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Palliative care for patients with advanced heart failure

Sarah J Goodlin, MD, FACC, FAAHPM
Section Editors
Sharon A Hunt, MD
R Sean Morrison, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


Heart failure (HF) is a common and frequently life-limiting illness with increasing prevalence, particularly among the growing population of older adults. Nearly 300,000 persons in the United States die with HF annually, and HF was the primary cause of death for over 60,000 persons in 2006 in the United States. Hospitalization rates for decompensated HF are high, and one-third or more of HF patients die within a year of a hospitalization for HF [1]. The average life expectancy following diagnosis of HF is under six years. However, the course of HF is variable, and some persons live 10 or more years with good medication response and dietary and lifestyle management. It is estimated that 10 percent of persons with HF progress to refractory HF with symptoms at rest or minimal exertion despite optimal medical management (advanced or Stage D HF). Others will live with HF and die from some other illness. Options in treatment of advanced HF now make longer survival possible with better quality of life for some persons. Decisions about interventions in advanced HF are complex and require an organized approach. (See "Prognosis of heart failure" and "Predictors of survival in heart failure due to systolic dysfunction" and "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Prognosis'.)

Variability in the course of HF makes identifying the end of life in patients with HF challenging and limited data are available to guide end-of-life care. Palliative care should be integrated into care for patients with advanced HF [2], as well as provided throughout the course of HF to relieve HF symptoms and assist patients and their families to cope with HF [3-5].

This topic will discuss palliative care for patients with advanced (stage D) HF, which has been defined as patients with refractory HF with symptoms at rest or with minimal exertion despite guideline-directed therapy [5,6]. General management of refractory HF is discussed separately. (See "Management of refractory heart failure with reduced ejection fraction".)


Individuals with advanced or end-stage heart failure (HF) have marked symptoms of dyspnea, fatigue, or symptoms relating to end-organ hypoperfusion at rest or with minimal exertion despite optimal medical therapy [2]. This description conforms to stage D as defined in the American College of Cardiology/American Heart Association (ACC/AHA) HF guidelines [5]. Persons with advanced HF typically have frequent admissions to the hospital or emergency department with decompensation and volume overload. Physical frailty, characterized by slow gait speed, coexists with advanced HF. (See "Determining the etiology and severity of heart failure or cardiomyopathy", section on 'Definition'.)

The challenge for a clinician evaluating a patient who appears to have advanced HF is whether there are remediable interventions, adjustments to medications, dietary sodium restriction, or other therapies that might improve the patient's function, or whether the patient truly has end-stage disease [2]. HF patients may have dramatic worsening of functional status and then impressive recovery to a plateau of reasonable function with medical therapy and/or device or surgical interventions. Patients with advanced HF who comply with self-care management have rates of hospitalization and other events comparable to less ill HF patients [7]. In frail older adult patients, it may be difficult to distinguish HF contribution to symptoms from other processes that lead to frailty.


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Literature review current through: Jan 2017. | This topic last updated: Wed Mar 25 00:00:00 GMT+00:00 2015.
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