Kelly Schlendorf, MD Vanderbilt University

1. Kelly Schlendorf, MD, MHS
Section Chief, Heart Failure and Transplantation
Medical Director, Adult Heart Transplant Program
Vanderbilt University Medical Center
When Everything Fails – Advanced Heart Failure:
When to Refer?

2. No disclosures

3. Learning Objectives
• Define & recognize features of the ‘advanced’ HF patient
• Appreciate the importance of timely referral in affording
patients more options and better outcomes
Don’t wait for everything to fail

4. Advanced HF

5. Advanced Heart Failure
“Conventional pharmacologic and device therapies no longer provide an adequate quality or duration of life”
Morris et al. AHA Scientific Statement. Circulation 2021
Among U.S. HF population
• Prevalence 5-10%
• Incidence ~5-10%/year
• 10x higher risk of hospitalization
• 1-year mortality ≥ 20-25%

6. Advanced Heart Failure
“Conventional pharmacologic and device therapies no longer provide an adequate quality or duration of life”
Morris et al. AHA Scientific Statement. Circulation 2021
Among U.S. HF population
• Prevalence 10-25%
• Frequent hospitalizations
• Intolerable symptoms
• Poor survival

7. Clues to Advancing/Advanced HF

8. Clues to Advancing/Advanced HF
• Repeated HF hospitalizations
Setoguchi et al. Clinical Investigation 2007

9. Clues to Advancing/Advanced HF
• Intolerance of GDMT
Bhagat et al. JACC: Heart Failure 2019
Beta Blockers
Withdrawn
Not treated
Continued
Newly started

10. Clues to Advancing/Advanced HF
• Intolerance of GDMT
Kittleson et al. JACC 2003
On ACE-i
No ACE-i, On inotropes
No ACE-i
No inotropes

11. Clues to Advancing/Advanced HF
• Persistent/Worsening NYHA Class III-IV symptoms
Briongos-Figuero et al. ESC Heart Failure 2020

12. Clues to Advancing/Advanced HF
• Defibrillator shocks
Poole et al. N Engl J Med 2008

13. Clues to Advancing/Advanced HF
• Persistent congestion despite escalating diuretics
• Worsening end organ function
• Concerning echo findings: LVEF < 20%, marked LV dilation
• Unintentional weight loss
• Presence of poor perfusion on invasive hemodynamic testing

14. I NEED HELP: Markers of Advanced HF
Baumwol et al. JHLT 2017

15. When to Refer

16. When to Refer
Morris et al. AHA Scientific Statement. Circulation 2021

17. Referral to Advanced Heart Failure
Advanced
directives
Assess HF
etiology
HF &
comorbidities
management
Assess
prognosis &
functional
status
Additional
therapeutic
options
GDMT
initiation
& titration
ADAPTED FROM
Morris et al. AHA
Scientific Statement.
Circulation 2021
Multidisciplinary HF Care

18. Referral to Advanced Heart Failure
Advanced
directives
Assess HF
etiology
HF &
comorbidities
management
Assess
prognosis &
functional
status
Additional
therapeutic
options
GDMT
initiation
& titration
ADAPTED FROM
Morris et al. AHA
Scientific Statement.
Circulation 2021
Multidisciplinary HF Care
Opportunities for
Co-Management
& Shared Care with Referring Providers

19. Referral to Advanced Heart Failure
Advanced
directives
Assess HF
etiology
HF &
comorbidities
management
Assess
prognosis &
functional
status
Additional
therapeutic
options
GDMT
initiation
& titration
ADAPTED FROM
Morris et al. AHA
Scientific Statement.
Circulation 2021
Evaluate candidacy for Transplant or LVAD
Multidisciplinary HF Care
Opportunities for
Co-Management
& Shared Care with Referring Providers

20. When NOT to Refer
• Advanced therapies NOT consistent with your patient’s goals
• Non-cardiac conditions severely limit patient’s functional status/survival
• Advanced COPD
• Metastatic cancer
• The Golden Window is long past
• When unsure, call a colleague

21. Take Aways
• Maintain a high index of suspicion for ‘advancing’ and ‘advanced’
heart failure, keeping in mind that not all advanced heart failure looks
or presents alike
• Err on the side of early as opposed to late referral to advanced heart
failure specialists. Remember the Golden Window

22. kelly.h.schlendorf@vumc.org