# Four-class medicine regimen in heart failure (guideline-directed medical therapy) Intervention · id `cardio:hfref-four-medicine-regimen` · Cardiovascular Atlas · release `73130c34862e2d06` (public) > General information from published sources, not medical advice, and not reviewed by clinicians. Check the cited source before relying on anything here. The atlas's own text and curation may be reused under Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0, https://creativecommons.org/licenses/by-nc/4.0/): credit the atlas, and do not use it commercially. See the atlas About page. Text quoted from a source stays under that source's own terms, given as the source's reuse\_basis. The atlas's reuse terms do not cover it. The downloads list each quotation with its source in third\_party\_quotations. Also called: Guideline-directed medical therapy; GDMT Browse, organ or system: Heart Browse, condition area: Heart failure ## In plain language The four classes of medicine that an ACC summary of the 2022 heart failure guideline from the AHA, ACC and HFSA calls guideline-directed medical therapy: renin-angiotensin system inhibition (an ARNI, ACE inhibitor or angiotensin receptor blocker), beta blockers, mineralocorticoid receptor antagonists and SGLT2 inhibitors. The summary says everyone with heart failure now or in the past, whatever their ejection fraction, should be considered for this therapy. It says an ARNI is now the first choice within the first class when the ejection fraction is reduced. ## Technical summary Regimen record. The source is the ACC key-perspectives summary of the guideline (hash only, cite only), not the guideline text. The summary gives no doses, no schedule, no starting order and no class of recommendation for the four-class statement, so none is recorded and the page does not say the classes are started together. The first component stands for the ARNI class, using the only ARNI record in this atlas as the example; an ACE inhibitor or an angiotensin receptor blocker is the alternative the summary names when an ARNI is not feasible. The id keeps the HFrEF wording of the plan, but the summary states the four classes for heart failure in general, and its own class 1a statements for the first and fourth classes are limited to reduced ejection fraction. No recommendation link is written for the regimen as a whole. PubMed lists three corrections to the guideline; their text was not read. ## Claims, with the population each applies to ## Context: Patients with current or prior heart failure, any ejection fraction (2022 AHA/ACC/HFSA, as summarized by the ACC) Recipient: Recipient not specified; Population: Patients with current or prior heart failure, whatever their ejection fraction, who according to the ACC summary should be considered for guideline-directed therapy. The summary gives no age limits.; Care setting: Not stated in the ACC summary.; Geography: Not stated in the ACC summary (issued by American societies; jurisdiction not verified); Life stage: Not stated in the ACC summary; Gestational age: Not reported; Postnatal age: Not reported; Follow-up: Not applicable (guideline context) ### An ACC summary of the 2022 heart failure guideline of the AHA, ACC and HFSA says that guideline-directed medical therapy now has four classes: renin-angiotensin system inhibition (with an angiotensin receptor-neprilysin inhibitor, an ACE inhibitor or an angiotensin receptor blocker), beta blockers, mineralocorticoid receptor antagonists and SGLT2 inhibitors. It says everyone with heart failure now or in the past, whatever their ejection fraction, should be considered for this therapy. - Category: Description - Evidence stage: Guidance - Certainty: Certainty not assessed - Applies to: Recipient: Recipient not specified; Population: Patients with current or prior heart failure, whatever their ejection fraction, who according to the ACC summary should be considered for guideline-directed therapy. The summary gives no age limits.; Care setting: Not stated in the ACC summary.; Geography: Not stated in the ACC summary (issued by American societies; jurisdiction not verified); Life stage: Not stated in the ACC summary; Gestational age: Not reported; Postnatal age: Not reported; Follow-up: Not applicable (guideline context) - Limitations: The source is the ACC key-perspectives summary of the guideline (ACC content, hash only), not the guideline text. This is a description of what the therapy consists of and a statement that patients should be considered for it, not a recommendation to use all four classes at every ejection fraction. The statements in the summary itself limit the first-line ARNI statement and the class 1a SGLT2 inhibitor statement to heart failure with reduced ejection fraction, and give SGLT2 inhibitors class 2a in mildly reduced and preserved ejection fraction. It gives no class of recommendation for the four-class statement, no doses and no order of starting, so none is recorded and nothing here says the classes are started together. PubMed lists three corrections to the guideline; their text was not read, so it is not known whether they change anything stated here. - Last checked: 2026-10-15 - Source problem: a cited source is corrected. Check the sources before relying on this claim. - Sources: 1. Supports: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines (Guideline, edition Published in Circulation 145(18):e895-e1032 (issue date 2022-05-03; electronic publication 2022-04-01). PubMed abstract and bibliographic data only. PubMed lists no PMC copy. The guideline text was not read. PubMed lists 3 corrections to the guideline; their text was not read. The same source also holds a snapshot of the ACC key-perspectives summary page of the guideline (dated Apr 01, 2022), which is an ACC summary and not the guideline text. The recommendation text for this atlas comes from that page. The publisher field is the journal title as PubMed gives it.) Locator: Key perspective 2, sentence 1, fragments 1 to 3. Retrieved 2026-10-15T13:50:22Z. Source state: Corrected. Snapshot hash: 9bf3f8d91011b793cc049e80db09ae5624271eb6cdb688f5331c7f8aa1556cad. How it applies: The four classes of guideline-directed medical therapy. 2. Supports: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines (Guideline, edition Published in Circulation 145(18):e895-e1032 (issue date 2022-05-03; electronic publication 2022-04-01). PubMed abstract and bibliographic data only. PubMed lists no PMC copy. The guideline text was not read. PubMed lists 3 corrections to the guideline; their text was not read. The same source also holds a snapshot of the ACC key-perspectives summary page of the guideline (dated Apr 01, 2022), which is an ACC summary and not the guideline text. The recommendation text for this atlas comes from that page. The publisher field is the journal title as PubMed gives it.) Locator: Key perspective 1, last sentence. Retrieved 2026-10-15T13:50:22Z. Source state: Corrected. Snapshot hash: 9bf3f8d91011b793cc049e80db09ae5624271eb6cdb688f5331c7f8aa1556cad. How it applies: Anyone with current or past HF should be considered for this therapy. 3. Background: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines (Guideline, edition Published in Circulation 145(18):e895-e1032 (issue date 2022-05-03; electronic publication 2022-04-01). PubMed abstract and bibliographic data only. PubMed lists no PMC copy. The guideline text was not read. PubMed lists 3 corrections to the guideline; their text was not read. The same source also holds a snapshot of the ACC key-perspectives summary page of the guideline (dated Apr 01, 2022), which is an ACC summary and not the guideline text. The recommendation text for this atlas comes from that page. The publisher field is the journal title as PubMed gives it.) Locator: CommentsCorrectionsList, three ErratumIn entries. Retrieved 2026-10-15T13:48:58Z. Source state: Corrected. Snapshot hash: 359253a28c2add87ff845ef77e0400c1886971358eacddb04f09833df0707f1f. How it applies: Shows that corrections exist. What they change is unknown. ## Connected pages - Medicine classes the ACC summary lists for heart failure: Heart failure (`cardio:heart-failure`) - Files under this front: Medicines (`cardio:front-medicines`) - Related to: Beta-blockers (drug class) (`cardio:beta-blockers`) ## Provenance Content hash: f380bf36eff217413bf9895b8917398ace607e006a8c49e6547d066902d878f4 Last substantive edit: 2026-10-15 Evidence last checked: 2026-10-15