Heart failure is a major public health problem, with a patient population of at least 10 million in Europe and approximately 5 million in North America.^1–3 Because of its age-dependent increase in incidence and prevalence, heart failure is one of the leading causes of death and hospitalisation among the elderly. As a consequence of the worldwide increase in life expectancy, and due to improvements in the treatment of heart failure in recent years, the proportion of patients that reach an advanced phase of the disease, so-called end stage, refractory or terminal heart failure, is steadily growing. Patients with end stage heart failure fall into stage D of the ABCD classification of the American College of Cardiology (ACC)/American Heart Association (AHA), and class III–IV of the New York Heart Association (NYHA) functional classification; they are characterised by advanced structural heart disease and pronounced symptoms of heart failure at rest or upon minimal physical exertion, despite maximal medical treatment according to current guidelines.^1–3 This patient population has a 1-year mortality rate of approximately 50% and requires special therapeutic interventions.⁴ Every attempt should be made to identify and correct reversible causes for a worsening of heart failure, such as poor patient compliance, myocardial ischaemia, tachy- or bradyarrhythmias, valvular regurgitation, pulmonary embolism, infection, or renal dysfunction. In this article, we describe current strategies for the treatment of end stage heart failure.

PHARMACOLOGICAL MANAGEMENT OF END STAGE HEART FAILURE

Current recommendations for the pharmacological treatment of heart failure patients with NYHA class III–IV are summarised in table 1, while table 2 gives an overview of the drugs discussed in this article.^1–3,5 Angiotensin-converting enzyme (ACE) inhibitors are recommended as first-line treatment in all patients with reduced left ventricular (LV) systolic function (ejection fraction (EF) ⩽35–40%) independent of clinical symptoms (NYHA I–IV), unless there are contraindications. …