TNF and congestive heart failure: The New York Heart Association recommendations are as follows: TNF-α inhibitors are contraindicated in class 3 or 4 CHF; echocardiogram should be done before treatment initiation in class 1 or 2 CHF and TNF-α inhibitors should be avoided in patients with ejection fraction 50%; TNF-α inhibitors should be discontinued in patients with new-onset CHF [126,129].