Recommendations for Therapies in the Hospitalized HF Patient Recommendations COR LOE References HF patients hospitalized with fluid overload should be treated with intravenous diuretics I B 310,311 HF patients receiving loop diuretic therapy should receive an initial parenteral dose greater than or equal to their chronic oral daily dose; then dose should be serially adjusted I B 312 HFrEF patients requiring HF hospitalization on GDMT should continue GDMT except in cases of hemodynamic instability or where contraindicated I B 307 309 Initiation of beta-blocker therapy at a low dose is recommended after optimization of volume status and discontinuation of intravenous agents I B 307 309 Thrombosis/thromboembolism prophylaxis is recommended for patients hospitalized with HF I B 22,324 328 Serum electrolytes, urea nitrogen, and creatinine should be measured during titration of HF medications, including diuretics I C N/A When diuresis is inadequate, it is reasonable to IIa a. give higher doses of intravenous loop diuretics; or b. add a second diuretic (e.g., thiazide) B 313 316 Low-dose dopamine infusion may be considered with loop diuretics to improve diuresis IIb B 317,318 Ultrafiltration may be considered for patients with obvious volume overload IIb B 319 Ultrafiltration may be considered for patients with refractory congestion IIb C N/A Intravenous nitroglycerin, nitroprusside, or nesiritide may be considered an adjuvant to diuretic therapy for stable patients with HF IIb A 320 323 In patients hospitalized with volume overload and severe hyponatremia, vasopressin antagonists may be considered IIb B 330,331 COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LOE, Level of Evidence; and N/A, not available. No No Warm and Dry Cold and Dry Yes Yes Warm and Wet Cold and Wet Congestion at rest? (e.g.


No No Warm and Dry Cold and Dry Yes Yes Warm and Wet Cold and Wet Congestion at rest? (e.g. orthopnea, elevated jugular venous pressure, pulmonary rales, S3 gallop, edema) (e.g. narrow pulse pressure, cool extremities, hypotension) Low perfusion at rest? Figure 4. Classi cation of patients presenting with acutely decompensated heart failure. Adapted with permission from Nohria et al. (306). JACC Vol. 62, No. 16, 2013 Yancy et al. October 15, 2013:1495 539 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary 3. The effect of HF treatment should be monitored with careful measurement of uid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of HF medi- cations. (Level of Evidence: C) CLASS IIa 1. When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: a. higher doses of intravenous loop diuretics (37,312) (Level of Evidence: B); b. addition of a second (e.g., thiazide) diuretic (313 316). (Level of Evidence: B) CLASS IIb 1. Low-dose dopamine infusion may be considered in addition to loop diuretic therapy to improve diuresis and better preserve renal function and renal blood ow (317,318). (Level of Evidence: B) 7.4. Renal Replacement Therapyd Ultra ltration CLASS IIb 1. Ultra ltration may be considered for patients with obvious volume overload to alleviate congestive symptoms and uid weight (319). (Level of Evidence: B) 2. Ultra ltration may be considered for patients with refractory congestion not responding to medical therapy. (Level of Evidence: C) 7.5. Parenteral Therapy in Hospitalized HF CLASS IIb 1.


(Level of Evidence: C) 7.5. Parenteral Therapy in Hospitalized HF CLASS IIb 1. If symptomatic hypotension is absent, intravenous nitro- glycerin, nitroprusside, or nesiritide may be considered an adjuvant to diuretic therapy for relief of dyspnea in patients admitted with acutely decompensated HF (320 323). (Level of Evidence: A) 7.6. Venous Thromboembolism Prophylaxis in Hospitalized Patients CLASS I 1. A patient admitted to the hospital with decompensated HF should receive venous thromboembolism prophylaxis with an anticoagulant medication if the riskLbene t ratio is favorable (22,324 328). (Level of Evidence: B) 7.7. Arginine Vasopressin Antagonists CLASS IIb 1. In patients hospitalized with volume overload, including HF, who have persistent severe hyponatremia and are at risk for or having active cognitive symptoms despite water restriction and maximization of GDMT, vasopressin antagonists may be considered in the short term to improve serum sodium concentration in hypervolemic, hypona- tremic states with either a V2 receptor selective or a nonselective vasopressin antagonist (330,331). (Level of Evidence: B) 7.8. Inpatient and Transitions of Care See Table 23 for a summary of recommendations from this section. CLASS I 1. The use of performance improvement systems and/or evidence-based systems of care is recommended in the hospital and early postdischarge outpatient setting to identify appropriate HF patients for GDMT, provide clinicians with useful reminders to advance GDMT, and assess the clinical response (151,332 338). (Level of Evidence: B) 2. Throughout the hospitalization as appropriate, before hospital discharge, at the rst postdischarge visit, and in Table 23.


Throughout the hospitalization as appropriate, before hospital discharge, at the rst postdischarge visit, and in Table 23. Recommendations for Hospital Discharge Recommendations or Indications COR LOE References Performance improvement systems in the hospital and early postdischarge outpatient setting to identify HF for GDMT I B 151,332 338 Before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed: a. initiation of GDMT if not done or contraindicated; b. causes of HF, barriers to care, and limitations in support; c. assessment of volume status and blood pressure with adjustment of HF therapy; d. optimization of chronic oral HF therapy; e. renal function and electrolytes; f. management of comorbid conditions; g. HF education, self-care, emergency plans, and adherence; and h. palliative or hospice care I B 57,337,339 341 Multidisciplinary HF disease management for patients at high risk for hospital readmission I B 336,342 344 A follow-up visit within 7 to 14 d and a telephone follow-up within 3 d of hospital discharge are reasonable IIa B 345,346 Use of clinical risk-prediction tools and/or biomarkers to identify higher-risk patients are reasonable IIa B 62 OR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; and LOE, Level of Evidence. Yancy et al. JACC Vol. 62, No. 16, 2013 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary October 15, 2013:1495 539 subsequent follow-up visits, the following should be addressed (57,337,339 341).


16, 2013 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary October 15, 2013:1495 539 subsequent follow-up visits, the following should be addressed (57,337,339 341). (Level of Evidence: B): a. initiation of GDMT if not previously established and not contraindicated; b. precipitant causes of HF, barriers to optimal care tran- sitions, and limitations in postdischarge support; c. assessment of volume status and supine/upright hypo- tension with adjustment of HF therapy as appropriate; d. titration and optimization of chronic oral HF therapy; e. assessment of renal function and electrolytes where appropriate; f. assessment and management of comorbid conditions; g. reinforcement of HF education, self-care, emergency plans, and need for adherence; and h. consideration for palliative care or hospice care in selected patients. 3. Multidisciplinary HF disease-management programs are recommended for patients at high risk for hospital read- mission, to facilitate the implementation of GDMT, to address different barriers to behavioral change, and to reduce the risk of subsequent rehospitalization for HF (336,342 344). (Level of Evidence: B) CLASS IIa 1. Scheduling an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge are reasonable (345,346). (Level of Evidence: B) 2. Use of clinical risk-prediction tools and/or biomarkers to identify patients at higher risk for postdischarge clinical events are reasonable (62). (Level of Evidence: B) 8. Important Comorbidities in HF Although there are additional and important comorbidities that occur in patients with HF as referenced in Table 24, it remains uncertain how best to generate speci c recommendations, given the status of current evidence. Interventional Treatments of HF: Recommendations See Table 25 for a summary of recommendations from this section. CLASS I 1.


Interventional Treatments of HF: Recommendations See Table 25 for a summary of recommendations from this section. CLASS I 1. Coronary artery revascularization via coronary artery bypass graft surgery (CABG) or percutaneous intervention is indicated for patients (HFpEF and HFrEF) on GDMT with angina and suitable coronary anatomy, especially for a left main stenosis (>50%) or left main equivalent disease (11,13,15,348). (Level of Evidence: C) CLASS IIa 1. CABG to improve survival is reasonable in patients with mild to moderate LV systolic dysfunction (EF 35% to 50%) and signi cant ( 70% diameter stenosis) multivessel CAD or proximal left anterior descending coronary artery stenosis when viable myocardium is present in the region of intended revascularization (348 350). (Level of Evidence: B) 2. CABG or medical therapy is reasonable to improve morbidity and cardiovascular mortality for patients with severe LV dysfunction (EF <35%), HF, and signi cant CAD (351,352). (Level of Evidence: B) 3. Surgical aortic valve replacement is reasonable for patients with critical aortic stenosis and a predicted surgical mortality of no greater than 10% (353). (Level of Evidence: B) 4. Transcatheter aortic valve replacement after careful candi- date consideration is reasonable for patients with critical aortic stenosis who are deemed inoperable (354). (Level of Evidence: B) CLASS IIb 1. CABG may be considered with the intent of improving survival in patients with ischemic heart disease with severe LV systolic dysfunction (EF <35%) and operable coronary anatomy whether or not viable myocardium is present (352,355,356). (Level of Evidence: B) Table 24. Ten Most Common Co-Occurring Chronic Conditions Among Medicare Beneficiaries With Heart Failure (N[4,947,918), 2011 Beneficiaries Age 65 y (N 4,376,150)* Beneficiaries Age <65 y (N 5,71,768)y N % N % Ischemic heart disease 3,145,718 71.9 Ischemic heart disease 365,889 64.0 *Mean No.


Ten Most Common Co-Occurring Chronic Conditions Among Medicare Beneficiaries With Heart Failure (N[4,947,918), 2011 Beneficiaries Age 65 y (N 4,376,150)* Beneficiaries Age <65 y (N 5,71,768)y N % N % Ischemic heart disease 3,145,718 71.9 Ischemic heart disease 365,889 64.0 *Mean No. of conditions is 6.1; median is 6. yMean No. of conditions is 5.5; median is 5. COPD indicates chronic obstructive pulmonary disease. Data source: Centers for Medicare and Medicaid Services administrative claims data, January 2011December 2011, from the Chronic Condition Warehouse (CCW), ccwdata.org (347). JACC Vol. 62, No. 16, 2013 Yancy et al. October 15, 2013:1495 539 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary 2. Transcatheter mitral valve repair or mitral valve surgery for functional mitral insuf ciency is of uncertain bene t and should only be considered after careful candidate selection and with a background of GDMT (357 360). (Level of Evidence: B) 3. Surgical reverse remodeling or LV aneurysmectomy may be considered in carefully selected patients with HFrEF for speci c indications, including intractable HF and ventricular arrhythmias (361). (Level of Evidence: B) 10. Coordinating Care for Patients With Chronic HF: Recommendations CLASS I 1. Effective systems of care coordination with special atten- tion to care transitions should be deployed for every patient with chronic HF that facilitate and ensure effective care that is designed to achieve GDMT and prevent hospitalization (333,336,362 377). (Level of Evidence: B) 2. Every patient with HF should have a clear, detailed, and evidence-based plan of care that ensures the achievement of GDMT goals, effective management of comorbid condi- tions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease.


Every patient with HF should have a clear, detailed, and evidence-based plan of care that ensures the achievement of GDMT goals, effective management of comorbid condi- tions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease. This plan of care should be updated regularly and made readily available to all members of each patient s healthcare team (14). (Level of Evidence: C) 3. Palliative and supportive care is effective for patients with symptomatic advanced HF to improve quality of life (31,378 381). (Level of Evidence: B) 11. Quality Metrics/Performance Measures: Recommendations CLASS I 1. Performance measures based on professionally developed clinical practice guidelines should be used with the goal of improving quality of care for HF (334,343,382). (Level of Evidence: B) CLASS IIa 1. Participation in quality improvement programs and patient registries based on nationally endorsed, clinical practice guidelineLbased quality and performance measures can be bene cial in improving quality of HF care (334,343). (Level of Evidence: B) See Table 26 for a revised ACCF/AHA/PCPI 2011 HF measurement set. 12. Evidence Gaps and Future Research Directions Despite the objective evidence compiled by the writing committee on the basis of hundreds of clinical trials, there are huge gaps in our knowledge base about many fundamental aspects of HF care. Some key examples include an effective management strategy for patients with HFpEF beyond blood pressure control; a convincing method to use biomarkers in the optimizationofmedicaltherapy;therecognitionandtreatmentof cardiorenalsyndrome; andthe critical needfor improving patient adherence to therapeutic regimens. Even the widely embraced dictum of sodium restriction in HF is not well supported by current evidence.


Even the widely embraced dictum of sodium restriction in HF is not well supported by current evidence. Moreover, the majority ofthe clinical trials that inform GDMT were designed around the primary endpoint of mortality, so that there is less certainty about the impact of therapies on the health-related quality of life of patients. It is also ofmajorconcernthatthemajorityofrandomizedcontrolledtrials failed to randomize a suf cient number of the elderly, women, and underrepresented minorities, thus limiting our insight into these important patient cohorts. A growing body of studies on patient-centered outcomes research is likely to address some of these de ciencies, but time will be required. HF is a syndrome with a high prevalence of comorbidities and multiple chronic conditions, but most guidelines are developed for patients with a single disease. Nevertheless, the coexistence of additional diseases such as arthritis, renal Table 25.


Nevertheless, the coexistence of additional diseases such as arthritis, renal Table 25. Recommendations for Surgical/Percutaneous/Transcatheter Interventional Treatments of HF Recommendations COR LOE References CABG or percutaneous intervention is indicated for HF patients on GDMT with angina and suitable coronary anatomy, especially significant left main stenosis or left main equivalent I C 11,13,15,348 CABG to improve survival is reasonable in patients with mild to moderate LV systolic dysfunction and significant multivessel CAD or proximal LAD stenosis when viable myocardium is present IIa B 348 350 CABG or medical therapy is reasonable to improve morbidity and mortality for patients with severe LV dysfunction (EF <35%), HF, and significant CAD IIa B 351,352 Surgical aortic valve replacement is reasonable for patients with critical aortic stenosis and a predicted surgical mortality of no greater than 10% IIa B 353 Transcatheter aortic valve replacement is reasonable for patients with critical aortic stenosis who are deemed inoperable IIa B 354 CABG may be considered in patients with ischemic heart disease, severe LV systolic dysfunction, and operable coronary anatomy whether or not viable myocardium is present IIb B 352,355,356 Transcatheter mitral valve repair or mitral valve surgery for functional mitral insufficiency is of uncertain benefit IIb B 357 360 Surgical reverse remodeling or LV aneurysmectomy may be considered in HFrEF for specific indications, including intractable HF and ventricular arrhythmias IIb B 361 CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COR, Class of Recommendation; EF, ejection fraction; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LAD, left anterior descending; LOE, Level of Evidence; and LV, left ventricular. Yancy et al. JACC Vol. 62, No.


Recommendations for Surgical/Percutaneous/Transcatheter Interventional Treatments of HF Recommendations COR LOE References CABG or percutaneous intervention is indicated for HF patients on GDMT with angina and suitable coronary anatomy, especially significant left main stenosis or left main equivalent I C 11,13,15,348 CABG to improve survival is reasonable in patients with mild to moderate LV systolic dysfunction and significant multivessel CAD or proximal LAD stenosis when viable myocardium is present IIa B 348 350 CABG or medical therapy is reasonable to improve morbidity and mortality for patients with severe LV dysfunction (EF <35%), HF, and significant CAD IIa B 351,352 Surgical aortic valve replacement is reasonable for patients with critical aortic stenosis and a predicted surgical mortality of no greater than 10% IIa B 353 Transcatheter aortic valve replacement is reasonable for patients with critical aortic stenosis who are deemed inoperable IIa B 354 CABG may be considered in patients with ischemic heart disease, severe LV systolic dysfunction, and operable coronary anatomy whether or not viable myocardium is present IIb B 352,355,356 Transcatheter mitral valve repair or mitral valve surgery for functional mitral insufficiency is of uncertain benefit IIb B 357 360 Surgical reverse remodeling or LV aneurysmectomy may be considered in HFrEF for specific indications, including intractable HF and ventricular arrhythmias IIb B 361 CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COR, Class of Recommendation; EF, ejection fraction; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LAD, left anterior descending; LOE, Level of Evidence; and LV, left ventricular. Yancy et al. JACC Vol. 62, No. 16, 2013 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary October 15, 2013:1495 539 insuf ciency, diabetes mellitus, or chronic lung disease with the HF syndrome should logically require a modi cation of treatment, outcome assessment, or follow-up care.


16, 2013 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary October 15, 2013:1495 539 insuf ciency, diabetes mellitus, or chronic lung disease with the HF syndrome should logically require a modi cation of treatment, outcome assessment, or follow-up care. About 25% of Americans have multiple chronic conditions; this gure rises to 75% in those >65 years of age, including the diseases referred to above, as well as asthma, hypertension, cognitive disorders, or depression (347). Most randomized controlled trials in HF speci cally excluded patients with signi cant Table 26. ACCF/AHA/AMA-PCPI 2011 HF Measurement Set Measure Description* Care Setting Level of Measurement 1. LVEF assessment Percentage of patients aged 18 y with a diagnosis of HF for whom the quantitative or qualitative results of a recent or prior (any time in the past) LVEF assessment is documented within a 12-mo period Outpatient Individual practitioner 2. LVEF assessment Percentage of patients aged 18 y with a principal discharge diagnosis of HF with documentation in the hospital record of the results of an LVEF assessment performed either before arrival or during hospitalization, OR documentation in the hospital record that LVEF assessment is planned for after discharge Inpatient  Individual practitioner  Facility 3. Symptom and activity assessment Percentage of patient visits for patients aged 18 y with a diagnosis of HF with quantitative results of an evaluation of both current level of activity and clinical symptoms documented Outpatient Individual practitioner 4.


Symptom and activity assessment Percentage of patient visits for patients aged 18 y with a diagnosis of HF with quantitative results of an evaluation of both current level of activity and clinical symptoms documented Outpatient Individual practitioner 4. Symptom managementy Percentage of patient visits for patients aged 18 y with a diagnosis of HF and with quantitative results of an evaluation of both level of activity AND clinical symptoms documented in which patient symptoms have improved or remained consistent with treatment goals since last assessment OR patient symptoms have demonstrated clinically important deterioration since last assessment with a documented plan of care Outpatient Individual practitioner 5. Patient self-care educationyz Percentage of patients aged 18 y with a diagnosis of HF who were provided with self-care education on 3 elements of education during 1 visits within a 12-mo period Outpatient Individual practitioner 6. Beta-blocker therapy for LVSD (outpatient and inpatient setting) Percentage of patients aged 18 y with a diagnosis of HF with a current or prior LVEF <40% who were prescribed beta-blocker therapy with bisoprolol, carvedilol, or sustained-release metoprolol succinate either within a 12-mo period when seen in the outpatient setting or at hospital discharge Inpatient and outpatient  Individual practitioner  Facility 7. ACE inhibitor or ARB therapy for LVSD (outpatient and inpatient setting) Percentage of patients aged 18 y with a diagnosis of HF with a current or prior LVEF <40% who were prescribed ACE inhibitor or ARB therapy either within a 12-mo period when seen in the outpatient setting or at hospital discharge Inpatient and outpatient  Individual practitioner  Facility 8.


ACE inhibitor or ARB therapy for LVSD (outpatient and inpatient setting) Percentage of patients aged 18 y with a diagnosis of HF with a current or prior LVEF <40% who were prescribed ACE inhibitor or ARB therapy either within a 12-mo period when seen in the outpatient setting or at hospital discharge Inpatient and outpatient  Individual practitioner  Facility 8. Counseling about ICD implantation for patients with LVSD on combination medical therapyyz Percentage of patients aged 18 y with a diagnosis of HF with current LVEF 35% despite ACE inhibitor/ARB and beta-blocker therapy for at least 3 mo who were counseled about ICD placement as a treatment option for the prophylaxis of sudden death Outpatient Individual practitioner 9. Postdischarge appointment for HF patients Percentage of patients, regardless of age, discharged from an inpatient facility to ambulatory care or home health care with a principal discharge diagnosis of HF for whom a follow-up appointment was scheduled and documented, including location, date, and time for a follow-up office visit or home health visit (as specified) Inpatient Facility N.B., Regarding test measure no. 8, implantation of an ICD must be consistent with published guidelines. This measure is intended to promote counseling only. *Refer to the complete measures for comprehensive information, including measure exception. yTest measure designated for use in internal quality improvement programs only. These measures are not appropriate for any other purpose (e.g., pay for performance, physician ranking, or public reporting programs). zNew measure. ACCF indicates American College of Cardiology Foundation; ACE, angiotensin-converting enzyme; AHA, American Heart Association; AMA-PCPI, American Medical AssociationPhysician Consortium for Performance Improvement; ARB, angiotensin-receptor blocker; HF, heart failure; ICD, implantable cardioverter-defibrillator; LVEF, left ventricular ejection fraction; and LVSD, left ventricular systolic dysfunction. Adapted from Bonow et al. (383). JACC Vol. 62, No.


Adapted from Bonow et al. (383). JACC Vol. 62, No. 16, 2013 Yancy et al. October 15, 2013:1495 539 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary other comorbidities from enrollment, thus limiting our ability to generalize our recommendations to many real-world patients. Therefore, the clinician must, as always, practice the art of using the best of the guideline recommendations as they apply to a speci c patient. Future research will need to focus on novel pharmacolog- ical therapies, especially for patients hospitalized with HF; regenerative cell-based therapies to restore myocardium; and new device platforms that will either improve existing tech- nologies (e.g., CRT, ICD, left ventricular assist device) or introduce simpler, less morbid devices that are capable of changing the natural history of HF. What is critically needed is an evidence base that clearly identi es best processes of care, especially in the transition from hospital to home. Finally, preventing the burden of this disease through more successful risk modi cation, sophisticated screening, perhaps using speci c omics technologies (i.e., systems biology), or effective treatment interventions that reduce the progression from stage A to stage B is an urgent need.


, systems biology), or effective treatment interventions that reduce the progression from stage A to stage B is an urgent need. Presidents and Staff American College of Cardiology Foundation John Gordon Harold, MD, MACC, President Shalom Jacobovitz, Chief Executive Of cer William J. Oetgen, MD, MBA, FACC, Senior Vice President, Science and Quality Charlene L. May, Senior Director, Science and Clinical Policy American College of Cardiology Foundation/ American Heart Association Lisa Brad eld, CAE, Director, Science and Clinical Policy Debjani Mukherjee, MPH, Associate Director, Evidence- Based Medicine Ezaldeen Ramadhan III, Specialist, Science and Clinical Policy Sarah Jackson, MPH, Specialist, Science and Clinical Policy American Heart Association Donna K. Arnett, PhD, MD, FAHA, President Nancy Brown, Chief Executive Of cer Rose Marie Robertson, MD, FAHA, Chief Science Of cer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Of ce of Science Operations Judy Bezanson, DSN, RN, CNS-MS, FAHA, Science and Medicine Advisor Jody Hundley, Production Manager, Scienti c Publications, Of ce of Science Operations References 1. ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/AHA Task Force on Practice Guidelines. Available at: http://assets.cardiosource.com/Methodology_Manual_for_ ACC_AHA_Writing_Committees.pdf and http://my.americanheart.org/ idc/groups/ahamah-public/@wcm/sop/documents/downloadable/ ucm_319826.pdf. American College of Cardiology Foundation and American Heart Association. Accessed May 16, 2012. 2. Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Institute of Medicine: Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press; 2011. 3. Committee on Standards for Systematic Reviews of Comparative Effectiveness Research, Institute of Medicine: Finding What Works in Health Care: Standards for Systematic Reviews. Washington, DC: The National Academies Press; 2011. 4. Yancy C, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.


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