Patients with Refractory End-Stage HF (Stage D)

Most patient with Heart Failure (HF) due to left ventricular systolic dysfunction respond favorably to pharmacological and nonpharmacological treatments and enjoy a good quality of life and enhanced survival. However, some patients do not improve or experience rapid recurrence of symptoms despite optimal medical therapy. Such patients characteristically have symptoms at rest or on minimal exertion (including profound fatigue); cannot perform most activities of daily living; frequently have evidence of cardiac cachexia; and typically require repeated and/or prolonged hospitalizations for intensive management. These individuals represent the most advanced stage of HF and should be considered for specialized treatment strategies, such as mechanical circulatory support, continuous intravenous positive inotropic therapy, referral for cardiac transplantation or hospice care.¹

Before a patient is considered to have refractory HF, physicians should confirm the accuracy of the diagnosis, identify any contributing conditions, and ensure that all conventional medical strategies have been optimally employed.¹

• Management of Fluid Status— A critical step in the successful management of end-stage HF is the recognition and meticulous control of fluid retention, because many patients with advanced HF have symptoms that are related to the retention of salt and water and, thus, will respond favorably to interventions designed to restore sodium balance.¹
  
• Utilization of Neurohormonal Inhibitors— Patients with advanced HF respond favorably to treatment with both ACE inhibitors and beta-blockers in a manner similar to those with mild to moderate disease. However, because neurohormonal mechanisms play an important role in the support of circulatory homeostasis as HF progresses, neurohormonal antagonism may be less well tolerated by patients with severe symptoms than by patients with mild symptoms. Patients who are at the end stage of their disease are at particular risk of developing hypotension and renal insufficiency after the administration of an ACE inhibitor and of experiencing worsening HF after treatment with a beta-blocker. As a result, patients with refractory HF may tolerate only small doses of these neurohormonal antagonists or may not tolerate them at all.¹
  
• Intravenous Peripheral Vasodilators and Positive Inotropic Agents— Patients with refractory HF are hospitalized frequently for clinical deterioration, and during such admissions, they commonly receive infusions of both positive inotropic agents and vasodilator drugs in an effort to improve cardiac performance, facilitate diuresis and promote clinical stability. Some physicians have advocated the placement of pulmonary artery catheters in these patients with the goal of obtaining hemodynamic measurements that might be used to guide the selection and titration of therapeutic agents. Regardless of whether invasive hemodynamic monitoring is used, once the clinical status of the patient has stabilized, very effort should be made to devise an oral regimen that can maintain symptomatic improvement and reduce the subsequent risk of deterioration.¹
  
  Patients who cannot be weaned from intravenous to oral therapy may require placement of an indwelling line to allow for the continuous infusion of dobutamine or milrinone. This is commonly used in patients who are awaiting heart transplantation, it but may also be used in the outpatient setting in patients who otherwise cannot be discharged from the hospital.¹
  
• Mechanical and Surgical Strategies— Surgical treatment should be directed towards the underlying etiology and mechanisms. In addition to revascularization procedures, it is important to approach patients with significant valvular disease before they develop significant left ventricular dysfunction. Such procedures may include: ^1,2

  - Cardiac transplantation is currently the only established surgical approach to the treatment of refractory HF, but it is limited to fewer than 2,500 patients in the U.S. per year.¹ Heart transplantation is considered to significantly increase survival, exercise capacity, return to work and quality of life compared to conventional treatment, provided proper selection criteria are applied.²

  - Mitral valve surgery— In selected heart failure patients with severe left ventricular dysfunction and severe mitral valve insufficiency, surgery may lead to symptomatic improvement. This is also true of patients with mitral valve insufficiency due to left ventricular dilatation.²

  - Left Ventricular Assist device— Extra-corporeal devices are approved for circulatory support in patients who are expected to recover from major cardiac insult or are expected to undergo a definitive treatment for HF. Left ventricular assist devices provide similar degrees of hemodynamic support, but many are implantable and thus allow the patient ambulation and hospital discharge.¹

Alternative surgical and mechanical approaches for the treatment of end-stage HF are under development.

For more information on treating specific stages of heart failure, click on the following topics:
Patients at High Risk for Developing Left Ventricular Dysfunction (Stage A)
Patients with Left Ventricular Dysfunction Who Have Not Developed Symptoms (Stage B)
Patients With Left Ventricular Dysfunction With Current or Prior Symptoms (Stage C)
Patients with Refractory End-Stage HF (Stage D)

For more information, please click on the following subjects:
Heart Failure: A Significant Problem
Clinical Assessment of Patients with Heart Failure
Evaluating the Cause of Ventricular Dysfunction
Treating Heart Failure Patients
Monitoring Heat Failure Patients

References