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When "Not A Candidate" Becomes a Verdict: Reframing Intensive Care for Patients with Advanced Heart Failure
Diana De Oliveira Gomes1, Shashank S Sinha2, Vanessa Blumer2
1Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Summary
Patients not eligible for advanced heart failure therapies (heart transplant or LVAD) may still benefit from cardiac intensive care unit (CICU) admission. Ineligibility for advanced therapies should not preclude critical care interventions that can improve outcomes.
Area of Science:
- Cardiology
- Critical Care Medicine
- Heart Failure Management
Background:
- The designation 'not an advanced heart failure candidate' is often misconstrued as futility.
- This misinterpretation can lead to reduced appropriateness for cardiac intensive care unit (CICU) admission.
- Advanced therapy ineligibility criteria are narrow and time-sensitive, not reflecting broader care needs.
Purpose of the Study:
- To challenge the conflation of advanced therapy ineligibility with overall futility in heart failure.
- To advocate for a nuanced triage framework for CICU admission in advanced heart failure patients.
- To emphasize that ineligibility for heart transplant or LVAD does not negate the potential benefit of critical care.
Main Methods:
- Review of contemporary data on cardiogenic shock and acute decompensated heart failure in CICUs.
- Analysis of the criteria for advanced heart failure therapy candidacy.
- Development of a proposed triage framework for CICU appropriateness.
Main Results:
- Acute decompensated heart failure is the primary driver of cardiogenic shock in contemporary CICUs.
- Many patients ineligible for advanced therapies can still benefit from critical care interventions.
- Thoughtful critical care can lead to hemodynamic improvement, end-organ recovery, and potential reassessment of candidacy.
Conclusions:
- Advanced therapy ineligibility should not be the sole determinant for CICU admission.
- A comprehensive triage framework considering physiologic need, reversibility, and prognosis is essential.
- Critical care decisions must be individualized, recognizing potential benefits beyond advanced therapies.
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