Advanced-Stage Chronic Heart Failure

The societal burden of heart failure is well recognized; there are currently estimated to be over six million adults with HF in the United States and over 23 million worldwide. Both age-adjusted death rates and hospitalizations for heart failure have been increasing, and despite advances in therapies the overall mortality remains high at 50% within 5 years. Classification by stages is important for prognostication, prevention, and management of heart failure. Advanced heart failure describes a subset of patients who have persistent and severe symptoms. There is a wide spectrum of symptomatic limitation among patients with advanced heart failure, and NYHA Class does not adequately discriminate patients who require certain therapies. The acronym INEEDHELP has been used to assist in decision making regarding the timing of referral for AdHF therapy. Stage C or D heart failure patients should be treated with guideline directed medical therapies. Keys to management include risk stratification, advanced medical therapy, and careful monitoring. Palliative care has historically been viewed as an alternative to curative therapies for heat failure, rather than as a complementary strategy. A durable LVAD is a form of palliative care because it is not a curative therapy but is intended to relieve those symptoms which are attributable to heart failure.