Heart failure is a complex condition that results from any structural or functional heart disease that reduces ejection fraction — the percentage of blood in the heart that’s expelled with each ventricular contraction. Usually, heart failure results from impaired function of the left ventricle. It also may result from diseases of the pericardium, myocardium, endocardium, or great vessels. Coronary artery disease, hypertension, valvular heart disease, and dilated cardiomyopathy are common causes of heart failure.

No matter what the cause of heart failure, if ejection fraction declines too far, the body’s need for oxygen goes unmet and the patient develops dyspnea, fatigue, and other symptoms. (See Symptoms of heart failure, page
130.) Keep in mind, however, that symptoms may not always match the degree of ventricular impairment. Some patients have symptoms of heart failure with a normal-size left ventricle and normal ejection fraction (diastolic dysfunction); others have symptoms only with severe left ventricular dilation, markedly reduced ejection fraction, or both (systolic dysfunction).

The New York Heart Association (NYHA) classification provides a system for categorizing heart failure patients functionally and therapeutically. (See New York Heart Association classification of heart failure.) It’s the most widely used scale, although it’s relatively insensitive to important changes in activity tolerance. The six-minute walk test, measurement of the distance a patient can walk in six minutes, may have more prognostic significance and may help in assessing functional capacity in end-stage heart failure.

Management of heart failure at all stages involves a substantial palliative component. However, determining the appropriate time to start end-of-life care can be quite difficult. Age may affect the patient’s treatment goals because younger patients may be better candidates for heart transplantation; older patients are more likely to be referred for hospice care.

There are no set criteria for determining when a patient has advanced to the end stages of heart failure. A patient with refractory heart failure may be referred to a clinic that specializes in heart failure treatment to make sure that medical management is optimized and that all viable surgical options have been considered.

As a general rule of thumb, patients may need a referral to palliative care if they have NYHA Class IV heart failure, an ejection fraction less than 25%despite optimal treatment, a 6-minute walk distance of less than 300 meters, symptoms that interfere with activities of daily living, and several of these prognostic indicators:

Two or three hospital admissions for heart failure in the previous year support a need for referral along with the patient fitting stage D heart failure on the scale developed by the American Heart Association and the American College of Cardiologists. (See Stages of heart failure.) This scale includes changes in ventricular structure, which is a hallmark of heart failure. The ventricular chamber dilates or hypertrophies and becomes more spherical in a process called cardiac remodeling. Usually, remodeling precedes the development of symptoms.

To help your heart failure patient receive the care he needs, assess his condition carefully, and provide comprehensive palliative care according to the patient’s symptoms and individual challenges. The goals of palliative care include the relief of suffering, management and control of symptoms, and improvement of functional capacity and quality of life.