Rapid Clinical Updates: Advanced Therapy for End-Stage Heart Failure-Handout

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This update addresses advanced heart failure (HF) management challenges for hospitalists, particularly focusing on patients with frequent readmissions and end-of-life care. While guideline-directed medical therapy (GDMT) initiation is emphasized, many patients with worsening symptoms despite optimized therapy require specialized interventions.<br /><br />Referral to heart failure specialists is recommended for patients with inotropic dependence, NYHA class IIIB/IV symptoms, end-organ dysfunction, left ventricular ejection fraction (EF) ≤35%, implantable cardioverter-defibrillator (ICD) shocks, recurrent hospitalizations, low blood pressure, or high heart rate despite escalating diuretics.<br /><br />Beyond optimized GDMT, newer pharmacotherapies including ivabradine, digoxin, vericiguat, polyunsaturated fatty acids (PUFA), and potassium binders may be considered. Palliation strategies, supported by the PAL-HF study, help manage symptoms, stabilize care trajectories, and reduce hospital readmissions. Right heart catheterization is valuable in patients with persistent symptoms, acute kidney injury during diuresis, or frequent hospitalizations. Implantable devices like CardioMEMS can monitor filling pressures in ambulatory HF, enabling tailored care. Remote monitoring tools such as electronic scales, smartphones, and electronic health records, combined with pharmacist-led medication adherence programs and cognitive behavioral therapy, support comprehensive HF management.<br /><br />Regarding advanced therapies, despite improved hemodynamics, positive inotropes lack survival benefit. Median survival after heart transplantation is about 12 years, compared with approximately 2 years for stage D HF without advanced therapy. Early referral for left ventricular assist device (LVAD) implantation, either as a bridge to transplantation or as destination therapy, is crucial. Delayed or absent referral may lead to worse outcomes for patients and families.<br /><br />References include recent guidelines and studies from 2021-2022, highlighting contemporary advanced HF management considerations.

Keywords

advanced heart failure

hospitalists

guideline-directed medical therapy

heart failure specialists

inotropic dependence

NYHA class IIIB/IV

implantable cardioverter-defibrillator

pharmacotherapies ivabradine digoxin vericiguat

palliation strategies PAL-HF

left ventricular assist device LVAD