetiology—e.g. hypertension, T2DM, AF and IHD Diuretics—relieve congestion and improve symptoms; typically loop diuretics but consider thiazides if hypertensive (I VLQE) Multidisciplinary interventions: • Multidisciplinary team HF disease management program referral if high-risk (I HQE) • Patient-centred education on self-management (I HQE) Exercise rehabilitation: • Regular exercise (I HQE) |
Treatment of comorbidities and aetiology—e.g. hypertension (I B) Diuretics—to relieve congestion (I C): • Preference of long-acting loop diuretics e.g. azosemide (IIb C) • Tolvaptan—initiate in acute HF and continue following discharge (IIa C) ARNI—consider administration (IIb B) ACEi/ARB, beta-blocker, MRA—increase dose to maximum tolerable level (IIb C) Dietary sodium restriction—consider low-salt diet (IIa C) Multidisciplinary interventions: • Comprehensive multidisciplinary team educational programs and medical care (I C) • Vaccination of infectious diseases (IIa C) Exercise rehabilitation: • Exercise therapy for select patients (IIa B/C) • Cardiac rehabilitation programs (IIa C) |
| Advanced treatment | Cardiac transplant—specialist referral if severe refractory symptoms or refractory cardiogenic shock Palliative care—consider referral if worsening HF despite optimal specialist treatment |
HF specialty care referral—review management and assess suitability for advanced therapies in patients with advanced HF (1 C-LD) Cardiac transplantation—for select patients with advanced HF refractory to guideline-directed medical therapy (1 C-LD) Inotropic support—consider for short-term usage as a bridge to transplantation in select patients (2a B-NR) or symptom control in palliation (2b B-NR) Palliative care—specialist consultation to improve quality of life and alleviate suffering (1 C-LD) Fluid restriction—reduce congestive symptoms if hyponatraemia, uncertain benefit (2b C-LD) |
Heart transplantation -if advanced HF refractory to medical therapy and no absolute contraindications (I C) Continuous vasopressors and/or inotropes—consider if low cardiac output and evidence of organ hypoperfusion as bridge to heart transplantation if eligible (IIb C) Renal replacement therapy—consider if refractory volume overload and end-stage kidney failure (IIa C) Ultrafiltration—consider in refractory volume overload unresponsive to diuretic treatment (IIb C) |
Specialist centre referral—assessment and management by team with expertise in treating severe HF for patients with acute severe or chronic advanced HF and good life expectancy (I MQE) Cardiac transplantation—recommended but specific guidelines for eligibility found elsewhere Inotropes and vasopressors—consider in cardiogenic shock to afford opportunity for evaluation of long-term options (I MQE) Palliative care—refer on basis of symptoms rather than life expectancy (I VLQE) |
Advanced HF team management—review treatment and assess suitability for advanced therapies for advanced HF patients (I) Cardiac transplantation—select cases with advanced HF despite optimal medical therapy (I) Inotropic support—consider continuous IV inotropes as a bridge to cardiac transplantation if eligible (IIa) or continuous/intermittent IV inotropes for symptomatic relief in palliation (IIb) Fluid restriction—consider to reduce congestive symptoms if hyponatraemia (IIb) |
Heart transplant—consider referral for assessment if advanced HF refractory to alternative therapies without overt contraindications (I LQE) Palliative care—consider to alleviate symptoms and improve quality of life in advanced HF and early involvement if trajectory towards advanced HF (I HQE) |
Palliative care—patients with end-stage HF for advance care planning (I B), continued HF treatment to manage complications and symptoms (I C) and frequent assessment of physical, mental, and spiritual needs (II C) |
| Surveillance | Review <2 weeks after hospital discharge Every 6 months to check functional status, fluid status, cognition, nutrition, medication and renal function. Monitoring interval should be <2 weeks if clinical status or medication has changed |
Review within 7 days of hospital discharge to optimize care and reduce re-hospitalization TTE if unexplained change in clinical status Monitoring: • Consider telemonitoring of PA pressure with implantable haemodynamic monitor (2b B-R) |
Review 1–2 weeks after hospital discharge to assess signs of congestion and drug tolerance Every 6 months to check symptoms, ECG, BP, full blood count, electrolytes, and renal function. TTE if deterioration in clinical status Monitoring: • Consider non-invasive home telemonitoring (IIb B) |
Frequency dependent on level of risk: • Lower—every 1 year • Intermediate—every 1–6 months • Higher—1–2 times per month TTE every 1–3 years or after a significant clinical event |
Consider referral to primary care for long-term follow-up of stable patients on optimal therapy Monitoring: • Monitoring of pulmonary pressures with implantable device if symptomatic HF and previous admissions (IIb) |
Review 1–2 weeks after hospital discharge Frequency of regular follow-up should be guided by clinical stability Monitoring: • Telemonitoring or telephone support program if above not available (I MQE) • Implantable PA pressure monitoring if persistent symptoms despite optimal care. Requires daily upload and at least weekly review (II LQE) |
Early review after hospital discharge Every 1 year in HF clinic |
ACEi, angiotensin-converting enzyme inhibitor; ACS, acute coronary syndrome; AF, atrial fibrillation; AGREE II, Appraisal of Guidelines Research and Evaluation II; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor/neprilysin inhibitor; BMI, body mass index; BNP, brain natriuretic peptide; BP, blood pressure; CAD, coronary artery disease; CKD, chronic kidney disease; CMR, cardiovascular magnetic resonance; CPET, cardiopulmonary exercise testing; CT, computed tomography; CVD, cardiovascular disease; ECG, electrocardiogram; eGFR, estimated glomerular filtration rate; EI, editorial independence declared; HF, heart failure; IV, intravenous; LA, left atrium; LGE, late gadolinium enhancement; LV, left ventricle; LVEDP, LV end diastolic pressure; LVEF, LV ejection fraction; MCS, mechanical circulatory support; MRA, mineralocorticoid receptor antagonist; NP, natriuretic peptide; NT-proBNP, N-terminal pro-B-type natriuretic peptide; PA, pulmonary artery; PaO2, partial pressure of oxygen; PCWP, pulmonary capillary wedge pressure; PET, positron emission tomography; RV, right ventricle; SBP, systolic BP; SCI, statement about conflicts of interest of group members present; SGLT2, sodium-glucose co-transporter-2; SPECT, single-photon emission CT; SpO2, oxygen saturation; T2DM, type two diabetes mellitus; TAPSE, tricuspid annular plane systolic excursion; TOE, transoesophageal echocardiogram; TR, tricuspid regurgitation; TTE, transthoracic echocardiogram; VTE, venous thromboembolism.
ESC and JSC/JHFS:
Level of evidence: A = data derived from multiple randomized clinical trials or meta-analysis. B = data derived from a single randomized trial or non-randomized studies. C = only consensus opinion of experts, and/or small studies, retrospective studies, registries.
Class of recommendation: I, evidence and/or general agreement that the procedure or treatment is beneficial, useful, and effective; Class II: conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment; IIa, weight of evidence/opinion is in favour of usefulness/efficacy; IIb, usefulness/efficacy is less well established by evidence/opinion; III, evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.
AHA/ACC/HFSA:
Level of evidence: A (high quality evidence); B (moderate quality evidence—B-R = randomized study, B-NR = non-randomized); C (C-LD = limited data, C-EO = consensus of expert opinion).
Class of recommendation: Class I = benefit >>> risk; Class IIa = benefit >> risk, Class IIb = benefit ≥ risk; class III = risk ≥ benefit.
SHA:
Class of recommendation: Class I (recommended), usefulness/efficacy is supported by available evidence; Class IIa (should be considered), usefulness/efficacy established by favourable expert opinion on conflicting evidence; Class IIb (may be considered), usefulness/efficacy not well established by evidence or expert opinion; Class III (not recommended), not useful or effective and is potentially harmful based on evidence and/or general agreement.
NHFA/CSANZ and CCS/CHFS:
Level of evidence: High-quality evidence (HQE), confident that true effect is similar to estimated effect; Moderate-quality evidence (MQE), true effect is probably close to estimated effect; Low-quality evidence (LQE), true effect may be markedly different from the estimated effect; very low quality of evidence (VLQE), true effect is probably markedly different from estimated effect.
Class of recommendation: I, strongly recommended—almost all persons would choose intervention; II, weakly recommended—important variation in decision that informed persons are likely to make; III, not recommended.
a—Relationship with industry is reported by any group member.
b—A group member is reported recused when a relevant area is under discussion.