48
Treatment
8.1. Specialty Referral for Advanced HF
COR LOE
Recommendation
1 C-LD 1. In patients with advanced HF, when consistent with the
patient's goals of care, timely referral for HF specialty care
is recommended to review HF management and assess
suitability for advanced HF therapies (e.g., LVAD, cardiac
transplantation, palliative care, and palliative inotropes).
8. Stage D (Advanced) HF
Table 16. ESC Definition of Advanced HF
All of these criteria must be present despite optimal guideline-directed
treatment:
1. Severe and persistent symptoms of HF (NYHA class III [advanced] or IV)
2. Severe cardiac dysfunction defined by ≥1 of these:
• LVEF ≤30%
• Isolated RV failure
• Nonoperable severe valve abnormalities
• Nonoperable severe congenital heart disease
• EF ≥40%, elevated natriuretic peptide levels and evidence of significant diastolic
dysfunction
3. Hospitalizations or unplanned visits in the past 12 mo for episodes of:
• Congestion requiring high-dose intravenous diuretics or diuretic combinations
• Low output requiring inotropes or vasoactive medications
• Malignant arrhythmias
4. Severe impairment of exercise capacity with inability to exercise or low 6-minute
walk test distance (<300 m) or peak VO
2
(<12–14 mL/kg/min) estimated to be of
cardiac origin
Criteria 1 and 4 can be met in patients with cardiac dysfunction (as described in
criterion 2) but who also have substantial limitations as a result of other conditions (e.g.,
severe pulmonary disease, noncardiac cirrhosis, renal disease). e therapeutic options
for these patients may be more limited.
