Guidance for Referral of Patients With Advanced HF

Quick Takes

  • An advanced HF clinic provides additional diagnostic and therapeutic components that would benefit patients with complex HF.
  • A two-step approach is described, which includes identifying when patients with HF are approaching stage D HF and who would benefit having care coordinated by an advanced HF clinic.
  • Advanced HF clinics incorporate a multidisciplinary team that includes cardiologists, cardiovascular surgeons, nurse practitioners and physician assistants, pharmacists, social workers, psychologists, and palliative care specialists.

Study Questions:

What is a framework for practitioners and health care systems to identify and refer patients with heart failure (HF) who are most likely to drive benefit from referral to an advanced HF clinic?


A two-step process can help clinicians determine the appropriate timing to refer patients to an advanced HF clinic. The first step is to identify patients with clinical features of advanced HF (stage D). Patients who have had recurrent hospitalizations, intolerance to guideline-directed medical therapy (GDMT), increasing burden of arrhythmias, and worsening renal function should be considered for referral to an advanced HF clinic. One readmission within 12 months has been associated with increase in mortality and may be the only trigger required to refer patients to an advanced HF clinic. The second step is to determine if the patient would benefit from care coordination by an advanced HF clinic. Resources are in place that allow for additional testing to determine HF etiology, GDMT initiation and titration with multidisciplinary approach with nurse practitioners and physician assistants and pharmacists, parenteral iron supplementation, and same-day intravenous diuretic access. Also available in an advanced HF clinic are additional therapeutic options, HF and comorbidities management, assessment of prognosis and functional capacity, and discussion of advance directives. In appropriate patients, evaluation for a left ventricular assist device (LVAD) or heart transplant is available in an advanced HF clinic. Patients who have expressed their goals of care to avoid surgical and complex care should not be referred to advanced HF clinic. In addition, patients whose life span or functional status are severely limited by non-cardiac conditions should be engaged in shared decision making before referral because of the potential for poor outcomes from advanced therapies. Patients with a low cardiac index but no evidence of hypotension or refractory end-organ dysfunction are in the optimal window for referral to an advanced HF clinic. Late referrals can have a significant adverse impact on outcomes. First, progressive cardiac cachexia and frailty increase risks associated with potential interventions. Second, patients who develop progressive liver or renal failure may be ineligible for LVAD or heart transplant. Third, the risk of fulminant deterioration and overt cardiogenic shock requiring temporary mechanical support increases risk of mortality. Forth, development of progressive right ventricular failure such that a durable LVAD is no longer an option and could be fatal makes the patient ineligible for heart transplant.


Patients with advanced HF would benefit from referral to an advanced HF clinic. Optimal timing is necessary to allow patients to receive the most benefit from coordination of care among a multidisciplinary team that typically includes HF cardiologists, clinicians, cardiothoracic surgeons, nurse practitioners and coordinators, pharmacists, psychologists, social workers, dietitians, palliative care specialists, and financial specialists. The advanced HF clinic team can rapidly engage consultants to manage comorbidities. The complexity of care of patients with advanced HF requires optimal GDMT, risk stratification, management and evaluation of medical and psychosocial comorbidities, education about HF self-care and adherence, assessment of advance directives, and evaluation for advanced therapies. A shared-care model can be used between referring clinicians and advanced HF clinicians to minimize the burden to patients. Barriers to referring patients to an advanced HF clinic include conscious and unconscious bias that can lead to delayed referral or nonreferral resulting from perceptions of nonadherence. Side effects of nausea and dizziness may lead to inappropriately being labeled as nonadherent. Lack of financial resources can limit the patients’ ability to access and pay for medications and adhere to a low-sodium diet. Open communication by clinicians is imperative to understand the ability of patients with HF to comply with the complex treatment plan.


Although electronic health records have improved information sharing, there are still barriers to sharing test results across health care systems and providers. Open communication between patients, primary care providers, and advanced HF specialist is critical. Patients should be encouraged to participate in shared decision making about referral to an advanced HF clinic.


A major benefit to referring patients with advanced HF to an advanced HF clinic is the availability of a multidisciplinary team that can address the complex physical, psychological, social, and financial needs of this vulnerable population. Referrals should be considered before the patient starts to exhibit end-organ damage from the systematic impact of HF syndrome in order to optimize the benefit of advanced therapies. Rehospitalization within 12 months for decompensated HF is an early trigger to referral to an advanced HF clinic.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support

Keywords: Heart Failure, Decision Making, Shared, Heart Transplantation, Referral and Consultation, Delivery of Health Care, Advance Directives, Patient Care Planning, Primary Health Care, Patient Care Team, Risk Assessment, Nurse Practitioners, Physician Assistants, Transplantation, Prognosis, Heart-Assist Devices

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