Management of refractory heart failure with reduced ejection fraction
- Shannon M Dunlay, MD, MS
Shannon M Dunlay, MD, MS
- Associate Professor of Health Services Research and Medicine
- Mayo Clinic College of Medicine
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
Although the majority of patients with heart failure with reduced ejection fraction (HFrEF) respond to optimal medical therapy, some patients do not improve or experience rapid and repetitive recurrences of symptoms. These patients have symptoms at rest or on minimal exertion and often require repeated prolonged hospitalizations for intensive management. Patients with chronic HF with severe symptoms despite maximum guideline-directed medical therapy are classified by the American College of Cardiology Foundation/American Heart Association as having stage D HF .
Specialized strategies for patients with refractory HFrEF include intravenous vasodilator and inotropic therapy, ultrafiltration, mechanical circulatory support, surgery including cardiac transplantation, and palliative care.
An overview of therapies used to treat refractory HFrEF is presented here. General treatment strategies for HFrEF and treatment of HF with preserved ejection fraction (HFpEF) are discussed separately. (See "Overview of the therapy of heart failure with reduced ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction".)
The general management of patients with refractory heart failure with reduced ejection fraction (HFrEF) includes optimizing all standard evidence-based drug and device therapy as well as volume management. Referral to a program with expertise in the management of refractory HF and advanced therapies is recommended. Monitoring is indicated to assess patient status as well as the effects of therapy.
Optimizing evidence-based therapy — The first step in managing suspected refractory HFrEF is to confirm that all conventional evidence-based strategies (including pharmacologic therapy and device therapy such as cardiac resynchronization therapy and implantable cardioverter-defibrillator) have been optimally employed and that contributing conditions have been recognized and treated. Recommendations for patients with other stages of HF are also appropriate for patients with end-stage (stage D) HF. (See "Overview of the therapy of heart failure with reduced ejection fraction" and "Primary prevention of sudden cardiac death in heart failure and cardiomyopathy" and "Secondary prevention of sudden cardiac death in heart failure and cardiomyopathy" and "Cardiac resynchronization therapy in heart failure: Indications".)
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- GENERAL MANAGEMENT
- Optimizing evidence-based therapy
- Volume and sodium management
- Appropriate referral
- - General monitoring
- - Use of pulmonary artery catheter
- SPECIALIZED STRATEGIES
- Approach to specialized strategies
- - Management of refractory volume overload
- - Management of low cardiac output
- - Role of palliative care
- Pharmacologic therapy
- - Intravenous vasodilator therapy
- - Intravenous inotropes
- - Dobutamine
- - Milrinone
- - Dopamine
- Mechanical circulatory support
- Cardiac transplantation
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS