Background   The physical and psychological symptom burden in the patient dying from heart failure (HF) is similar to that in the dying cancer patient.  Symptom prevalence data in HF includes pain (78%), dyspnea (61%), depression (59%), insomnia (45%), anorexia, (43%), anxiety (30%), constipation (37%), nausea/vomiting (32%), fatigue, difficulty ambulating, and edema.  This Fast Fact reviews domains of medical management common to most end-stage HF patients.

General Symptom Management

• Pain.  Common causes include: peripheral edema, arthritis, diabetic neuropathy, and post-herpetic neuralgia.  NSAIDs are generally contraindicated because they antagonize the effects of diuretics and ACE inhibitors, promoting fluid retention while decreasing glomerular filtration and impairing renal function.  Opioids are the agents of choice for nociceptive and neuropathic pain because of efficacy, rapidity of onset and potential to relieve dyspnea.  See Fast Fact #18, Fast Fact #28, Fast Fact #53, Fast Fact #54, and Fast Fact #72.
• Dyspnea: reassess/optimize HF medications, utilize diuretics as appropriate, assess for reversible causes, e.g. pleural/pericardial effusions, dysrhythmias, COPD exacerbation.  See Fast Fact #27.
• Depression: short-term psychotherapy can be helpful for mild-moderate depression, but patient participation and logistical issues can be problematic. Selective serotonin reuptake inhibitors (SSRIs) are the antidepressants of choice because they preserve ejection fraction, lack hypotensive/ dysrhythmogenic effects, and have few drug interactions. Sertraline may be the agent of choice in HF patients.  Note: as there exists no data on the safety of psychostimulants in HF, therapy should be initiated with caution. 

Heart failure pharmacotherapy   Optimal drug use can improve symptoms and should be continued until the burden of administration outweighs benefits.  Diuretic therapy can be crucial, but diuretic resistance (especially to oral diuretics when patients are in a HF exacerbation) is common. The following strategies can help overcome diuretic resistance: 

• Optimize the dose of oral loop diuretic (e.g. furosemide).  Doses of up to 4000 mg/day have been found to be safe and effective.
• Change to a parenteral route (intravenous or subcutaneous).  IV boluses can produce symptom relief within minutes.  Continuous infusions (3-200 mg/hr; 10-20 mg/hr in most patients) provide increased efficacy. See Fast Fact #353 for further information on subcutaneous diuretics.
• Add a PRN oral adjuvant diuretic (e.g. hydrochlorothiazide 25-100 mg/day, metolazone 5-20 mg/day, or spironolactone 12.5-50 mg/day.  This can reestablish diuresis in a loop diuretic-resistant patient.  Note: high dose and combination diuretics can result in electrolyte imbalances; consider electrolyte monitoring if death is not imminent.

Inotropes    Intravenous inotrope therapy (dobutamine, milrinone, dopamine) has a substantial record of use.  Data suggest these agents may improve symptoms, but with an increased risk of dysrhythmic death.  In hospitalized inotrope-dependent HF patients, discharge on inotropes may provide the opportunity for death to occur at home if desired by patient/family.

Device therapies     Decisions regarding advanced heart failure therapies like ventricular assist devices (VADs) and heart transplantation should be made in the context of goals of care.  See Fast Fact #111 and Fast Fact #112 for a discussion of implantable devices and issues surrounding deactivation; Fast Fact #205 discusses VADs.

Prognostic uncertainty   Accurate prognostication is virtually impossible in HF (see Fast Fact #143).  While this uncertainty is frustrating for physicians, it provides a basis for initiating end-of-life discussions.  The American Heart Association released a scientific statement to help clinicians guide their patients: 

• Initiate yearly “heart failure reviews” or advance care planning discussions.
• Utilize a HF hospitalization (which triples one-year mortality) as a bridge to either optimizing medical therapy or palliative care.
• Educate patients and families about the unpredictable, but usually terminal nature of HF, and the ever-present danger of sudden cardiac death (even when feeling well).
• Ascertain specific goals of care (e.g. quality of life vs. length of life, living/dying at home vs. hospital).
• Assess options for achieving these goals (e.g. initiating/handling device therapies including when and how to deactivate, hospice vs. serial hospital/critical care unit admissions). 
• Assess resuscitation preferences.

References 

1. Albert NM, Davis M, Young J. Improving the care of patients dying of heart failure. Cleve Clin J Med. 2002; 69(4):321-328.
2. Alvarez W, Pickworth KK. Safety of antidepressant drugs in the patient with cardiac disease: a review of the literature. Pharmacotherapy. 2003; 23(6):754-771.
3. Berger JT. The ethics of deactivating implanted cardioverter defibrillators. An Intern Med. 2005; 142(8):631-634.
4. DeBruyne LKM. Mechanisms and management of diuretic resistance in congestive heart failure. Postgrad Med J. 2003; 79:268-271.
5. Ward C. The need for palliative care in the management of heart failure. Heart. 2002; 87:294-298.
6. Braun TC, Hagen NA, Hatfield RE. Cardiac pacemakers and implantable defibrillators in terminal care.  J Pain Symptom Manage. 1999; 18(2):126-131.
7. Allen LA, Stevenson LW, et al.  Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation. 2012; 125:1928-1952.

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in October 2005.  Version re-copy-edited in April 2009; revised again in July 2015 by Sean Marks MD; and again in February 2026.
Conflicts of Interest: None to report.