The following are key points to remember from a review comparing contemporary clinical practice recommendations for the management of heart failure (HF) in the American and European guidelines:

1. HF Stages: Both guidelines describe the stages of HF as Stage A (risk factors), Stage B (asymptomatic structural heart disease, elevated ventricular filling pressures, or abnormal biomarkers), Stage C (current or prior symptomatic HF), and Stage D (advanced HF).
2. HF Classification: Both guidelines classify HF based on left ventricular ejection fraction (LVEF) as reduced (HFrEF, LVEF ≤40%), mildly reduced (HFmrEF, LVEF 41-49%), and preserved (HFpEF, LVEF ≥50%). The American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) guideline also includes a new classification of HF with improved EF (HFimpEF), defined by a previous LVEF ≤40% and currently >40%.
3. HF Prevention: Healthy lifestyles are recommended in both guidelines. ACC/AHA/HFSA suggests benefit from plant-based diets (Mediterranean, DASH). The European Society of Cardiology (ESC) guideline suggests avoiding excessive alcohol intake. Both guidelines emphasize treatment of HF risk factors. Of note, sodium-glucose co-transporter 2 inhibitors (SGLT2i) are recommended to prevent HF hospitalization in patients with type 2 diabetes (T2D). ESC additionally recommends SGLT2i and finerenone for HF prevention in patients with T2D and chronic kidney disease.
4. HF Diagnosis: Both guidelines support that use of natriuretic peptides in the diagnosis of HF. ACC/AHA/HFSA also recommends natriuretic peptide use for HF risk stratification. Since HFpEF can be difficult to diagnose, additional testing is proposed, including the use of natriuretic peptides, assessing for elevated filling pressures, and use of other imaging modalities when echocardiography is insufficient (ESC suggests cardiac magnetic resonance imaging).
5. Treatment of HFrEF: The two guidelines are concordant in expanding recommendations for angiotensin receptor-neprilysin inhibitors (ARNi), beta-blockers (BB), mineralocorticoid receptor antagonists (MRA), and SGLT2i as disease-modifying therapies. ACC/AHA/HFSA recommends de novo ARNi initiation or switching to ARNi from an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB), while ESC recommends initial ACEi initiation and a subsequent switch to ARNi if patients remain symptomatic. Both guidelines emphasize prompt initiation and optimization of guideline-directed medical therapies (GDMTs).
6. Treatment of HFimpEF: ACC/AHA/HFSA explicitly recommends continuation of HFrEF GDMT despite improvement in LVEF to reduce the risk of HF relapse. ESC does not have formal recommendations, but also suggests benefit to continued GDMT.
7. Treatment of HFmrEF: This group of patients has not been well studied in dedicated trials. ESC gives a Class 1 recommendation for SGLT2i use, whereas ACC/AHA/HFSA gives a Class 2a recommendation. BB, ARNi/ACEi/ARB, and MRA receive a Class 2b recommendation in both guidelines.
8. Treatment of HFpEF: ESC gives a Class 1 recommendation for SGLT2i use, whereas ACC/AHA/HFSA gives a Class 2a recommendation. ARNi/ACEi/ARB and MRA therapy receive a Class 2b recommendation in the ACC/AHA/HFSA guideline, particularly for patients with a lower LVEF. ESC does not include recommendations on these therapies.
9. Nonpharmacological Interventions: Both guidelines recommend multidisciplinary teams to optimize care, vaccinations against preventable respiratory illnesses, and cardiac rehabilitation. ACC/AHA/HFSA recommends screening for barriers to self-care and avoidance of excessive dietary sodium. ESC recommends home- and clinic-based programs to support self-care and does not have specific recommendations on dietary sodium.
10. Device-Based Monitoring and Treatment: Both guidelines give a Class 2b recommendation for wireless pulmonary artery (PA) pressure monitors, though ESC specifically recommends this only for patients with HFrEF. Both give a Class 1 recommendation for primary prevention implantable cardioverter-defibrillators (ICDs) in patients with ischemic cardiomyopathy and LVEF ≤35% despite HF GDMT. For similar patients with nonischemic cardiomyopathy, ACC/AHA/HFSA still has a Class 1 recommendation for ICDs, while ESC has downgraded their recommendation to Class 2a. Cardiac resynchronization therapy (CRT) is recommended by both guidelines in symptomatic patients with sinus rhythm, LVEF ≤35% on GDMT, left bundle branch block (LBBB), and QRS duration ≥150 msec as a Class 1 indication. Differences in CRT indications do exist for other indications.
11. Valvular Heart Disease and Comorbidities: Both guidelines highlight the importance of medical and device optimization prior to secondary mitral regurgitation (SMR) interventions and give a Class 2a recommendation for transcatheter edge-to-edge repair (TEER) if feasible. ESC suggests an effective regurgitant orifice area (EROA) >30 mm² as a cutoff for significant SMR, whereas ACC/AHA/HFSA suggests an EROA cutoff of >40 mm². Focus on management of other cardiac and noncardiac comorbidities is also present in both documents.
12. Special Populations: For symptomatic transthyretin cardiac amyloidosis, tafamidis treatment receives a Class 1 recommendation in both guidelines. To address disparities in care for vulnerable populations, ACC/AHA/HFSA recommends risk assessment for social determinants of health. For patients who may become pregnant, ACC/AHA/HFSA recommends preconception counseling for those with a history of HF or cardiomyopathy. Additionally, anticoagulation for patients with peripartum cardiomyopathy and LVEF <30% receives a Class 2b recommendation (up to 6-8 weeks postpartum).
13. Acute HF: Both guidelines recommend initiation and optimization of GDMT during the hospitalization and close follow-up during the transitions in care. ESC also identifies the first few weeks post-discharge as an opportunity for further optimization. ESC provides additional guidance on management of acute pulmonary edema, isolated right ventricular failure, and role of acetazolamide and thiazide diuretics. ACC/AHA/HFSA recommends the continuation of GDMT when there is a mild reduction in estimated glomerular filtration rate with therapies.
14. Cost/Value: ACC/AHA/HFSA now includes value statements for certain recommendations, highlighting the cost-effectiveness of therapies. ESC does not have a similar statement, though this group represents many countries with different health care considerations.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Heart Failure

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