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....................................................................................................................................................................... centre’s surgical experience, and resources, can also influence decision making.413

10.2.4 Symptom control and end-of-life care While the disease trajectory of each patient with HF is unique, there is a generalizable pattern of gradual decline, punctuated by episodes of acute deterioration leading either to sudden death or death due to progressive HF. Communication about the disease trajectory and anticipatory planning should start when a patient is diagnosed with advanced HF. Indications for and key components of a palliative care service are reported in Tables 18 and 19.312,418 A team-based approach to palliative and end-of-life care for patients with HF has been proposed.419 Specific models of palliative care for patients with advanced HF have been also reported. They reduce hospitalizations, without a clear effect on survival, and have some effects on QOL and symptom burden.420,421 Symptom assessment should be performed on a regular basis. In addition to clinical assessment, symptoms can be assessed using the Numeric Rating Scale, the Edmonton Symptom Assessment Scale (ESAS) or ESAS-HF, or the Integrated Palliative care Outcome Scale. Treatment for symptoms needs to be considered and might include additional intervention on top of OMT:

• Breathlessness: repeat doses of opioids may be considered for the relief of dyspnoea; however, their effectiveness is not demonstrated.422,423 While using opioids, all patients should be guided about opioid side effects such as constipation and nausea, urinary retention, and mental status changes. Benzodiazepines may be considered as a second- or third-line treatment, when opioids and non-pharmacological measures have failed to control breathlessness. Increasing the inspired oxygen concentration may provide relief of dyspnoea. • Pain: non-pharmacologic management can be helpful. In addition, opioid, oxycodone, hydromorphone, and fentanyl are generally viewed as safe options and can be provided orally, intravenously, and transdermally, especially in the hospital or in patient palliative care or hospice setting.424 • Anxiety and depression: adequate conventional treatment should be offered. Proactive decisions and advanced planning with regard to palliative and end-of-life care discussions should be documented, regularly reviewed, and routinely communicated to all those involved in the patient’s care. Healthcare providers should make sure that patients’ and carer preferences are followed, wherever possible. They should also take into account that patients may choose not to, or may not be in a position to, express preferences (e.g. due to symptoms of depression or cognitive impairment).

11 Acute heart failure

11.1 Epidemiology, diagnosis and

prognosis AHF refers to rapid or gradual onset of symptoms and/or signs of HF, severe enough for the patient to seek urgent medical attention, leading to an unplanned hospital admission or an emergency department visit. Patients with AHF require urgent evaluation with subsequent initiation or intensification of treatment, including i.v. therapies or procedures. AHF is a leading cause of hospitalizations in subjects aged >65 years and is associated with high mortality and rehospitalization rates. In-hospital mortality ranges from 4% to 10%.425428 Post-discharge 1-year mortality can be 2530% with up to more than 45% deaths or readmission rates.104,426,427,429,430 AHF may be the first manifestation of HF (new onset) or, more frequently, be due to an acute decompensation of chronic HF. Compared to patients with acutely decompensated CHF, those with new onset HF may have a higher in-hospital mortality425 but have lower post-discharge mortality and rehospitalization rates.425,428,431,432 Specific extrinsic factors may precipitate, but not cause, AHF in patients with pre-existing cardiac dysfunction (Supplementary Table 16). Clinical severity and in-hospital trajectory are determined by the complex interplay between precipitants, the underlying cardiac substrate, and the patient’s comorbidities.

Table 18 Patients with heart failure in whom end-of-life care should be considered

Progressive functional decline (physical and mental) and dependence in most activities of daily living. Severe heart failure symptoms with poor QOL despite optimal pharmacological and non-pharmacological therapies. Frequent admissions to hospital or other serious episodes of decompensation despite optimal treatment. Heart transplantation and MCS ruled out. Cardiac cachexia. Clinically judged to be close to end of life. MCS = mechanical circulatory support; QOL = quality of life.

Table 19 Key components of palliative care service in patients with advanced heart failure

Focus on improving or maintaining the QOL of a patient and his/her family as well as possible until he/she dies. Frequent assessment of symptoms (including dyspnoea and pain) resulting from advanced heart failure and other comorbidities and focus on symptom relief. Access for the patient and his/her family to psychological support and spiritual care according to need. Advanced care planning, taking into account preferences for place of death and resuscitation (which may include deactivating devices, such as ICD or long-term MCS that may require a multidisciplinary team decision). ICD = implantable cardioverter-defibrillator; MCS = mechanical circulatory support; QOL = quality of life. ESC 2021 ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026