2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways

The 2017 ACC/AHA/Heart Failure Society of America (HFSA) heart failure (HF) guidelines (1) reflect a focused update of the ACC/AHA 2013 HF guidelines (2) and include guidance based on new evidence supporting novel drug therapies, a new treatment algorithm replete with more options for care than before, an updated approach to prevention, and important updates regarding various forms of HF and important comorbidities. The care of patients with HF is more involved than ever. Current care for the patient with HF with reduced ejection fraction (EF) includes no fewer than 7 evidence-based medications, 3 evidence-based device strategies, and a number of recommend processes of care. The opportunity to change the natural history of HF with reduced EF has never been better, but with more choices comes greater complexity. This necessitates careful guidance to clinicians, emphasis on best principles for initiating and titrating guideline-directed medical therapy for HF with reduced EF, and advice on managing the overall complexity of the condition. This ACC Expert Consensus Decision Pathway addresses steps to follow when introducing numerous evidence-based therapies, improving adherence, overcoming treatment barriers, acknowledging contraindications and situations for which little data exist, affording expensive therapies, treating special cohorts, and making the transition to palliative care. Rather than focusing on expansive text, the document provides practical tips, tables, and figures to make clear the steps, tools, and provisos needed to successfully and expeditiously treat the patient with HF with reduced EF. Many of the pivotal issues addressed in this document are not the substance of clinical trials; rather, they represent the challenge of clinical practice. Whenever possible, resources are included or hyperlinked. The treatment of HF with reduced EF can feel overwhelming, and many opportunities to improve patient outcomes are being missed; hopefully, this Expert Consensus Decision Pathway may streamline care to realize best possible patient outcomes in HF.