What is the management approach for patients with advanced World Health Organization (WHO) functional class heart failure?

Management of Advanced Heart Failure (WHO Functional Class III-IV)

Patients with advanced heart failure (WHO functional class III-IV) require comprehensive palliative care integrated with guideline-directed medical therapy, with timely referral to hospice for those with expected survival <6 months to improve quality of life.

Assessment and Classification of Advanced Heart Failure

Advanced heart failure (Stage D) is characterized by:

• Persistent severe symptoms at rest despite maximal medical therapy (WHO/NYHA class III-IV)
• Recurrent hospitalizations (≥2 hospitalizations or ED visits for HF in past year)
• Progressive deterioration in renal function
• Cardiac cachexia (unintentional weight loss)
• Intolerance to ACE inhibitors/beta blockers due to hypotension or worsening HF
• Frequent systolic blood pressure <90 mmHg
• Persistent dyspnea with basic activities like dressing/bathing
• Inability to walk 1 block due to dyspnea/fatigue
• Need for escalating diuretics (often >160 mg/day furosemide equivalent)
• Progressive decline in serum sodium (<133 mEq/L)
• Frequent ICD shocks 1

Management Approach

1. Optimize Guideline-Directed Medical Therapy (GDMT)

• Pharmacological therapy:
  • ACE inhibitors/ARBs/ARNI
  • Beta-blockers
  • Mineralocorticoid receptor antagonists
  • SGLT2 inhibitors
  • Diuretics for congestion 2

2. Integrate Palliative Care Early

• Palliative care should be integrated throughout the course of illness by all healthcare professionals, not just at end-of-life 1
• Palliative care focuses on:
  • Symptom management (dyspnea, pain, depression)
  • Clarifying goals of care
  • Advance care planning
  • Supporting caregivers 1

3. Consider Advanced Therapies for Eligible Patients

• Mechanical Circulatory Support (MCS):

  • Beneficial in carefully selected patients with stage D HF in whom definitive management is anticipated 1
  • Nondurable MCS reasonable as "bridge to recovery" or "bridge to decision" 1
  • Durable MCS reasonable to prolong survival in carefully selected patients 1

• Cardiac Transplantation:

  • Evaluation indicated for carefully selected patients with stage D HF despite GDMT, device, and surgical management 1

• Inotropic Support:

  • Long-term continuous intravenous inotropic support may be considered as palliative therapy for patients with advanced HF 1
  • Note: Routine intravenous use, either continuous or intermittent, is potentially harmful in stage D HF unless used for palliative purposes 1

4. Palliative and End-of-Life Care

• For patients with expected survival <6 months:

  • Timely referral to hospice is useful to improve quality of life 1
  • Execution of advance care directives improves documentation of treatment preferences and dying in preferred place 1

• Symptom Management:

  • Fluid restriction (1.5-2 L/day) reasonable in stage D, especially with hyponatremia 1
  • Consider palliative inotropic support for symptom relief 1

• Device Management:

  • Discuss deactivation of ICDs and other devices as part of advance care planning 1
  • Address potential ICD deactivation before implantation and as disease progresses 1

Multidisciplinary Approach

• Enrollment in a multidisciplinary HF management program is recommended to reduce HF hospitalization risk and improve survival 1
• Team should include:
  • HF specialists
  • Palliative care specialists
  • Nurses
  • Social workers
  • Pharmacists 1

Common Pitfalls and Caveats

1. Delayed palliative care integration: Palliative care should be introduced early in the disease course, not just at end-of-life 1

2. Failure to address device management: Discussions about deactivation of ICDs should occur before implantation and throughout the disease course 1

3. Inadequate symptom management: Symptoms often undertreated in advanced HF; regular assessment and management is crucial 1

4. Overlooking caregiver needs: Family caregivers require support, education, and inclusion in the care plan 1

5. Missing the window for hospice referral: Patients with expected survival <6 months should be referred to hospice to improve quality of life 1

By following this comprehensive approach that integrates both disease-modifying and palliative interventions, clinicians can improve quality of life, reduce suffering, and provide appropriate end-of-life care for patients with advanced heart failure.