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May 3, 2022 Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 e924

CLINICAL STATEMENTS AND GUIDELINES

all-cause mortality.1 In a separate meta-analysis of 22 RCTs, specialized multidisciplinary team followup was associated with reduced HF hospitalizations and all-cause hospitalizations.2 In a recent metaanalysis of 22 RCTs, multidisciplinary interventions that included a pharmacist reduced HF hospitalizations.3 In a recent Cochrane systematic review and meta-analysis of 43 RCTs, both case management (ie, active management of complex patients by case managers working in integrated care systems) and multidisciplinary interventions (ie, coordinated multidisciplinary health care interventions and communications) were shown to reduce all-cause mortality, all-cause readmission, and readmission for HF.4 2.	 Meta-analyses of RCTs have shown that interventions focused on improving HF self-care significantly reduce the risk of HF-related hospitalization,2,5–8 all-cause hospitalization,2,8,9 and all-cause mortality,6,9 as well as improve QOL.5 Interventions that aim to improve self-care knowledge and skill,2,5,8 and those that focus on enhancing medication adherence9 or reinforce self-care with structured telephone support,6,7 are effective in patients with HF. There is uncertainty whether mobile health–delivered educational interventions improve self-care in patients with HF.39 In a single RCT involving rural patients with HF, an educational intervention was shown to improve knowledge and self-care40 but did not significantly decrease the combined endpoint of cardiac death or HF hospitalization.41 In a recent pragmatic trial, a transitional care services program that included

Figure 6. Treatment of HFrEF Stages C and D. Colors correspond to COR in Table 2. Treatment recommendations for patients with HFrEF are displayed. Step 1 medications may be started simultaneously at initial (low) doses recommended for HFrEF. Alternatively, these medications may be started sequentially, with sequence guided by clinical or other factors, without need to achieve target dosing before initiating next medication. Medication doses should be increased to target as tolerated. ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; COR, Class of Recommendation; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; ICD, implantable cardioverter-defibrillator; hydral-nitrates, hydralazine and isosorbide dinitrate; HFrEF, heart failure with reduced ejection fraction; LBBB, left bundle branch block; MCS, mechanical circulatory support; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; NSR, normal sinus rhythm; NYHA, New York Heart Association; and SGLT2i, sodium-glucose cotransporter 2 inhibitor. *Participation in investigational studies is appropriate for stage C, NYHA class II and III HF.

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