Heart failure with reduced ejection fraction
ICD-10 I50.1 · ICD-11 BD11.2

Treatment of Advanced Heart Failure with Reduced Ejection Fraction Refractory to Guideline-Directed Medical Therapy

This protocol addresses a specific, high-acuity population: patients with advanced (stage D) heart failure with reduced ejection fraction (HFrEF) who remain severely symptomatic despite maximal guideline-directed medical therapy (GDMT) and device treatment.

Clinical scenario: Advanced (stage D) HFrEF refractory to both GDMT and device therapy — including patients with NYHA class IV symptoms who depend on continuous intravenous inotropic support or temporary mechanical circulatory support.
Treatment approach — partial overview

The protocol outlines advanced mechanical circulatory and surgical strategies — used either as bridge or as definitive interventions — for patients who have exhausted standard medical and device options; complete selection criteria, sequencing, and indications are available in the full protocol.

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References

DOI: 10.1161/CIR.0000000000001063

In patients with advanced (stage D) HF refractory to GDMT and device therapy who are eligible for and awaiting MCS or cardiac transplantation, continuous intravenous inotropic support is reasonable as "bridge therapy."

In select patients with advanced HFrEF with NYHA class IV symptoms who are deemed to be dependent on continuous intravenous inotropes or temporary MCS, durable LVAD implantation is effective to improve functional status, QOL, and survival.

For selected patients with advanced HF despite GDMT, cardiac transplantation is indicated to improve survival and QOL.

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