AHA 2025 Guidelines for Heart Failure Management in Adults
The 2022 AHA/ACC/HFSA guidelines represent the most current comprehensive recommendations for heart failure management, emphasizing four foundational medication classes (ACE inhibitors/ARBs/ARNi, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors) that should be initiated rapidly and titrated to target doses in all patients with HFrEF, with SGLT2 inhibitors now recommended across the entire ejection fraction spectrum. 1, 2, 3
Staging and Prevention Framework
The guidelines use a revised staging system to emphasize prevention and early intervention 1:
Stage A ("At Risk for HF"): Patients with risk factors but no structural heart disease or symptoms. Aggressively control hypertension to target BP <130/80 mmHg if cardiovascular risk >10%, treat hyperlipidemia with statins (reduces incident HF risk by ~50%), and consider ACE inhibitors or ARBs in patients with atherosclerotic disease, diabetes, or hypertension 3, 1
Stage B ("Pre-HF"): Patients with structural heart disease but no symptoms. Continue neurohormonal antagonists and monitor closely for symptom development 1
Stage C (Symptomatic HF): Requires immediate initiation of guideline-directed medical therapy based on ejection fraction 1
Stage D (Advanced HF): Requires specialized interventions including mechanical circulatory support, continuous inotropes, transplant evaluation, or palliative care 1
Heart Failure with Reduced Ejection Fraction (HFrEF)
Four Pillars of Therapy
All four medication classes should be initiated rapidly—ideally within the first 3 months of diagnosis—and titrated to target doses over 2-4 weeks, not sequentially over months. 2, 3, 4
1. ACE Inhibitors/ARBs/ARNi
ACE inhibitors are first-line therapy with Class I, Level A evidence for all patients with reduced LVEF, regardless of symptom severity, to prevent symptomatic HF and reduce mortality 2, 1
ARBs serve as alternatives for patients intolerant to ACE inhibitors due to cough or angioedema 2, 3
ARNi (sacubitril/valsartan) can replace ACE inhibitors/ARBs in patients who remain symptomatic despite optimal therapy, with Class 2b recommendation 1, 2
Titrate to target doses over 2-4 weeks with monitoring of blood pressure, renal function, and electrolytes at 1-2 weeks after each dose increment 2
2. Beta-Blockers
Recommended for all patients with stable HFrEF in NYHA class II-IV unless contraindicated, with Class I, Level A evidence 2, 3
Reduce mortality and hospitalizations; should be continued during hospitalization unless hemodynamically unstable 3
In patients with LV systolic dysfunction following acute MI, long-term beta-blockade is recommended in addition to ACE inhibition 2
3. Mineralocorticoid Receptor Antagonists (MRAs)
Recommended for patients with NYHA class II-IV and LVEF ≤35% with Class I recommendation 2, 3
Spironolactone specifically indicated in patients with recent or current class IV symptoms, preserved renal function, and normal potassium concentration 2
Monitor potassium and renal function closely to avoid hyperkalemia, especially when combined with ACE inhibitors 1, 2, 3
4. SGLT2 Inhibitors
Now recommended across the entire LVEF spectrum (HFrEF, HFmrEF, and HFpEF) with proven mortality benefit 1, 3, 5
Class 2b recommendation for HFrEF in the 2022 guidelines, but evidence has strengthened since publication 1
Should be initiated early, ideally within first 3 months of diagnosis 4
Symptomatic Management with Diuretics
Essential when fluid overload manifests as pulmonary congestion or peripheral edema 2, 3
Always administered in combination with ACE inhibitors, never as monotherapy 2
For hospitalized patients with significant fluid overload, initiate IV loop diuretics at doses equal to or exceeding chronic oral daily dose within 1 hour of presentation 3
Teach flexible diuretic regimen based on daily weight monitoring 3
Avoid thiazide diuretics when GFR <30 mL/min except synergistically with loop diuretics 2
Device Therapy
Implantable cardioverter-defibrillator (ICD) for primary prevention in patients with LVEF ≤30-35%, NYHA class II-III on optimal medical therapy ≥3 months, life expectancy >1 year 3
Cardiac resynchronization therapy (CRT) with LVEF ≤35%, sinus rhythm, NYHA class II-IV, QRS ≥150 ms with left bundle branch block 3
Heart Failure with Preserved Ejection Fraction (HFpEF)
Diagnostic Criteria
Evidence of increased filling pressures is critical for diagnosis when LVEF >40%, obtained from noninvasive testing (natriuretic peptides, diastolic function on imaging) or invasive hemodynamic measurement 1
Treatment Approach
SGLT2 inhibitors are now recommended for HFpEF with proven benefit 1, 5
Optimal blood pressure control is a new performance measure with Class I recommendation 1, 3
Diuretics cautiously for fluid overload, avoiding excessive diuresis as diastolic dysfunction is highly preload-dependent 3
ACE inhibitors to improve relaxation, reduce hypertrophy, and control hypertension 3
Beta-blockers to lower heart rate and increase diastolic filling period 3
Consider verapamil-type calcium antagonists to improve function, particularly in hypertrophic cardiomyopathy 3
Heart Failure with Improved Ejection Fraction (HFimpEF)
Patients with previous HFrEF who now have LVEF >40% should continue their HFrEF treatment, as this is a new recommendation emphasizing continuation of guideline-directed medical therapy 1
Cardiac Amyloidosis
Diagnostic Algorithm
Every patient undergoing bone scintigraphy must first have monoclonal protein screening—a scintigraphy scan alone cannot distinguish ATTR-CM from AL-CM 1
Screen with serum and urine immunofixation electrophoresis and serum free light chains in patients with clinical suspicion (LV wall thickness ≥14 mm with fatigue, dyspnea, or edema, especially with discordance between wall thickness and QRS voltage) 1
If monoclonal protein screen is abnormal, refer to hematologist for further evaluation 1
If monoclonal protein screen is negative, perform bone scintigraphy to confirm transthyretin cardiac amyloidosis 1
If transthyretin cardiac amyloidosis is confirmed, perform TTR gene sequencing to differentiate hereditary variant from wild-type 1
Acute Decompensated Heart Failure
Immediate Management
Administer IV loop diuretics within 1 hour of presentation at doses equal to or exceeding chronic oral daily dose 3
Continue ACE inhibitors and beta-blockers unless hemodynamically unstable 3
Monitor continuously for at least 24 hours: heart rate, rhythm, blood pressure, oxygen saturation 3
Consider natriuresis-guided diuretic therapy for optimization 5
Post-Discharge Care
Schedule early follow-up within 7-14 days and telephone follow-up within 3 days of discharge 3
Implement "high-intensity care" strategy with rapid up-titration of quadruple therapy and close follow-up with frequent clinical and laboratory reassessment 5
Monitoring Requirements
At each visit, assess: symptoms, weight, blood pressure, heart rate, volume status, renal function, electrolytes 3
Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 2
Consider natriuretic peptides (BNP or NT-proBNP) at baseline to guide therapy 3
Daily monitoring during acute decompensation: fluid intake/output, weight, clinical signs 2
Critical Medications to Avoid
Never use the following in heart failure patients 2, 3, 6:
Calcium channel blockers (diltiazem, verapamil) as treatment for HF—they increase risk of worsening HF and hospitalization 3, 6
Long-term intermittent positive inotropic therapy 3
NSAIDs and COX-2 inhibitors—they interfere with ACE inhibitor efficacy, worsen fluid retention, and increase risk of HF worsening 2, 6
Class I anti-arrhythmic agents 2
Routine nutritional supplements (coenzyme Q10, carnitine, taurine, antioxidants) or hormonal therapies 3, 6
ARB added to ACE inhibitor plus MRA combination—increases risk of renal dysfunction and hyperkalemia 3, 6
Special Populations and Comorbidities
Atrial Fibrillation
Treatment of atrial fibrillation carries Class 2a recommendation 1
Consider ablation of AF in appropriate candidates 1
Secondary Mitral Regurgitation
Optimize guideline-directed medical therapy prior to intervention for chronic secondary severe MR 1
Consider MV transcatheter edge-to-edge repair in selected patients 1
Iron Deficiency
- Recommendations provided for treatment of iron deficiency in HF patients 1
Type 2 Diabetes and Chronic Kidney Disease
- SGLT2 inhibitors and finerenone (nonsteroidal selective MRA) are recommended for prevention of HF in patients with diabetic CKD 5
Obesity and HFpEF
- Semaglutide 2.4 mg once weekly decreased body weight and significantly improved quality of life and 6-minute walk distance in obese patients with HFpEF 5
Implementation Pitfalls to Avoid
Never withhold neurohormonal antagonists in stable patients due to concerns about tolerability—these are mortality-reducing therapies 2
Do not delay initiation of all four pillars—real-world data shows only 18% receive ARNI, 35% receive MRA, and 26% receive SGLT2i within 3 months of diagnosis, representing a major implementation gap 4
Avoid sequential titration over many months—guidelines recommend rapid initiation and titration within weeks, not months 2, 3
Do not use diuretics as monotherapy—always combine with neurohormonal antagonists 2
Advanced Heart Failure (Stage D)
Patients with advanced HF who wish to prolong survival should be referred to a HF specialty team for review of management, assessment for advanced therapies (LVAD, transplant), and palliative care including palliative inotropes where consistent with patient goals 1
Confirm diagnosis accuracy, identify and reverse contributing conditions, and ensure all conventional strategies optimally employed before declaring refractory HF 1
Meticulous control of fluid retention is critical in end-stage HF 1
Patients may tolerate only small doses of neurohormonal antagonists or may not tolerate them at all due to risk of hypotension and renal insufficiency 1