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May 3, 2022 Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 e970

CLINICAL STATEMENTS AND GUIDELINES

improving outcomes.20–22 CKD and HF are closely intertwined in pathophysiology and have a complex and bidirectional relationship.23 Renal dysfunction increases the risk of toxicities of HF therapies and impairs response to diuretics.23 The effectiveness of GDMT in patients with HF and concomitant kidney disease is uncertain, because data for treatment outcomes in this patient population are sparse.24 Recommendations surrounding the management of anemia, hypertension, diabetes, and sleep disorders that are attributable to the presence of evolving evidence for specific treatment strategies in HF are discussed next. Other comorbidities not addressed in the recommendations are, of course, also important and warrant attention but, because of lack of large-scale trial data, are not addressed as specific recommendations. Figure 14 summarizes COR 1 and 2a for management of select HF comorbidities. Recommendation-Specific Supportive Text

Anemia

1.	 Routine baseline assessment of all patients with HF includes an evaluation for anemia. Anemia is independently associated with HF disease severity and mortality,25 and iron deficiency appears to be uniquely associated with reduced exercise capacity.26 Iron deficiency is usually defined as ferritin level <100 μg /L or 100 to 300 μg/L, if the transferrin saturation is <20%. Intravenous repletion of iron has been shown to improve exercise capacity and QOL.1–3,27 The FAIR-HF (Ferric Carboxymaltose Assessment in Patients With Iron Deficiency and Chronic Heart Failure) trial showed significant improvement in NYHA classification,

Figure 14. Recommendations for Treatment of Patients With HF and Selected Comorbidities. Colors correspond to COR in Table 2. Recommendations for treatment of patients with HF and select comorbidities are displayed. ACEi indicates angiotensin-converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin receptor blocker; AV, atrioventricular; CHA2DS2-VASc, congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack [TIA], vascular disease, age 65 to 74 years, sex category; CPAP, continuous positive airway pressure; CRT, cardiac resynchronization therapy; EF, ejection fraction; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; SGLT2i, sodium-glucose cotransporter-2 inhibitor; and VHD, valvular heart disease. *Patients with chronic HF with permanent-persistent-paroxysmal AF and a CHA2DS2-VASc score of ≥2 (for men) and ≥3 (for women).

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