Advanced heart failure is characterized by persistent symptoms, recurrent hospitalizations, and poor survival. In this cohort, mortality remains high without advanced heart failure therapies. This article provides updates on therapeutic options specific to the advanced heart failure population, including durable mechanical circulatory support (MCS) and heart transplantation (HT), and highlights the important role of palliative care.

Heart failure (HF) comorbidities are extremely common and complicate management due to increased prescriptions and adverse drug effects, declining functional status, and more frequent health care utilization. Comorbidities are associated with poor outcomes in these patients, with worsened mortality, hospitalization, and quality of life. Clinicians should understand how to address common HF comorbidities to provide optimal care of patients with HF and avoid adverse outcomes.

This review examines the role of diagnostic and prognostic testing in heart failure. It discusses the use of biomarkers, genetic testing, and advanced imaging techniques, such as echocardiography and cardiac MRI, for heart failure diagnosis and severity assessment. Key prognostic markers include natriuretic peptides, functional capacity measures, and imaging parameters. Collectively, these provide a comprehensive evaluation of disease progression and prognosis. These diagnostic and prognostic tools are essential for heart failure diagnosis and for guiding treatment strategies to improve outcomes.

Chronic heart failure is characterized by periods of stability punctuated by clinical decline often requiring hospitalization. Following hospitalization, patients remain at an increased risk of morbidity and mortality, often requiring rehospitalization due to recurrent deterioration. Transitional care interventions aim to improve the movement from the inpatient to ambulatory setting. Promising interventions, such as patient education, novel uses of loop diuretics, and invasive hemodynamic monitoring, have been developed over the past 20 years all with varying degrees of success.

Heart failure (HF) mortality rates have been increasing in the United States since 2012, with disproportionate increases in those aged under 65 years and in individuals who identify as Black. Expanded medical and device therapies across the range of ejection fractions have been proven to be effective in clinical trials and are endorsed by HF guidelines but can also impose considerable costs to patients and payers. Understanding of the mortality risk from HF along with the costs and cost-effectiveness of contemporary therapies is central to combating the HF epidemic.

Cardiogenic shock is a complex clinical syndrome primarily resulting from acute myocardial infarction or decompensated heart failure, though other less common causes exist. It is characterized by hypotension, reduced organ perfusion, and diminished cardiac output, potentially leading to extremis and, if untreated, death. Advances in hemodynamic monitoring and the use of vasoactive support can promote recovery, along with mechanical circulatory support. Given the high mortality rate associated with cardiogenic shock, early identification and intervention by specialized shock teams have been explored. Additionally, palliative care is integral to multidisciplinary teams in establishing and addressing patient and family goals of care.

Loop diuretics are Class I recommended for managing congestion in chronic heart failure, though their effect on morbidity and mortality remains uncertain due to limited large-scale evidence. Current guidelines recommend using the lowest effective dose to maintain euvolemia while minimizing adverse effects through individualized care. Personalized monitoring-including clinical evaluation, biomarkers, and hemodynamic parameters-is essential to guide therapy. Optimizing guideline-directed medical therapy (GDMT), particularly angiotensin receptor-neprilysin inhibitors, sodium-glucose cotransporter 2 inhibitors, and mineralocorticoid receptor antagonists, may support diuretic minimization. Integrating GDMT with tailored monitoring may improve loop diuretic use and improve clinical outcomes in chronic heart failure management.

Hospitalizations for decompensated heart failure confer significant morbidity, mortality, and health care costs. There are multiple clinical trials, which offer strong evidence that medications and interventions improve outcomes; however, hospitalization and mortality rates remain high. Key components of effective management during the heart failure hospitalization include appropriate diagnostic evaluation, triage and risk stratification, early implementation of guideline-directed medical therapy, adequate diuresis, management of cardiogenic shock, and appropriate discharge planning.

Heart failure with preserved ejection fraction (HFpEF) is a complex clinical syndrome affecting patients with signs and symptoms of heart failure with a normal or near normal left ventricular ejection fraction. The diagnosis of HFpEF can be challenging and often involves an extensive evaluation to rule out other conditions that might explain the symptom burden affecting patients. Clinical trials specifically targeting the management of HFpEF have been conducted, and clinical practice guidelines do exist although to a lesser degree in terms of the strength of recommendations as compared with other heart failure classifications.

Heart failure (HF) is no longer centered on the failing ventricle. Various salutary treatment discoveries now support substantially improved survival with lesser likelihood for urgent care or hospitalization. Careful assessment of comorbidities and early recognition of symptoms further support the care for patients with HF. Advanced care strategies are effective, but not only includes mechanical circulatory assist and heart transplantation, but also clinical trial participation, palliative care, and hospice. With this contemporary view of HF, failure is supplanted with opportunity. At the patient level, longer healthier lives, in concert with expert management of ventricular dysfunction, becomes the contemporary expectation.