New Heart Failure Recommendations Address Advanced Disease

Of the 5.7 million Americans who have heart failure (HF), about 10% progress to advanced Stage D designated by the Heart Failure Society of America (HFSA).

Advanced HF occurs when treatment is ineffective, patients experience shortness of breath and other symptoms even at rest, and only 2 therapeutic options remain: left ventricular assist device (LVAD) or heart transplant.

In a new statement published in the Journal of Cardiac Failure, the HFSA Guidelines Committee stressed that identifying Stage D HF patients is critical since few treatments exist, morbidity will progress, and death may be imminent.

The committee advised clinicians to monitor for advanced HF, watching to determine when medical and device therapies fail. Ideally, clinicians should use signs and symptoms, hemodynamics, exercise testing, biomarkers, and risk prediction models.

An essential point to remember is clinical trial populations are dissimilar to many Stage D HF patients, as they tend to be younger and have less comorbidity. Therefore, survival or treatment benefit in trial populations may not apply to actual Stage D HF patients.

In selecting treatment, clinicians need to consider a patient’s age, frailty, and psychosocial issues, as well as understand these factors affect outcomes. Most HF patients will be older and quite infirm. In the rare patient who is otherwise healthy and experiences HF at a young age, advanced intervention such as LVAD is usually appropriate.

The statement authors recommended heart transplant and mechanical circulatory support devices in select Stage D HF patients. They also underscored the importance of the patient’s palliative care preference, as some will prefer a short-term, low-risk strategy such as medication management until eventual death, despite its poor long-term outcomes.

Continuous inotrope infusions (CII) at home may improve quality of life and reduce hospitalization and associated costs, but median survival is estimated at just a few months. The statement included guidelines for patient selection for CII.

As with many other conditions, HF predisposes patients to depression. Clinicians must be vigilant, especially since depression is associated with medication nonadherence.

Research on this population is sorely lacking, and the committee recommended more aggressive attempts to understand which approaches works and which ones do not. Only additional well-designed research can validate optimal strategies for patients with Stage D HF.