Congestive heart failure treatment of patients with refractory end-stage heart failure (Stage D)

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Medical Therapy:

Summary
Acute Pharmacotherapy
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Chronic Pharmacotherapy in HFrEF
Diuretics
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Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
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ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
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Congestive heart failure end-of-life considerations

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Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]Mahmoud Sakr, M.D. [3]

2013 ACCF/AHA Guideline/2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Heart Failure in the Adult (DO NOT EDIT) [1][2]

Patients with Refractory End-Stage Heart Failure (Stage D) (DO NOT EDIT) [1][2][3]

Class I
"1. Fluid restriction (1.5 to 2 L/d) is reasonable in stage D, especially in patients with hyponatremia, to reduce congestive symptoms. (Level of Evidence: C) "
"2. Meticulous identification and control of fluid retention is recommended in patients with refractory endstage HF. [4][5][6][7][8][9][10][11] (Level of Evidence: B) "
"3. Until definitive therapy (e.g., coronary revascularization, mechanical circulatory support, heart transplantation) or resolution of the acute precipitating problem, patients with cardiogenic shock should receive temporary intravenous inotropic support to maintain systemic perfusion and preserve end-organ performance. (Level of Evidence: C) "
"4. Referral for cardiac transplantation in potentially eligible patients is recommended for patients with refractory end-stage HF.[12] [13] (Level of Evidence: C)"
"5. Referral of patients with refractory end-stage HF to a HF program with expertise in the management of refractory HF is useful. [14][15][16][17] (Level of Evidence: A) "
"6. Options for end-of-life care should be discussed with the patient and family when severe symptoms in patients with refractory end-stage HF persist despite application of all recommended therapies. (Level of Evidence: C) "
"7. Patients with refractory end-stage HF and implantable defibrillators should receive information about the option to inactivate defibrillation. (Level of Evidence: C) "
Class III (No Benefit)
"1. Partial left ventriculectomy is not recommended in patients with non ischemic cardiomyopathy and refractory end-stage HF. (Level of Evidence: C) "
"2. Routine intermittent infusions of vasoactive and positive inotropic agents are not recommended for patients with refractory end-stage HF. [18][19] (Level of Evidence: A) "
Class IIa
"1.Continuous intravenous inotropic support is reasonable as “bridge therapy” in patients with stage D refractory to GDMT and device therapy who are eligible for and awaiting mechanical circulatory support or cardiac transplantation.[20][21](Level of Evidence: B) "
"2. MCS is beneficial in carefully selected patients with stage D HFrEF in whom definitive management (e.g., cardiac transplantation) or cardiac recovery is anticipated or planned.[22][23] (Level of Evidence: B) "
"3. Nondurable MCS, including the use of percutaneous and extracorporeal ventricular assist devices (VADs), is reasonable as a “bridge to recovery” or “bridge to decision” for carefully selected patients with HFrEF with acute, profound hemodynamic compromise.[24] [25][26] (Level of Evidence: B) "
"4. Durable MCS is reasonable to prolong survival for carefully selected* patients with stage D HFrEF. [25][27](Level of Evidence: B) "
Class IIb
"1. Short-term, continuous intravenous inotropic support may be reasonable in those hospitalized patients presenting with documented severe systolic dysfunction who present with low blood pressure and significantly depressed cardiac output to maintain systemic perfusion and preserveend-organ performance.[28][29][30](Level of Evidence: B) "
"2. Continuous intravenous infusion of a positive inotropic agent may be considered for palliation of symptoms in patients with refractory end-stage HF.[31][32] [33][34](Level of Evidence: B) "
"3. Pulmonary artery catheter placement may be reasonable to guide therapy in patients with refractory end-stage HF and persistently severe symptoms. [13][35] (Level of Evidence: C) "
"4. The effectiveness of mitral valve repair or replacement is not established for severe secondary mitral regurgitation in refractory end-stage HF. [36][37][38] (Level of Evidence: C) "

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References

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  2. 2.0 2.1 2.2 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016.DOI:10.1161/CIRCULATIONAHA.109.192064 PMID:19324967
  3. 3.0 3.1 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al. (2005) ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 112 (12):e154-235. DOI:10.1161/CIRCULATIONAHA.105.167586 PMID: 16160202
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