Changing our Approach to Stage D Heart Failure

Prog Cardiovasc Dis. 2017 Sep-Oct;60(2):205-214. doi: 10.1016/j.pcad.2017.08.003. Epub 2017 Aug 9.


Despite the tremendous progress made in the management of heart failure (HF), many patients reach advanced stages. This paper aims to present a practical approach to the stage D HF patient who is no longer responding to optimal medical therapy. We discuss all available therapies for this patient population. We also offer some important caveats with regard to identification, risk stratification, evaluation and treatment including early patient referral to a center with an advanced HF program. Given the changing landscape of heart transplantation and an impending change in the allocation system, we also intend to engage a discussion on the need for a paradigm shift towards left ventricular assist device therapy in this population.

Keywords: Heart failure; Heart transplantation; Left ventricular assist device; Mechanical circulatory support.

Publication types

  • Review

MeSH terms

  • Cardiotonic Agents / adverse effects
  • Cardiotonic Agents / therapeutic use*
  • Early Diagnosis
  • Heart Failure / diagnosis
  • Heart Failure / mortality
  • Heart Failure / physiopathology
  • Heart Failure / therapy*
  • Heart Transplantation* / adverse effects
  • Heart Transplantation* / mortality
  • Heart-Assist Devices* / adverse effects
  • Humans
  • Palliative Care
  • Patient Selection
  • Predictive Value of Tests
  • Recovery of Function
  • Referral and Consultation
  • Risk Factors
  • Severity of Illness Index
  • Stroke Volume / drug effects
  • Terminal Care
  • Tissue Donors / supply & distribution
  • Treatment Outcome
  • Ventricular Function, Left / drug effects


  • Cardiotonic Agents