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status, liver, kidney, and thyroid function). What is needed, at which interval and who has to perform the follow-up assessment depend on HF stage (Figure 22). The necessity of cardiologist-led follow-up for these patients remains uncertain, with some studies suggesting that primary care follow-up may be appropriate.1054 However, evidence-based intervention uptake is low in many settings, and studies indicate that follow-up by an HF clinic, alongside quality improvement registries, may lead to better therapy optimization and improved outcomes.990,994,1054–1057 An ECG is recommended to detect QRS prolongation, which may qualify patients for CRT, as well as to identify conduction disturbances, AF, and other arrhythmias. Echocardiography should be performed if there is clinical deterioration or if otherwise deemed relevant. Trials investigating the use of biomarkers, such as BNP and NT-proBNP, to guide therapy in HFrEF have yielded inconsistent results.1058–1060 Although these biomarkers are strong prognostic indicators, it remains unclear what additional value a biomarker-guided strategy offers beyond strict adherence to FMT. As such, routine biomarker measurement for guidance on diuretic therapy is not currently supported by the evidence. 11.6.2 Advance care planning and palliative 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 to death. Communication about disease trajectory and advance care planning should be incorporated by all healthcare professionals throughout the course of the disease.1061,1062 Advance care planning is a structured process that facilitates the exploration and communication of the patient’s personal values, life goals, and preferences regarding future medical care, and may include preferences for place of death and resuscitation (which may include deactivating devices, such as ICD or durable MCS). Advance care planning should be documented, regularly reviewed, and routinely communicated to all those involved in the patient’s care. Evidence shows that proactive advance care planning can reduce hospitalizations and improve QoL and end-of-life care, yet many patients with HF lack formalized plans, highlighting the need for better implementation.627 Palliative care, defined as patient- and family-centred care aimed at optimizing health-related QoL by anticipating, preventing, and alleviating suffering, should be integrated into the management of patients with HF in an advanced stage of the
At risk for heart failure Pre-heart
failure Symptomatic
heart failure Advanced heart failure
Figure 22 Long-term follow-up of patients with stable heart failure—what—when—who. CIED, cardiac implantable electronic device; CPET, cardiopulmonary exercise testing; ECG, electrocardiogram; HF, heart failure; HF-MDT, heart failure multidisciplinary team; RHC, right heart catheterization. aIf deemed clinically relevant. bCheck ‘I NEED HELP’ criteria, Figure 16; Table 15 (Section 8). cIntervals may be shorter. Downloaded from academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehag100/8766302 by guest on 31 August 2026
