Heart failure, advanced/decompensated treatment

Stage D heart failure includes patients with symptoms at rest that are refractory despite maximal medical therapy. This includes patients who undergo recurrent hospitalizations or cannot be discharged from the hospital without special interventions. These individuals have the most advanced form of heart failure and should be considered for specialized therapies, including mechanical circulatory support, continuous positive inotropic therapy, cardiac transplantation, or hospice care. The approach to treatment of patients with stage D heart failure is discussed in more detail in the section Treatment Advanced/ Decompensated Heart Failure. ... 

I Thiazide Diuretics. Thiazide diuretics such as hydrochlorothiazide block sodium and chloride reabsorption in the distal convoluted tubule (approximately 5% to 8% of filtered sodium). The thiazides therefore are relatively weak diuretics and infrequently are used alone in heart failure. However, as is reviewed in detail in the section Treatment Advanced/Decompensated Heart Failure under Diuretic Resistance, thiazides or the thiazide-like diuretic metolazone can be used in combination with loop diuretics to promote a very effective diuresis. 

FIGURE 14-8. General treatment algorithm for advanced/decompensated heart failure based on clinical presentation. Intravenous vasodilators that may be used include nitroglycerin, nesiritide, and nitroprusside. (Adapted with permission from Am Heart J 1998 135 5293-309.)... 

Treatment strategies for progressive pulmonary venous hypertension should focus on treatment of the underlying disease. For patients with advanced decompensated systolic heart failure and secondary pulmonary hypertension, it is essential to reduce the pulmonary vascular resistance prior to heart transplantation to prevent acute RV failure of the donor heart. The use of continuous milrinone, occasionally nesirit-ide, and earlier intervention with mechanical circulatory device support (19) as a bridge to cardiac transplantation is considered a standard approach for this group of patients. Earlier intervention with valve repair or replacement for patients with mitral valve disease and aortic valve disease with associated pulmonary hypertension is recommended. 

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