Therapeutic adjustments in stage D heart failure: challenges and strategies

The morbidity and mortality associated with heart failure (HF) represents a significant public health challenge. Stage D HF identifies a distinct subgroup of advanced HF patients characterized by adverse clinical and hemodynamic factors which warrant evaluation for specialized advanced management strategies and/or consideration of palliative care in tandem with the same recommendations for goal-directed optimal medical therapy as earlier stages of HF. In fact, one of the inherent markers of progression to stage D disease is the need to withdraw previously tolerated neurohormonal agents in the setting of systemic circulatory limitations or renal dysfunction. Furthermore, the requirement for aggressive diuresis in the setting of borderline blood pressures and renal insufficiency is often complicated by worsening renal impairment. Assessment of the appropriate need for inotropic support, given the significant complications associated with their use, is also a frequently encountered challenge complicating the medical management of Stage D HF. This review outlines some of the most relevant challenges of pharmacological therapy in stage D HF and describes current and future strategies that may be employed to overcome some of these obstacles.