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Most patients with HF due to left ventricular systolic dysfunction respond favorably to pharmacological and non-pharmacological treatments and enjoy a good quality of life and enhanced survival. However, despite optimal medical therapy, some patients do not improve with treatment or experience rapid recurrence of symptoms. Such patients generally have symptoms (including profound fatigue) at rest or on minimal exertion, cannot perform most activities of daily living, frequently have evidence of cardiac cachexia, and typically require repeated or prolonged hospitalizations for intensive management.

These individuals represent the most advanced state of HF and should be considered for specialized treatment strategies such as mechanical circulatory support, continuous intravenous positive inotropic therapy, referral for cardiac transplantation, or hospice care.

Before a patient is considered to have refractory HF, it is critical that physicians confirm the accuracy of the diagnosis; identify and reverse, if possible, any contributing conditions; and ensure that all conventional medical strategies have been optimally employed. Many patients with advanced HF have symptoms that are related to the retention of salt and water and thus will respond favorably to interventions designed to restore sodium balance. Hence, a critical step in the successful management of end-stage HF is the recognition and meticulous control of fluid retention.

Intravenous Peripheral Vasodilators and Positive Inotropic Agents

Patients with refractory HF are hospitalized frequently for clinical deterioration, and during such admissions, they commonly receive infusions of both positive inotropic agents (dobutamine, dopamine, or milrinone) and vasodilator drugs (nitroglycerin, nitroprusside, or nesiritide) in an effort to improve cardiac performance, facilitate diuresis, and promote clinical stability. Once the clinical status of the patient has stabilized, every effort should be made to devise an oral regimen that can maintain symptomatic improvement and reduce the subsequent risk of deterioration.

Patients who cannot be weaned from intravenous to oral therapy despite repeated attempts may require placement of an indwelling intravenous catheter to allow for the continuous infusion of dobutamine or milrinone, or as has been used more recently, nesiritide. Such a strategy is commonly used in patients who are awaiting cardiac transplantation, but it may also be used in the outpatient setting in patients who otherwise cannot be discharged from the hospital.

The decision to continue intravenous infusions at home should not be made until all alternative attempts to achieve stability have failed repeatedly, because such an approach can present a major burden to the family and health services and may ultimately increase the risk of death. However, continuous intravenous support can provide palliation of symptoms as part of an overall plan to allow the patient to die with comfort at home.

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