Table 1

Guidelines for the diagnosis and management of heart failure with level of evidence

Quality indicatorGuidelineLevel of evidence (ACC)*
ACEI = angiotensin converting enzyme inhibitor; LVSD = left ventricular systolic dysfunction; HF = heart failure; AF = atrial fibrillation; INR = international normalisation ratio.
*ACC = American College of Cardiology rating system; class I: conditions for which there is evidence and/or general agreement that a given procedure/therapy is useful and effective; class II: conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure/therapy; class III: conditions for which there is evidence and/or general agreement that a procedure/therapy is not useful/effective and in some cases may be harmful; level A: data derived from multiple randomised clinical trials; level B: data derived from a single randomised trial or non-randomised studies; level C: when consensus opinion of experts was the primary source of recommendation.14
**Anticoagulation for atrial fibrillation not discussed in ACC heart failure guidelines but in ACC guidelines for the management and treatment of patients with atrial fibrillation.34
1Determination of left ventricular functionPatients with suspected HF should undergo echocardiography or radionuclide ventriculography to measure the ejection fraction (if information about ventricular function is not available from previous tests).Class I, level C
2Use and dosing of ACEI in patients with LVSDPatients with LVSD should be given trial of ACEIs unless contraindicated. Doses of ACEIs should be titrated upwards to the doses shown to decrease mortality in large randomised controlled trials.Class I, level A
3Use of β blocker in patients with LVSD*Patients with stable NYHA class II and III HF due to LVSD should receive a β blocker unless contraindicated.Class I, level A
4Use of warfarin in patients with HF and AF**HF patients with a history of systemic or pulmonary embolism, recent AF, or mobile left ventricular thrombi should be anticoagulated to a prothrombin time ratio of 1.2–1.8 times each individual laboratory control time (INR 2.0–3.0).Class I, level A