Management of End Stage Heart Failure

2]3 Because of its age-dependent increase in incidence and prevalence, heart failure is one of the leading causes of death and hospitalisation among the elderly.As a consequence of the worldwide increase in life expectancy, and due to improvements in the treatment of heart failure in recent years, the proportion of patients that reach an advanced phase of the disease, so-called end stage, refractory or terminal heart failure, is steadily growing.2]3 This patient population has a 1-year mortality rate of approximately 50% and requires special therapeutic interventions. 4 Every attempt should be made to identify and correct reversible causes for a worsening of heart failure, such as poor patient compliance, myocardial ischaemia, tachy-or bradyarrhythmias, valvular regurgitation, pulmonary embolism, infection, or renal dysfunction.In this article, we describe current strategies for the treatment of end stage heart failure. PHARMACOLOGICAL MANAGEMENT OF END STAGE HEART FAILURE cCurrent recommendations for the pharmacological treatment of heart failure patients with NYHA class III-IV are summarised in table 1, while table 2 gives an overview of the drugs discussed in this article. 1-3 52]3 In several large clinical heart failure trials ACE inhibitors have been shown to improve symptoms and functional capacity while decreasing the rate of hospitalisations and mortality. 1-3 6Moreover, ACE inhibitors are indicated in patients who develop heart failure after the acute phase of myocardial infarction, and have been shown to improve survival and reduce reinfarctions and hospitalisations in this patient group.ACE inhibitors should not be titrated based on symptomatic improvement but should be uptitrated to the target dosages shown to be effective in the large, placebo-controlled heart failure trials, or to the maximal dose that is tolerated.Treatment should be closely monitored by assessing blood pressure (supine and standing), renal function, and serum electrolytes (especially potassium) at regular intervals.In patients with symptomatic chronic heart failure who do not tolerate ACE inhibitors, angiotensin II type I receptor blockers (ARBs) can be used as an alternative to improve morbidity and mortality. 7 8In heart failure patients remaining symptomatic despite optimal medical treatment including ACE inhibitors, administration of ARBs on top of ACE inhibitors leads to an additive reduction in cardiovascular morbidity and mortality. 8 9However, the higher rate of hypotension, renal dysfunction, and hyperkalaemia with such a combination therapy warrants close monitoring of these parameters.As patients with end stage heart failure frequently show signs of fluid retention or have a history of such, inhibitors of the renin-angiotensin system should be co-administered with diuretics, which usually leads to rapid symptomatic improvement of dyspnoea and exercise tolerance while lacking significant effects on survival.End stage heart failure usually requires the use of loop diuretics, which may be effectively used in combination with thiazides in case of treatment refractory fluid overload due to a synergistic mechanism of action (sequential nephron blockade).2]3 Results from several large clinical trials show that the