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Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e925 CLINICAL STATEMENTS AND GUIDELINES self-care education improved discharge preparedness, quality of transition, and QOL but did not significantly improve clinical outcomes compared with usual care.42 3. In propensity-adjusted models, influenza vaccination was associated with a significant reduction in all-cause mortality among participants in PARADIGM-HF (Prospective Comparison of ARNi with ACEi to Determine Impact on Global Mortality and Morbidity in Heart Failure).14 In adjusted models, influenza vaccination was associated with significant reductions in all-cause mortality and cardiovascular mortality12 in 1 registry study and was associated with significant reductions in all-cause mortality and the composite of all-cause mortality and cardiovascular hospitalizations in another large cohort study.11 In a self-controlled case series study of patients with HF, influenza vaccination was associated with a significantly lower risk of cardiovascular, respiratory, and all-cause hospitalization.43 In a meta-analysis of 16 studies of patients with CVD, influenza vaccination was associated with a lower risk of all-cause, cardiovascular mortality, and major adverse cardiovascular events compared with control patients.15 In the Cardiovascular Health Study, pneumococcal vaccination was associated with significant reductions in incident HF, all-cause mortality, and cardiovascular mortality.16 Patients with HF are uniquely susceptible to poor outcomes in the setting of SARS-CoV-2 infection44–47 and should be vaccinated against COVID-19.10 4. Many health and social factors are associated with poor HF self-care.36,37 (Table 11) but have also been linked to poor clinical outcomes and fundamentally change how education and support must be delivered. Depression is a risk factor for poor selfcare,40 rehospitalization,17 and all-cause mortality18 among patients with HF. Interventions that focus on improving HF self-care have been reported to be effective among patients with moderate/ severe depression with reductions in hospitalization and mortality risk.5 Nonrandomized studies have provided evidence of a link between social isolation and mortality in patients with HF19,20 In a recent meta-analysis of 29 cohort studies, frailty was associated with an increased risk of all-cause mortality and hospitalization.23 Frailty also has been shown to impair self-care among elderly patients with HF.24 A recent meta-analysis of observational studies revealed social isolation to be common among adults with HF (ie, 37%) and associated with a 55% greater risk of HF-related rehospitalization.21 Poor social support also has been shown in nonrandomized studies to be associated with lower HF self-care.22 A recent meta-analysis of observational studies showed that inadequate/ marginal health literacy is common among adults with HF (ie, 24%) and associated independently with the risk of mortality and hospitalization.25 Low literacy also is associated with poor HF self-care, as most interventions depend on both literacy and health literacy/numeracy.26 7.1.2 Dietary Sodium Restriction Recommendation for Dietary Sodium Restriction COR LOE Recommendation 2a C-LD 1. For patients with stage C HF, avoiding excessive sodium intake is reasonable to reduce congestive symptoms.1–6 Synopsis Restricting dietary sodium is a common nonpharmacological treatment for patients with HF symptomatic with congestion, but specific recommendations have been based on low-quality evidence.7 Concerns about the quality of data regarding clinical benefits or harm of sodium restriction in patients with HF include the lack of current pharmacological therapy, small samples without sufficient racial and ethnic diversity, questions about the correct threshold for clinical benefit, uncertainty about which subgroups benefit most from sodium restriction,7,8 and serious questions about the validity of several RCTs in this area.9–11 However, there are promising pilot trials of sodium restriction in patients with HF3,5,6 The AHA currently recommends a reduction of sodium intake to <2300 mg/d for general cardiovascular health promotion12; however, there are no trials to support this level of restriction in patients with HF.13 Sodium restriction can result in poor dietary quality with inadequate macronutrient and micronutrient intake.14 Nutritional inadequacies have been associated with clinical instability,15–17 but routine supplementation of oral iron,18 thiamine,19 zinc,20 vitamin D,21 or multivitamins has not proven beneficial.22 The DASH diet is rich in antioxidants and potassium, can achieve sodium restriction without compromising nutritional adequacy when accompanied by dietary counseling,5 and may be associated with reduced hospitalizations for HF.23 Recommendation-Specific Supportive Text 1. A registered dietitian- or nurse-coached intervention with 2 to 3 g/d sodium restriction improved NYHA functional class and leg edema in patients with HFrEF.1 In a nonrandomized study (>2.5 g/d versus <2.5 g/d), lower dietary sodium was associated with worse all-cause mortality in patients with HFrEF.2 In small RCTs, aggressive sodium restriction (0.8 g/d) during hospitalization for acute decompensated HF has not reduced weight, congestion, diuretic use, rehospitalization, or all-cause mortality in patients with HFrEF24 or in patients with HFpEF.25 Downloaded from http://ahajournals.org by on October 7, 2026