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Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e919 CLINICAL STATEMENTS AND GUIDELINES

machine learning.1–14 These risk scores are for use in ambulatory, hospitalized patients, and the general population.

Recommendation-Specific Supportive Text

1.	 For HF, there are several clinical models to consider that include the spectrum of HF based on EF and clinical setting. For chronic HF, the Seattle Heart Failure Model,2 the Heart Failure Survival score,1 and the MAGGIC score3 have commonly been used to provide estimates of survival. The MAGGIC predictive model may be quite useful given its derivation and validation across multiple clinical trials and cohorts, including more recent studies. For chronic HFrEF, there are additional models that include other clinical variables, including exercise capacity7 and natriuretic peptide levels.8 Likewise, for chronic HFpEF there are more specific predictive models for that population derived from clinical trial data.9,10 In acute HF, several clinical models may be used to predict short-term survival.11–13

5 STAGE A (PATIENTS AT RISK FOR HF)

5.1 Patients at Risk for HF (Stage A: Primary

Prevention) Recommendations for Patients at Risk for HF (Stage A: Primary Prevention) Referenced studies that support the recommendations are summarized in the Online Data Supplements.

COR LOE Recommendations

1 A 1.	 In patients with hypertension, blood pressure should be controlled in accordance with GDMT for hypertension to prevent symptomatic HF.1–9

1 A 2.	 In patients with type 2 diabetes and either established CVD or at high cardiovascular risk, SGLT2i should be used to prevent hospitalizations for HF.10–12

1 B-NR 3.	 In the general population, healthy lifestyle habits such as regular physical activity, maintaining normal weight, healthy dietary patterns, and avoiding smoking are helpful to reduce future risk of HF.13–21

2a B-R 4.	 For patients at risk of developing HF, natriuretic peptide biomarker–based screening followed by team-based care, including a cardiovascular specialist optimizing GDMT, can be useful to prevent the development of LV dysfunction (systolic or diastolic) or new-onset HF.22,23

2a B-NR 5.	 In the general population, validated multivariable risk scores can be useful to estimate subsequent risk of incident HF.24–26

Synopsis Healthy lifestyle habits such as maintaining regular physical activity; normal weight, blood pressure, and blood glucose levels; healthy dietary patterns, and not smoking reduce primordial risk and have been associated with a lower lifetime risk of developing HF.13–21,27 The AHA/ ACC primary prevention guidelines provide recommendations for diet, physical activity, and weight control, all of which have been associated with the risk of HF.28 Blood pressure is an important risk factor for HF, and a treatment goal of <130/80 mm Hg is recommended for those with a CVD risk of ≥10%.29,30 Multiple RCTs have found that patients with diabetes and CVD without HF have improved survival and reduced HF hospitalizations with SGLT2i.31 Patients at risk for HF screened with BNP or NT-proBNP followed by collaborative care, diagnostic evaluation, and treatment in those with elevated levels can reduce combined rates of LV systolic dysfunction, diastolic dysfunction, and HF.22,23 See Figure 5 for COR 1 and 2a for stage A (at risk for HF) and stage B (pre-HF).

Recommendation-Specific Supportive Text

1.	 Elevated systolic and diastolic blood pressure are major risk factors for the development of symptomatic HF.8,9,32 Many trials have shown that hypertension control reduces the risk of HF.1–7 Although the magnitude of benefit varies with the patient population, target blood pressure reduction, and HF criteria, effective hypertension treatment invariably reduces HF events. In the SPRINT (Systolic Blood Pressure Intervention Trial) trial, control to an SBP goal <120 mm Hg decreased incident HF by 38% and mortality by 23% compared with an SBP goal of <140 mm Hg6,7 A meta-analysis showed that blood pressure control was associated with an approximately 40% reduction in HF events.5 Therefore, SBP and diastolic blood pressure should be controlled in accordance with published clinical practice guidelines.30 2.	 Multiple RCTs in patients with type 2 diabetes and at risk for, or with established CVD or at high risk for CVD, have shown that SGLT2i prevent HF hospitalizations compared with placebo.10–12 The benefit for reducing HF hospitalizations in these trials predominantly reflects primary prevention of symptomatic HF, because only approximately 10% to 14% of participants in these trials had HF at baseline. The mechanisms for the improvement in HF events have not been clearly elucidated but seem to be independent of glucose lowering. Proposed mechanisms include reductions in plasma volume, cardiac preload and afterload, alterations in cardiac metabolism, reduced arterial stiffness, and interaction with the Na+/H+ exchanger.33,34 SGLT2i are generally well tolerated, but these agents have not been evaluated in those with severe renal impairment (estimated glomerular filtration rate [eGFR] <25 mL/min/1.73 m2).35 3.	 Greater adherence to healthy lifestyle habits such as regular physical activity, avoiding obesity, maintaining normal blood pressure and

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