For patients with biven- tricular physiology, systemic left ventricular (LV) dys- function, no repairable residual hemodynamic abnor- malities, and persistent HF symptoms, standard GDMT is ostensibly preferable to no treatment. However, ex- pectations of its benefit should be tempered, and risk may be different in patients with acquired CVD, be- cause CHD patients have not been included in the trials by which those guidelines were developed. Recommendation-Specific Supportive Text 1. HF is common in patients with ACHD and is associ- ated with increased morbidity and mortality.S3.14.1-1 There are many causes of HF symptoms that may be reversible, including valve dysfunc- tion, shunts, arrhythmias, venous obstruction, and systolic and/or diastolic ventricular dysfunction, which require evaluation and treatment when possible. Unlike acquired HF, and despite the clin- ical importance of HF in ACHD, data to support a treatment recommendations including typical HF medical therapy (eg, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta blockers, and aldosterone antagonists)S3.14.1-5 are limited in patients with ACHD.S3.14.1-6 S3.14.1-22 HF in patients with ACHD is multifactorial and may manifest as variable response to pharmacotherapy. Advanced HF therapies may be technically difficult or considered too late in the course. Thus, timely evaluation by ACHD and HF specialists is crucial to optimal care of such patients. 3.14.2. Heart Transplant Because of the prevalence of HF among patients with CHD, heart transplantation is increasingly being con- sidered as a therapeutic option. Data on proper timing of transplantation are limited, particularly for individual lesions. 