Refractory heart failure: Optimizing therapy, managing end-stage disease. A guide to making the best use of standard and new treatments

Heart failure is deemed refractory when it is severe enough to resist maximal standard medical therapy. Before reaching that conclusion, however, confirm the accuracy of diagnosis, absence of other illness, full compliance with therapy, absence of complicating drug therapy, and other obvious points. Ensure, too, that the patient has indeed received optimal therapy, which may include the following, as indicated: restriction of dietary salt and water, aggressive diuresis, digoxin when left ventricular ejection fraction is less than 35%, an angiotensin-converting enzyme inhibitor given at a dosage proved to be effective and safe, a β-blocker, an angiotensin II receptor antagonist, and anticoagulation. For ischemic cardiomyopathy with large areas of injured but viable tissue, coronary artery bypass graft surgery can improve survival, ventricular function, and symptoms. Left ventricular assist devices can serve as bridges to heart transplantation.