Table 1.

Clinical indicators of advanced heart failure

Clinical indicators of advanced HF	High-risk features
INEEDHELP Mnemonic (2017)[59]	I Inotropes- H/o or current use of dobutamine, milrinone, dopamine, or levosimendan N NYHA class and/or natriuretic peptides — NYHA class III/IV and/or ↑ BNP or NT-proBNP E End-organ dysfunction — deteriorating renal or liver function E Ejection fraction less than 25% D Defibrillator shocks — recurrent and appropriate shocks H Hospitalizations — one or more hospitalization for HF within 1 year E Edema/increased use of diuretic agents L Low BP — systolic < 90 to 100 mmHg P Prognostic medications — unable to ↑ or needing to stop/↓ ACE-I, BBs, ARNIs, or MRAs
Patient profiles per the Interagency Registry for Mechanically Assisted Circulatory Support* (INTERMACS) (2008)[60]	Profile 1: Critical cardiogenic shock, other organ hypoperfusion, increased need for inotrope/pressor support Profile 2: Progressive decline where patient relies on inotrope support and has signs of worsened organ dysfunction Profile 3: Stable, still relies on inotrope support, no signs of clinical deterioration unless weaned from inotropes or temporary circulatory support device Profile 4: Symptomatic at rest or with minimal daily living tasks while on appropriate oral medications at home Profile 5: Exertion intolerant: no symptoms at rest, remains mostly at home because cannot participate in any activities other than minimal daily living tasks Profile 6: Exertion limited: no symptoms at rest or minimal daily living tasks, able to participate in minor activities, develops fatigue quickly, unable to do significant physical exertion Profile 7: Advanced NYHA class III: distant history of decompensation (> 1 month) who can participate comfortably in significant physical exertion Modifiers: Temporary Circulatory Support (TCS) — able to modify patients in hospital only (other devices would be INTERMACS devices). Examples of these devices are Levitronix, ECMO, Impella BVS 5000, IABP, AB5000, or TandemHeart. These apply to 1, 2, 3 profiles in the hospital Arrhythmia (A) — able to modify any profile. For example, frequent and recent ventricular tachyarrhythmias contributing to significant clinical deterioration (i.e., frequent ICD shocks or needing an external defibrillator, more than once per week Frequent Flyer (FF) — only modifies outpatients. Patients that require frequent emergency visits and/or hospitalizations needing intravenous vasopressors, diuresis, or ultrafiltration. These apply to profile 3 if at home, 4, 5, 6. Important to mention a Frequent Flyer would rarely be profile 7
Heart Failure Survival Score Criteria (1997)[61]	- Ischemic cardiomyopathy - LVEF as a measure of systolic dysfunction - PCWP as a measure of diastolic dysfunction - Serum sodium as a measure of activation of the RAAS system - Resting heart rate as a measure of activation of the SNS - Intraventricular conduction delay as a measure of myocardial injury/fibrosis - Peak V̇O2 and mean blood pressure
Seattle Heart Failure Model Criteria (2006)[62]	- Clinical: age, gender, NYHA class, weight, EF, systolic BP, presence of ischemia, LBBB, QRS > 150 ms - Medications: Ace-I, BBs, ARBs, statins, allopurinol, aldosterone blockers - Diuretics: furosemide, bumetamide, torsemide, metolazone, HCTZ, chlorthalidone - Lab data: Hgb, lymphocyte %, uric acid, sodium, total cholesterol - Devices: Biv Pacer, ICD, BiV ICD, IABP, Vent, UF
Other clinical indicators of advanced HF based on American Heart Association/American College of Cardiology/HeartFailure Society of America[63]as well as European Society of Cardiology criteria[[64]]	- Increased predicted 1-year mortality (e.g., > 20%) according to HF survival models (e.g., MAGGIC, SHFM) - Repeated hospitalizations or emergency department visits for HF in the past 12 mo - Refractory or recurrent ventricular arrhythmias; frequent ICD shocks - Need for intravenous inotropic therapy - Persistent hyponatremia (serum sodium < than 134 mEq) - Persistent NYHA functional class III to IV symptoms despite therapy - Worsening right HF or secondary pulmonary hypertension - Severely reduced exercise capacity (peak VO2, < 12–14 mL/kg/min or < 50% predicted, 6-min walk test distance < 300 m, or inability to walk 1 block on level ground because dyspnea or fatigue) - Refractory clinical congestion - Progressive deterioration in renal or hepatic function - Intolerance to RAASi because of hypotension or worsening renal function - Recent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose > 160 mg/d or use of supplemental metolazone therapy - Intolerance to beta blockers because of worsening HF or hypotension - Frequent SBP < 90 mmHg - Cardiac cachexia

NYHA New York Heart Association, BNP brain natriuretic peptide, NT natriuretic, HF heart failure, BP blood pressure, ACE-I angiotensin-converting enzyme inhibitor, BB beta blockers, ARNIs angiotensin receptor-neprilysin inhibitors, MRA mineralocorticoid receptor antagonist, LVEF left ventricular ejection fraction, PCWP pulmonary capillary wedge pressure, RAAS renin–angiotensin–aldosterone system, SNS systemic nervous system, VO₂ oxygen consumption/oxygen uptake, EF ejection fraction, LBBB left bundle branch block, ARBs aldosterone receptor blockers, HCTZ hydrochlorothiazide, Biv biventricular, ICD implantable cardioverter-defibrillator, IABP intraaortic balloon pump, Vent ventilator, UF ultrafiltration, MAGGIC Meta-analysis Global Group in Chronic Heart Failure, mEg milliequivalents, RAASi renin–angiotensin–aldosterone system inhibitors

*INTERMACS score has been commonly used for both identification of advanced HF severity and prognostic factor for operative outcomes, with lower INTERMACS scores associated with worse outcomes, see text