title: Advanced (stage D) heart failure: a statement from the Heart Failure Society of America Guidelines Committee.
abstract: We propose that stage D advanced heart failure be defined as the presence of progressive and/or persistent severe signs and symptoms of heart failure despite optimized medical, surgical, and device therapy. Importantly, the progressive decline should be primarily driven by the heart failure syndrome. Formally defining advanced heart failure and specifying when medical and device therapies have failed is challenging, but signs and symptoms, hemodynamics, exercise testing, biomarkers, and risk prediction models are useful in this process. Identification of patients in stage D is a clinically important task because treatments are inherently limited, morbidity is typically progressive, and survival is often short. Age, frailty, and psychosocial issues affect both outcomes and selection of therapy for stage D patients. Heart transplant and mechanical circulatory support devices are potential treatment options in select patients. In addition to considering indications, contraindications, clinical status, and comorbidities, treatment selection for stage D patients involves incorporating the patient's wishes for survival versus quality of life, and palliative and hospice care should be integrated into care plans. More research is needed to determine optimal strategies for patient selection and medical decision making, with the ultimate goal of improving clinical and patient centered outcomes in patients with stage D heart failure.
authors.affiliation: Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah.
authors.forename: James C
authors.initials: JC
authors.lastname: Fang
authors.affiliation: Washington University School of Medicine, St. Louis, Missouri.
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Ewald
authors.affiliation: University of Colorado School of Medicine, Aurora, Colorado.
authors.forename: Larry A
authors.initials: LA
authors.lastname: Allen
authors.affiliation: Stony Brook Heart Institute, Stony Brook University School of Medicine, Stony Brook, New York.
authors.forename: Javed
authors.initials: J
authors.lastname: Butler
authors.affiliation: School of Nursing, Azusa Pacific University, Azusa, California.
authors.forename: Cheryl A
authors.initials: CA
authors.lastname: Westlake Canary
authors.affiliation: University of Michigan, Ann Arbor, Michigan.
authors.forename: Monica
authors.initials: M
authors.lastname: Colvin-Adams
authors.affiliation: Spectrum Health, Grand Rapids, Michigan.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Dickinson
authors.affiliation: Wayne State University, Detroit, Michigan.
authors.forename: Phillip
authors.initials: P
authors.lastname: Levy
authors.affiliation: Department of Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, North Carolina.
authors.forename: Wendy Gattis
authors.initials: WG
authors.lastname: Stough
authors.affiliation: Sarver Heart Center, University of Arizona, Tucson, Arizona.
authors.forename: Nancy K
authors.initials: NK
authors.lastname: Sweitzer
authors.affiliation: San Francisco Veterans Affairs Medical Center and University of California San Francisco, San Francisco, California.
authors.forename: John R
authors.initials: JR
authors.lastname: Teerlink
authors.affiliation: Department of Medicine, Jefferson Medical College, Philadelphia, Pennsylvania.
authors.forename: David J
authors.initials: DJ
authors.lastname: Whellan
authors.affiliation: Nursing Institute and Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Nancy M
authors.initials: NM
authors.lastname: Albert
authors.affiliation: Advanced Cardiovascular Institute, Middletown, Ohio.
authors.forename: Rajan
authors.initials: R
authors.lastname: Krishnamani
authors.affiliation: Washington University School of Medicine, St. Louis, Missouri.
authors.forename: Michael W
authors.initials: MW
authors.lastname: Rich
authors.affiliation: The Care Group, Indianapolis, Indiana.
authors.forename: Mary N
authors.initials: MN
authors.lastname: Walsh
authors.affiliation: University of Toledo, Toledo, Ohio.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Bonnell
authors.affiliation: Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC.
authors.forename: Peter E
authors.initials: PE
authors.lastname: Carson
authors.affiliation: University of Alberta, Alberta, Edmonton, Canada.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Chan
authors.affiliation: Temple Heart and Vascular Institute, Temple University Hospital, Philadelphia, Pennsylvania.
authors.forename: Daniel L
authors.initials: DL
authors.lastname: Dries
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Adrian F
authors.initials: AF
authors.lastname: Hernandez
authors.affiliation: The Ohio State University, Columbus, Ohio.
authors.forename: Ray E
authors.initials: RE
authors.lastname: Hershberger
authors.affiliation: Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York.
authors.forename: Stuart D
authors.initials: SD
authors.lastname: Katz
authors.affiliation: Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Moore
authors.affiliation: University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina.
authors.forename: Jo E
authors.initials: JE
authors.lastname: Rodgers
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Joseph G
authors.initials: JG
authors.lastname: Rogers
authors.affiliation: Tufts Medical Center, Boston, Massachusetts.
authors.forename: Amanda R
authors.initials: AR
authors.lastname: Vest
authors.affiliation: Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address: mgivertz@partners.org.
authors.forename: Michael M
authors.initials: MM
authors.lastname: Givertz
mesh_terms: D019468:Disease Management; D018450:Disease Progression; D006333:Heart Failure / Q000175:diagnosis / Q000503:physiopathology / Q000523:psychology / Q000628:therapy; D006801:Humans; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011788:Quality of Life; D012720:Severity of Illness Index
keywords: Heart failure; advanced; stage D