ABSTRACT
The definition and prevalence of advanced heart failure (HF) are changing, in parallel with the development of new treatment options. The current management of advanced HF is based more on expert consensus rather than randomized trials. Patients with advanced HF are underrepresented in most trials of medical management. Therefore, evidence on optimal dosing and the effectiveness of medical therapies for patients with advanced HF is still limited. Many patients respond inadequately to medical therapy as outpatients or during hospitalization, and almost invariably require parenteral therapy. A number of these patients will require mechanical circulatory support to achieve volume homeostasis and stable hemodynamics. In this chapter, we summarize pharmacological and nonpharmacological therapeutic options for these patients, including implantable device therapy, mechanical circulatory support devices, and heart transplantation. Long-term mechanical circulatory support devices have emerged as an alternative to heart transplantation and have been shown to improve quality of life and reduce mortality. However, the optimal window for advanced therapeutic options is relatively narrow, as the disease is progressive, and survival is often short. On the other hand, these high-risk therapies are unlikely to benefit patients with less advanced disease. In view of this delicate balance, patients with advanced HF should be identified and referred timely.
