Refractory cardiac failure

Definition: persistent symptoms of heart failure at rest or on minimal exertion (NYHA class IV) with recurrent congestion or low output, despite maximal tolerated guideline-directed therapy — corresponds to ACC/AHA Stage D, advanced heart failure.

Recognition ("I NEED HELP" markers): repeated hospitalisations, intravenous inotrope dependence, escalating diuretic requirement, intolerance of neurohormonal drugs because of hypotension, rising urea and creatinine, hyponatraemia, persistently low ejection fraction and cardiac cachexia.

Step 1 — exclude pseudo-refractoriness: poor adherence (common with polypharmacy and cognitive impairment), excess dietary salt and fluid, and inadequate drug doses.

Step 2 — stop aggravating drugs: NSAIDs, corticosteroids, glitazones, verapamil/diltiazem, class I antiarrhythmics, and drugs causing sodium retention.

Step 3 — treat reversible precipitants: uncontrolled atrial fibrillation or other arrhythmia, silent myocardial ischaemia, severe valve disease, anaemia and iron deficiency, thyroid dysfunction, infection, pulmonary embolism, renal failure, uncontrolled hypertension, sleep apnoea, and previously undiagnosed cardiac amyloidosis.

Step 4 — overcome diuretic resistance: use intravenous furosemide (bolus or infusion) because gut wall oedema impairs oral absorption; add a thiazide such as metolazone for sequential nephron blockade; add an MRA; consider acetazolamide (ADVOR) or an SGLT2 inhibitor; correct hypoalbuminaemia; monitor electrolytes and renal function closely.

Step 5 — mechanical and device options: ultrafiltration for genuinely diuretic-resistant congestion; cardiac resynchronisation therapy in ventricular dyssynchrony; revascularisation or valve intervention (including TAVI in older patients with aortic stenosis) where appropriate.

Step 6 — advanced therapies: intravenous inotropes (dobutamine, milrinone, levosimendan) are for short-term bridging or palliation only, as continuous inotropes increase mortality. Left ventricular assist devices and transplantation apply to a very small, carefully selected group and are usually limited by biological age and comorbidity.

Step 7 — palliative and end-of-life care (the geriatric emphasis in Pathy's): prioritise quality of life; withhold unnecessary blood tests and medications; treat breathlessness, agitation and anxiety with judicious opioids and benzodiazepines; discuss advance care planning and deactivation of ICD shocks; involve the multidisciplinary team; consider hospice care in the final days.

Prognosis: advanced heart failure carries a one-year mortality commonly exceeding 50%; discussions about ceilings of care should occur early rather than in the last admission. Latest Updates and Current Practice Update (concise) ADVOR trial (NEJM 2022, now in practice): adding intravenous acetazolamide to loop diuretics improves decongestion in acute decompensated HF — a practical addition not present in the textbooks. SGLT2 inhibitors improve diuretic efficiency and are continued (not stopped) during decompensation; EMPULSE showed clinical benefit when empagliflozin was started in hospital. This reverses the older instinct to withhold new agents during decompensation. Vericiguat (VICTORIA) is licensed for worsening HFrEF after a recent decompensation, and omecamtiv mecarbil remains investigational; both extend the options for the patient who has exhausted the four pillars.