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Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e923 CLINICAL STATEMENTS AND GUIDELINES 5. The Framingham studies have shown a 60% increased risk of death in patients with asymptomatic low LVEF compared with those with normal LVEF, and almost half of these patients remained free of HF before their death.25 MADIT-II (Multicenter Automatic Defibrillator Implantation Trial II) showed a 31% relative risk reduction in all-cause mortality in patients with post-MI with LVEF ≤30% receiving a prophylactic ICD compared with standard of care.14 These findings provided justification for the broad adoption of ICDs for primary prevention of SCD in the post-MI setting with reduced LVEF, even in the absence of HF symptoms. 6. Although beta blockers have been shown to improve outcomes in patients with symptomatic HFrEF and in patients with reduced LVEF after MI,11 few data exist regarding the use of beta blockers in asymptomatic patients with depressed LVEF without a history of MI. There is evidence to support the role of beta blockers to prevent adverse LV remodeling in asymptomatic patients with LV systolic dysfunction, including those with nonischemic cause.43 Also, in a post hoc analysis of the SOLVD prevention trial, which included approximately 20% of participants with nonischemic HF cause, beta blockers were associated with a reduction in the risk of death and in death or hospitalization for symptomatic HF in those patients randomized to enalapril, a finding that was not seen in the placebo group.12 Given the longterm benefits of beta blockers to reduce HF hospitalizations in patients with symptomatic HFrEF,44 beta-blocker therapy is recommended to prevent symptomatic HF in patients with reduced LVEF. 7. Thiazolidinediones have been associated with fluid retention and increased rates of HF in RCTs of patients with type 2 diabetes who were predominantly free of symptomatic HF at baseline.47–49 In a smaller RCT of patients with more severely symptomatic HFrEF, pioglitazone was associated with increased rates of HF hospitalization compared with placebo.50 In patients with more mild symptoms (NYHA class I to II) but with depressed LVEF,15 rosiglitazone was associated with more fluid-related events, including worsening edema and need for increased HF medications.15 Given the evidence, thiazolidinediones should be avoided in patients with reduced LVEF. 8. Nondihydropiridine calcium channel blockers diltiazem and verapamil are myocardial depressants and generally not tolerated in HF. In previous studies of patients with HF or reduced LVEF after acute MI, diltiazem was associated with increased risk of HF,16,17 although in a smaller study of patients with nonischemic cardiomyopathy, diltiazem had no impact on mortality.45 Verapamil had no impact on survival or major cardiovascular events after acute MI.46 Although not specifically tested in asymptomatic patients with low LVEF, nondihydropyridine calcium channel blockers may be harmful in this population because of their negative inotropic effects. 7 STAGE C HF 7.1 Nonpharmacological Interventions 7.1.1 Self-Care Support in HF Recommendations for Nonpharmacological Interventions: Self-Care Support in HF Referenced studies that support the recommendations are summarized in the Online Data Supplements. COR LOE Recommendations 1 A 1. Patients with HF should receive care from multidisciplinary teams to facilitate the implementation of GDMT, address potential barriers to self-care, reduce the risk of subsequent rehospitalization for HF, and improve survival.1–4 1 B-R 2. Patients with HF should receive specific education and support to facilitate HF self-care in a multidisciplinary manner.2,5–9 2a B-NR 3. In patients with HF, vaccinating against respiratory illnesses is reasonable to reduce mortality.10–16 2a B-NR 4. In adults with HF, screening for depression,17,18 social isolation,19–22 frailty,23,24 and low health literacy25,26 as risk factors for poor self-care is reasonable to improve management. Synopsis Because of the complexity of HF management and coordination of other health and social services required, HF care is ideally provided by multidisciplinary teams27–30 that include cardiologists, nurses, and pharmacists who specialize in HF as well as dieticians, mental health clinicians, social workers, primary care clinicians, and additional specialists.31–33 Self-care in HF comprises treatment adherence and health maintenance behaviors.34,35 Patients with HF should learn to take medications as prescribed, restrict sodium intake, stay physically active, and get vaccinations.36,37 They also should understand how to monitor for signs and symptoms of worsening HF, and what to do in response to symptoms when they occur.36,37 Knowledge alone is insufficient to improve self-care.38 Patients with HF need time and support to gain skills and overcome barriers to effective self-care.37 Measures listed as Class 1 recommendations for patients in stages A and B are recommended where appropriate for patients in stage C. GDMT, as depicted in Figure 6, should be the mainstay of pharmacological therapy for HFrEF. Recommendation-Specific Supportive Text 1. In a meta-analysis of 30 RCTs, multidisciplinary interventions reduced hospital admission and Downloaded from http://ahajournals.org by on October 7, 2026