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An organizational model between centres with different levels of care complexity, based on a ‘Hub and Spoke’ network, is key to good patient management. A recent consensus document focuses on identifying and overcoming barriers to early referral to an advanced HF centre.574 Patients with contraindications to MCS or heart transplantation should receive palliative care (see Section 11.6.2). Advance care planning should be discussed in all patients with advanced HF regardless of treatment strategy (see Section 11). Frailty, malnutrition, cardiac cachexia, and sarcopenia are highly prevalent in patients with advanced HF and are associated with a greater risk of death (see Supplementary data online, Table S17 for detailed definitions).586–589 When evaluating frailty in patients with advanced HF, it is important to assess whether frailty is primarily due to the cardiac condition or other factors.590

Figure 16 Triage and timely referral of patients with advanced heart failure. AMT, additional medical therapy; FMT, foundational medical therapy; GDIT, guideline-directed interventional therapy; HF, heart failure; LVAD, left ventricular assist device; NYHA, New York Heart Association; QoL, quality of life. aLimited life expectancy may be due to major comorbidities, such as cancer, dementia, end-stage irreversible organ dysfunction; other conditions that may impair follow-up or worsen post-treatment prognosis include frailty, irreversible cognitive dysfunction, psychiatric disorder, or psychosocial issues. bRefer to Table 15 for ‘Rule of three’ or ‘I NEED HELP’ criteria. cA centre performing LVAD implantation and/or heart transplantation.

Table 15 Criteria for high risk of advanced heart failure Rule of three criteria (at least 1): • HFH (≥2 or ≥1 requiring inotropes within the last year) • Diuretic resistance • Intolerance to neurohormonal drugs with onset of cardiorenal

syndrome I NEED HELP criteria (at least 1): • Inotropes • NYHA class III/IV or persistently high natriuretic peptides • End-organ dysfunction (liver, kidney) • EF <20% or poor RV function • Defibrillator shocks • HFH >1 • Escalating diuretics • Low blood pressure, high heart rate • Prognostic medication intolerance or the need to downtitrate © ESC 2026 EF, ejection fraction; HFH, heart failure hospitalization; NYHA, New York Heart Association; RV, right ventricular. Recommendation Table 11 — Recommendations for diagnosis and evaluation of advanced heart failure (see Evidence Tables 70 and 71)

Recommendations Classa Levelb Early consultation with an advanced HF centrec is recommended in patients with advanced HF or at risk of advanced HF, who are motivated and do not have absolute contraindications for heart transplantation or durable MCSd, in order to evaluate candidacy.e 573,591 I A Cardiopulmonary exercise testing is recommended in patients with advanced HF, as part of the evaluation for heart transplantation and durable MCS.579,580,582 I C

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