2013 ACCF/AHA Guideline for the Management of Heart Failure: A

350 Pages·2013·3.24 MB·English

Accepted Manuscript
2013 ACCF/AHA Guideline for the Management of Heart Failure
Clyde W. Yancy, MD, MSc, FACC, FAHA Mariell Jessup, MD, FACC, FAHA Biykem
Bozkurt, MD, PhD, FACC, FAHA Frederick A. Masoudi, MD, MSPH, FACC, FAHA
Javed Butler, MBBS, FACC, FAHA Patrick E. McBride, MD, MPH, FACC Donald
E. Casey, John J.V. McMurray, MD, FACC Mark H. Drazner, MD, MSc, FACC,
FAHA Judith E. Mitchell, MD, FACC, FAHA Gregg C. Fonarow, MD, FACC, FAHA
Pamela N. Peterson, MD, MSPH, FACC, FAHA Stephen A. Geraci, MD, FACC,
FAHA, FCCP Tamara Horwich, MD, FACC James L. Januzzi, MD, FACC Maryl R.
Johnson, MD, FACC, FAHA Edward K. Kasper, MD, FACC, FAHA Wayne C. Levy,
MD, FACC Barbara Riegel, DNSc, RN, FAHA Flora Sam, MD, FACC, FAHA Lynne
W. Stevenson, MD, FACC W.H. Wilson Tang, MD, FACC Emily J. Tsai, MD, FACC
Bruce L. Wilkoff, MD, FACC, FHRS Jeffrey L. Anderson, MD, FACC, FAHA Alice K.
Jacobs, MD, FACC, FAHA Jonathan L. Halperin, MD, FACC, FAHA Nancy M. Albert,
PhD, CCNS, CCRN, FAHA Richard J. Kovacs, MD, FACC, FAHA Biykem Bozkurt,
MD, PhD, FACC, FAHA Frederick G. Kushner, MD, FACC, FAHA Ralph G. Brindis,
MD, MPH, MACC E. Magnus Ohman, MD, FACC Mark A. Creager, MD, FACC,
FAHA Susan J. Pressler, PhD, RN, FAAN, FAHA Lesley H. Curtis, PhD Frank W.
Sellke, MD, FACC, FAHA David DeMets, PhD Win-Kuang Shen, MD, FACC, FAHA
Robert A. Guyton, MD, FACC William G. Stevenson, MD, FACC, FAHA Judith S.
Hochman, MD, FACC, FAHA Clyde W. Yancy, MD, MSc, FACC, FAHA
PII: S0735-1097(13)02114-1
DOI: 10.1016/j.jacc.2013.05.019
Reference: JAC 18939
To appear in: Journal of the American College of Cardiology
Please cite this article as: Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE, Casey Jr
DE, McMurray JJV, Drazner MH, Mitchell JE, Fonarow GC, Peterson PN, Geraci SA, Horwich T, Januzzi
JL, Johnson MR, Kasper EK, Levy WC, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff
BL, 2013 ACCF/AHA Guideline for the Management of Heart Failure, Journal of the American College of
Cardiology (2013), doi: 10.1016/j.jacc.2013.05.019.
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Yancy, CW et al.
2013 ACCF/AHA Heart Failure Guideline
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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Developed in Collaboration With the Heart Rhythm Society
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Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation
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WRITING COMMITTEE MEMBERS*
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TnQTable1
ACCF/AHA TASK FORCE MEMBERS
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Jeffrey L. Anderson, MD, FACC, FAHA, Chair
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Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair‡‡
Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect
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TnQTable2*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships
with industry and other entities may apply; see Appendix 1 for recusal information.
†ACCF/AHA representative. A
‡ACCF/AHA Task Force on Practice Guidelines liaison.
§American College of Physicians representative. M
║American College of Chest Physicians representative.
¶International Society for Heart and Lung Transplantation representative.
#ACCF/AHA Task Force on Performance Measures liaison.

**American Academy of Family Physicians representative.
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††Heart Rhythm Society representative.
‡‡Former Task Force member during this writing effort.
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This document was approved by the American College of Cardiology Foundation Board of Trustees and the American Heart Association
Science Advisory and Coordinating Committee in May 2013.
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The American College of Cardiology Foundation requests that this document be cited at follows: Yancy CW, Jessup M, Bozkurt B,
Butler J, Casey DE Jr, Drazner MH, Fonarow PGC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA,
McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013
ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart
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Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013 June 5 [E-pub ahead of print].

This article is copublished in CirculCation.

Copies: This document is available on the World Wide Web sites of the American College of Cardiology (http://www.cardiosource.org)
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and the American Heart Association (my.americanheart.org). For copies of this document, please contact the Elsevier Inc. Reprint
Department, fax [phone], e-mail [email protected].
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Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the
express permission of the American College of Cardiology Foundation. Please contact [email protected].

© 2013 by the American College of Cardiology Foundation and the American Heart Association, Inc.

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Table of Contents
Preamble................................................................................................................................................................5
1. Introduction.......................................................................................................................................................7
1.1. Methodology and Evidence Review.............................................................................................................7
1.2. Organization of the Writing Committee.......................................................................................................8
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1.3. Document Review and Approval..................................................................................................................8
1.4. Scope of This Guideline With Reference to Other Relevant Guidelines or Statements...............................9
2. Definition of HF.....................................................................................................................P..........................10
2.1. HF With Reduced EF (HFrEF)...................................................................................................................11
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2.2. HF With Preserved EF (HFpEF).................................................................................................................11
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3. HF Classifications...........................................................................................................................................12
4. Epidemiology...................................................................................................................................................13
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4.1. Mortality.....................................................................................................................................................13
4.2. Hospitalizations...........................................................................................................................................14
4.3. Asymptomatic LV Dysfunction..............................................................S....................................................14
4.4. Health-Related Quality of Life and Functional Status................................................................................14
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4.5. Economic Burden of HF.............................................................................................................................15
4.6. Important Risk Factors for HF (Hypertension, Diabetes Mellitus, Metabolic Syndrome, and
Atherosclerotic Disease)...................................................................N.................................................................15
5. Cardiac Structural Abnormalities and Other Causes of HF......................................................................16
5.1. Dilated Cardiomyopathies.................................................A.........................................................................16
5.1.1. Definition and Classification of Dilated Cardiomyopathies..............................................................16
5.1.2. Epidemiology and Natural History of DCM.....M................................................................................16
5.2. Familial Cardiomyopathies.........................................................................................................................17
5.3. Endocrine and Metabolic Causes of Cardiomyopathy................................................................................17

5.3.1. Obesity...................................................D............................................................................................17
5.3.2. Diabetic Cardiomyopathy..................................................................................................................17
5.3.3. Thyroid Disease.................................................................................................................................18
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5.3.4. Acromegaly and Growth Hormone Deficiency.................................................................................18
5.4. Toxic Cardiomyopathy...............................................................................................................................18
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5.4.1. Alcoholic Cardiomyopathy...............................................................................................................18
5.4.2. Cocaine Cardiomyopathy..................................................................................................................18
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5.4.3. Cardiotoxicity Related to Cancer Therapies......................................................................................19
5.4.4. Other Myocardial Toxins and Nutritional Causes of Cardiomyopathy.............................................19
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5.5. Tachycardia-Induced Cardiomyopathy.......................................................................................................19
5.6. Myocarditis and Cardiomyopathies Due to Inflammation..........................................................................20
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5.6.1. Myocarditis........................................................................................................................................20
5.6.2. Acquired Immunodeficiency Syndrome............................................................................................20
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5.6.3. Chagas’ Disease................................................................................................................................20
5.7. Inflammation-Induced Cardiomyopathy: Noninfectious Causes................................................................21
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5.7.1. Hypersensitivity Myocarditis............................................................................................................21
5.7.2. Rheumatological/Connective Tissue Disorders.................................................................................21
5.8. Peripartum Cardiomyopathy.......................................................................................................................21
5.9. Cardiomyopathy Caused By Iron Overload................................................................................................22
5.10. Amyloidosis..............................................................................................................................................22
5.11. Cardiac Sarcoidosis...................................................................................................................................22
5.12. Stress (Takotsubo) Cardiomyopathy.........................................................................................................23
6. Initial and Serial Evaluation of the HF Patient............................................................................................23
6.1. Clinical Evaluation......................................................................................................................................23
6.1.1. History and Physical Examination: Recommendations.....................................................................23
6.1.2. Risk Scoring: Recommendation........................................................................................................24
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6.2. Diagnostic Tests: Recommendations..........................................................................................................24
6.3. Biomarkers: Recommendations..................................................................................................................25
6.3.1. Natriuretic Peptides: BNP or NT-proBNP........................................................................................26
6.3.2. Biomarkers of Myocardial Injury: Cardiac Troponin T or I.............................................................27
6.3.3. Other Emerging Biomarkers..............................................................................................................27
6.4. Noninvasive Cardiac Imaging: Recommendations.....................................................................................28
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6.5. Invasive Evaluation: Recommendations.....................................................................................................30
6.5.1. Right-Heart Catheterization...............................................................................................................31
6.5.2. Left-Heart Catheterization.......................................................................................P..........................31
6.5.3. Endomyocardial Biopsy....................................................................................................................32
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7. Treatment of Stages A to D............................................................................................................................32
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7.1. Stage A: Recommendations........................................................................................................................32
7.1.1. Recognition and Treatment of Elevated Blood Pressure...................................................................32
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7.1.2. Treatment of Dyslipidemia and Vascular Risk..................................................................................33
7.1.3. Obesity and Diabetes Mellitus...........................................................................................................33
7.1.4. Recognition and Control of Other Conditions That May Lead to HSF...............................................33
7.2. Stage B: Recommendations........................................................................................................................34
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7.2.1. Management Strategies for Stage B................................................................................................35
7.3. Stage C........................................................................................................................................................37
7.3.1. Nonpharmacological Interventions..................................N.................................................................37
7.3.1.1. Education: Recommendation.......................................................................................................37
7.3.1.2. Social Support.....................................................A.........................................................................38
7.3.1.3. Sodium Restriction: Recommendation.........................................................................................38
7.3.1.4. Treatment of Sleep Disorders: RecommendaMtion........................................................................39
7.3.1.5. Weight Loss.................................................................................................................................39
7.3.1.6. Activity, Exercise Prescription, and Cardiac Rehabilitation: Recommendations........................40

7.3.2. Pharmacological Treatment for Stage CD HFrEF: Recommendations................................................40
7.3.2.1. Diuretics: Recommendation.........................................................................................................41
7.3.2.2. ACE Inhibitors: Recommendation...............................................................................................43
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7.3.2.3. ARBs: Recommendations............................................................................................................44
7.3.2.4. Beta Blockers: Recommendation.................................................................................................46
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7.3.2.5. Aldosterone Receptor Antagonists: Recommendations...............................................................48
7.3.2.6. Hydralazine and Isosorbide Dinitrate: Recommendations...........................................................50
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7.3.2.7. Digoxin: Recommendation..........................................................................................................51
7.3.2.8. Other Drug Treatment..................................................................................................................53
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7.3.2.8.1. Anticoagulation: Recommendations.....................................................................................53
7.3.2.8.2. Statins: Recommendation......................................................................................................55
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7.3.2.8.3. Omega-3 Fatty Acids: Recommendation..............................................................................55
7.3.2.9. Drugs of Unproven Value or That May Worsen HF: Recommendations....................................56
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7.3.2.9.1. Nutritional Supplements and Hormonal Therapies...............................................................56
7.3.2.9.2. Antiarrhythmic Agents..........................................................................................................57
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7.3.2.9.3. Calcium Channel Blockers: Recommendation......................................................................57
7.3.2.9.4. Nonsteroidal Anti-Inflammatory Drugs................................................................................58
7.3.2.9.5. Thiazolidinediones................................................................................................................58
7.3.3. Pharmacological Treatment for Stage C HFpEF: Recommendations...............................................59
7.3.4. Device Therapy for Stage C HFrEF: Recommendations..................................................................60
7.3.4.1. Implantable Cardioverter-Defibrillator........................................................................................61
7.3.4.2. Cardiac Resynchronization Therapy............................................................................................63
7.4. Stage D........................................................................................................................................................66
7.4.1. Definition of Advanced HF...............................................................................................................66
7.4.2. Important Considerations in Determining If the Patient Is Refractory..............................................66
7.4.3. Water Restriction: Recommendation................................................................................................67
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7.4.4. Inotropic Support: Recommendations...............................................................................................68
7.4.5. Mechanical Circulatory Support: Recommendations........................................................................69
7.4.6. Cardiac Transplantation: Recommendation......................................................................................70
8. The Hospitalized Patient.................................................................................................................................72
8.1. Classification of Acute Decompensated HF...............................................................................................72
8.2. Precipitating Causes of Decompensated HF: Recommendations...............................................................73
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8.3. Maintenance of GDMT During Hospitalization: Recommendations.........................................................74
8.4. Diuretics in Hospitalized Patients: Recommendations...............................................................................75
8.5. Renal Replacement Therapy—Ultrafiltration: Recommendations...................................P..........................77
8.6. Parenteral Therapy in Hospitalized HF: Recommendation........................................................................77
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8.7. Venous Thromboembolism Prophylaxis in Hospitalized Patients: Recommendation................................78
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8.8. Arginine Vasopressin Antagonists: Recommendation................................................................................80
8.9. Inpatient and Transitions of Care: Recommendations................................................................................81
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9. Important Comorbidities in HF.....................................................................................................................83
9.1. Atrial Fibrillation........................................................................................................................................83
9.2. Anemia....................................................................................................S....................................................86
9.3. Depression..................................................................................................................................................88
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9.4. Other Multiple Comorbidities.....................................................................................................................88
10. Surgical/Percutaneous/Transcather Interventional Treatments of HF: Recommendations.................88
11. Coordinating Care for Patients With Chronic HF..................N..................................................................90
11.1. Coordinating Care for Patients With Chronic HF: Recommendations.....................................................90
11.2. Systems of Care to Promote Care Coordination for PatieAnts With Chronic HF.......................................91
11.3. Palliative Care for Patients With HF.........................................................................................................92
12. Quality Metrics/Performance Measures: RecommenMdations...................................................................92
13. Evidence Gaps and Future Research Directions........................................................................................94
Appendix 1. Author Relationships With Industry and Other Entities (Relevant)........................................96

Appendix 2. Reviewer Relationships With IndustDry and Other Entities (Relevant)....................................96
Appendix 3. Abbreviations.................................................................................................................................99
References..........................................................................................................................................................100
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Preamble
The medical profession should play a central role in evaluating the evidence related to drugs, devices, and
procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of
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available data on the benefits and risks of these therapies and procedures can improve the quality of care,
optimize patient outcomes, and favorably affect costs by focusing resources on the most effecPtive strategies. An
organized and directed approach to a thorough review of evidence has resulted in the prodIuction of clinical
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practice guidelines that assist clinicians in selecting the best management strategy for an individual patient.
Moreover, clinical practice guidelines can provide a foundation for other applicatioCns, such as performance
measures, appropriate use criteria, and both quality improvement and clinical decision support tools.
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The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA)
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have jointly produced guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force
on Practice Guidelines (Task Force), charged with developing, updating, and revising practice guidelines for
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cardiovascular diseases and procedures, directs and oversees this effort. Writing committees are charged with
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regularly reviewing and evaluating all available evidence to develop balanced, patient-centric recommendations
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for clinical practice.
Experts in the subject under consideration are selected by the ACCF and AHA to examine subject-

specific data and write guidelines in partnership withD representatives from other medical organizations and
specialty groups. Writing committees are asked to perform a literature review; weigh the strength of evidence
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for or against particular tests, treatments, or procedures; and include estimates of expected outcomes where such
data exist. Patient-specific modifiers, comoTrbidities, and issues of patient preference that may influence the
choice of tests or therapies are considered. When available, information from studies on cost is considered, but
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data on efficacy and outcomes constitute the primary basis for the recommendations contained herein.
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In analyzing the data and developing recommendations and supporting text, the writing committee uses
evidence-based methodologieCs developed by the Task Force (1). The Class of Recommendation (COR) is an
estimate of the size of the treatment effect considering risks versus benefits in addition to evidence and/or
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agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm.
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The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing
committee reviews and ranks evidence supporting each recommendation with the weight of evidence ranked as
LOE A, B, or C according to specific definitions that are included in Table 1. Studies are identified as
observational, retrospective, prospective, or randomized where appropriate. For certain conditions for which
inadequate data are available, recommendations are based on expert consensus and clinical experience and are
ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate
references (including clinical reviews) are cited if available. For issues for which sparse data are available, a
survey of current practice among the clinicians on the writing committee is the basis for LOE C
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recommendations and no references are cited. The schema for COR and LOE are summarized in Table 1, which
also provides suggested phrases for writing recommendations within each COR. A new addition to this
methodology is separation of the Class III recommendations to delineate whether the recommendation is
determined to be of “no benefit” or is associated with “harm” to the patient. In addition, in view of the
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increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing
recommendations for the comparative effectiveness of one treatment or strategy versus another have been added
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for COR I and IIa, LOE A or B only.
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In view of the advances in medical therapy across the spectrum of cardiovasculRar diseases, the Task
Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy
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as defined by ACCF/AHA guideline−recommended therapies (primarily Class I). This new term, GDMT, will
be used herein and throughout all future guidelines. S
Because the ACCF/AHA practice guidelines address patient popuUlations (and clinicians) residing in
North America, drugs that are not currently available in North America are discussed in the text without a
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specific COR. For studies performed in large numbers of subjects outside North America, each writing
committee reviews the potential influence of different practice pAatterns and patient populations on the treatment
effect and relevance to the ACCF/AHA target population to determine whether the findings should inform a
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specific recommendation.
The ACCF/AHA practice guidelines are inten ded to assist clinicians in clinical decision making by
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describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific
diseases or conditions. The guidelines attempt Eto define practices that meet the needs of most patients in most
circumstances. The ultimate judgment regarding care of a particular patient must be made by the clinician and
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patient in light of all the circumstances presented by that patient. As a result, situations may arise for which
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deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of
the quality and availability of expeErtise in the area where care is provided. When these guidelines are used as the
basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force
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recognizes that situations arise in which additional data are needed to inform patient care more effectively; these
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areas will be identified within each respective guideline when appropriate.
Prescribed cAourses of treatment in accordance with these recommendations are effective only if
followed. Because lack of patient understanding and adherence may adversely affect outcomes, clinicians
should make every effort to engage the patient’s active participation in prescribed medical regimens and
lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment
and be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, for which the
benefit-to-risk ratio may be lower.
The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may
arise as a result of industry relationships or personal interests among the members of the writing committee. All
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writing committee members and peer reviewers of the guideline are required to disclose all current healthcare-
related relationships, including those existing 12 months before initiation of the writing effort. In December
2009, the ACCF and AHA implemented a new policy for relationship with industry and other entities (RWI)
that requires the writing committee chair plus a minimum of 50% of the writing committee to have no relevant
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RWI (Appendix 1 for the ACCF/AHA definition of relevance). These statements are reviewed by the Task
Force and all members during each conference call and/or meeting of the writing committee and are updated as
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changes occur. All guideline recommendations require a confidential vote by the writing committee and must be
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approved by a consensus of the voting members. Members are not permitted to draft orR vote on any text or
recommendations pertaining to their RWI. Members who recused themselves from voting are indicated in the
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list of writing committee members, and specific section recusals are noted in Appendix 1. Authors’ and peer
reviewers’ RWI pertinent to this guideline are disclosed in Appendixes 1 andS 2, respectively. Additionally, to
ensure complete transparency, writing committee members’ comprehensiUve disclosure information(cid:190) including
RWI not pertinent to this document(cid:190) is available as an online supplement
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(http://jaccjacc.cardiosource.com/DataSupp/ACCF/2013_HFGL_Comprehensive_RWI_Table.pdf).
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Comprehensive disclosure information for the Task Force is also available online at
http://www.cardiosource.org/en/ACC/About-ACC/Who-WeM-Are/Leadership/Guidelines-and-Documents-Task-
Forces.aspx. The work of writing committees is supported exclusively by the ACCF and AHA without

commercial support. Writing committee members volunteered their time for this activity.
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In an effort to maintain relevance at the point of care for practicing clinicians, the Task Force continues
to oversee an ongoing process improvement iniEtiative. As a result, in response to pilot projects, several changes
to these guidelines will be apparent, includTing limited narrative text, a focus on summary and evidence tables
(with references linked to abstracts in PubMed), and more liberal use of summary recommendation tables (with
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references that support LOE) to serve as a quick reference.
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In April 2011, the Institute of Medicine released 2 reports: Clinical Practice Guidelines We Can Trust
and Finding What Works in HCealth Care: Standards for Systematic Reviews (2, 3). It is noteworthy that the
ACCF/AHA practice guidelines are cited as being compliant with many of the proposed standards. A thorough
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review of these reports and of our current methodology is under way, with further enhancements anticipated.
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The recommendations in this guideline are considered current until they are superseded by a focused
update or the full-text guideline is revised. Guidelines are official policy of both the ACCF and AHA.

Jeffrey L. Anderson, MD, FACC, FAHA
Chair, ACCF/AHA Task Force on Practice Guidelines

1. Introduction
1.1. Methodology and Evidence Review
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The recommendations listed in this document are, whenever possible, evidence based. An extensive evidence
review was conducted through October 2011 and selected other references through April 2013. Searches were
extended to studies, reviews, and other evidence conducted in human subjects and that were published in
English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other
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selected databases relevant to this guideline. Key search words included but were not limited to the following:
heart failure, cardiomyopathy, quality of life, mortality, hospitalizations, prevention, biomarkers, hypertension,
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dyslipidemia, imaging, cardiac catheterization, endomyocardial biopsy, angiotensin-converting enzyme
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inhibitors, angiotensin-receptor antagonists/blockers, beta blockers, cardiac, cardiac rResynchronization
therapy, defibrillator, device-based therapy, implantable cardioverter-defibrillator, device implantation,
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medical therapy, acute decompensated heart failure, preserved ejection fraction, terminal care and
transplantation, quality measures, and performance measures. Additionally, Sthe committee reviewed documents
related to the subject matter previously published by the ACCF and AHAU. References selected and published in
this document are representative and not all-inclusive.
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To provide clinicians with a representative evidence base, whenever deemed appropriate or when
published, the absolute risk difference and number needed to treAat or harm are provided in the guideline (within
tables), along with confidence intervals and data related to the relative treatment effects such as odds ratio,
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relative risk, hazard ratio, and incidence rate ratio.

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1.2. Organization of the Writing Committee
The committee was composed of physicians anEd a nurse with broad expertise in the evaluation, care, and
management of patients with heart failure (HF). The authors included general cardiologists, HF and transplant
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specialists, electrophysiologists, general internists, and physicians with methodological expertise. The
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committee included representatives from the ACCF, AHA, American Academy of Family Physicians, American
College of Chest Physicians, HearEt Rhythm Society, and International Society for Heart and Lung
Transplantation.
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1.3. Document Review and Approval
This documeAnt was reviewed by 2 official reviewers each nominated by both the ACCF and the AHA,
as well as 1 to 2 reviewers each from the American Academy of Family Physicians, American College of Chest
Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation, as well as 32
individual content reviewers (including members of the ACCF Adult Congenital and Pediatric Cardiology
Council, ACCF Cardiovascular Team Council, ACCF Council on Cardiovascular Care for Older Adults, ACCF
Electrophysiology Committee, ACCF Heart Failure and Transplant Council, ACCF Imaging Council, ACCF
Prevention Committee, ACCF Surgeons' Scientific Council, and ACCF Task Force on Appropriate Use
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