Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology

Abstract

This article updates the Heart Failure Association of the European Society of Cardiology (ESC) 2007 classification of advanced heart failure and describes new diagnostic and treatment options for these patients. Recognizing the patient with advanced heart failure is critical to facilitate timely referral to advanced heart failure centres. Unplanned visits for heart failure decompensation, malignant arrhythmias, co-morbidities, and the 2016 ESC guidelines criteria for the diagnosis of heart failure with preserved ejection fraction are included in this updated definition. Standard treatment is, by definition, insufficient in these patients. Inotropic therapy may be used as a bridge strategy, but it is only a palliative measure when used on its own, because of the lack of outcomes data. Major progress has occurred with short-term mechanical circulatory support devices for immediate management of cardiogenic shock and long-term mechanical circulatory support for either a bridge to transplantation or as destination therapy. Heart transplantation remains the treatment of choice for patients without contraindications. Some patients will not be candidates for advanced heart failure therapies. For these patients, who are often elderly with multiple co-morbidities, management of advanced heart failure to reduce symptoms and improve quality of life should be emphasized. Robust evidence from prospective studies is lacking for most therapies for advanced heart failure. There is an urgent need to develop evidence-based treatment algorithms to prolong life when possible and in accordance with patient preferences, increase life quality, and reduce the burden of hospitalization in this vulnerable patient population.

Clinical phenotypes of acute heart failure based on signs and symptoms of perfusion and congestion at emergency department presentation and their relationship with patient management and outcomes

“…showed that hypoperfusion was present in more than 10% of cases included in the hypertensive category. This fact probably accounts for the high presence of hypoperfusion in internal medicine and geriatric wards and represents very advanced forms of chronic heart failure in elderly patients, most of whom could receive palliative care . Remarkably, in both our series and that of Chioncel et al ., a few AHF patients were warm‐dry (15% and 6%, respectively) and probably represent the mildest forms of AHF, with very subtle clinical signs of congestion or hypoperfusion.…”

February 2019 at a glance: pathophysiology, exercise capacity, diuretics and valve disease

“…Palliative care of patients with advanced HF is still underused in most of the hospitals . Straw et al .…”

November 2018 at a glance: from prediction of heart failure in asymptomatic subjects to advanced chronic heart failure

“…It is therefore mandatory to better identify these patients with advanced chronic HF (ACHF). The Heart Failure Association has issued an updated version of a first statement about ACHF . This second statement provides a new definition of ACHF, including aspects such as the possibility that episodes of decompensation are treated without patient's hospitalization, the inclusion of patients with HF and preserved ejection fraction (HFpEF), the role of co‐morbidities or malignant arrhythmias.…”

“…This second statement provides a new definition of ACHF, including aspects such as the possibility that episodes of decompensation are treated without patient's hospitalization, the inclusion of patients with HF and preserved ejection fraction (HFpEF), the role of co‐morbidities or malignant arrhythmias. Prognostic variables, treatment options, including devices, and disease management programmes are described and discussed …”