Severe acute respiratory syndrome

Disease Description (Causes and Symptoms)

• Definition summary: Advanced heart failure (advanced heart failure, Stage D heart failure) refers to a condition in which symptoms do not improve despite standard drug and device treatments, or in which heart replacement therapy such as heart transplantation or long-term mechanical circulatory support devices (LVAD) is required because of repeated worsening. (The same concept as Stage D of the American College of Cardiology)
• Main pathophysiology: Progression of chronic heart failure leads to reduced ventricular function and inability to maintain cardiac output → fluid retention, pulmonary congestion, and peripheral hypoperfusion occur → the condition becomes advanced with repeated episodes of dehydration, hospitalization, and increased venous pressure.
• Common causes: Ischemic heart disease (underlying damage after myocardial infarction), dilated cardiomyopathy, heart valve disease, prolonged hypertension, recurrent arrhythmias, etc.
• Main symptoms: Dyspnea (shortness of breath at rest or with mild activity), fatigue and exercise intolerance, weight gain and edema, nocturnal dyspnea and cough, recurrent hospitalization (requiring injectable diuretics), etc.
• Diagnostic features: Persistent or recurrent worsening of symptoms at NYHA functional class 3–4. Echocardiography, cardiac catheterization, exercise capacity testing (6-minute walk/CPET), BNP/NT‑proBNP, etc. are used for diagnosis and follow-up.

Treatment Methods and Precautions

• Drug treatment (latest standard treatment)
  • ARNI (sacubitril/valsartan), ACE inhibitor or ARB (when switching to an ARNI is not possible), beta-blocker, mineralocorticoid receptor antagonist (MRA), SGLT2 inhibitor (with a heart failure indication), and diuretics (for symptom control).
  • If necessary, intravenous diuretics or short-term use of inotropes (such as dobutamine).
• Devices/Procedures
  • When indicated: ICD (prevention of ventricular arrhythmias), CRT (ventricular resynchronization), coronary revascularization, or valve surgery/replacement.
  • In severe, refractory cases: left ventricular assist device (LVAD) — long-term support (bridge-to-transplant or destination therapy).
• Transplantation and Palliative Care
  • Heart transplantation: Performed after evaluating the indications and contraindications for transplantation.
  • Palliative care and hospice: Symptom management, relief of pain and dyspnea, and treatment focused on quality of life.
• Other treatments
  • Renal replacement therapy (if necessary), anticoagulation (when indicated for devices, atrial fibrillation, etc.), and management of infection, nutrition, and rehabilitation.
• Lifestyle management and preventive measures
  • Low-sodium diet (daily Na restriction), fluid intake management, daily weight measurement, adherence to medications, smoking cessation and moderation of alcohol consumption, and regular exercise (as directed by a physician).
  • Recommended vaccinations: Seasonal influenza, pneumococcal vaccination, etc.
  • Medications to avoid: Use caution with medications that can cause reduced cardiac function, such as NSAIDs and some antiarrhythmic and anticancer drugs.
• Precautions and risk of complications
  • Kidney failure, liver failure, electrolyte abnormalities, ventricular arrhythmias, pulmonary edema and hypoperfusion shock, LVAD-related infection, thrombosis, and bleeding, thromboembolism, etc.
• Prognosis
  • Advanced heart failure has a poor prognosis. The reported 1-year survival rate is approximately 84% and the 5-year survival rate approximately 66% among patients with heart failure requiring hospitalization (rates vary depending on the data). Early specialized treatment and referral to a specialized center are important.

Checklist Before an Outpatient Visit (Including Preparation Items and Sample Questions)

• Items to prepare (recommended to bring)
  • A list of currently used medications (including doses and administration times) and a history of allergies
  • Copies of recent test results (echocardiography report, cardiac catheterization/coronary artery test results, blood test results, BNP, etc.)
  • Records of recent hospitalizations or emergency room visits, or a hospital discharge summary
  • Records of weight changes (if possible, data measured daily), and notes on changes in urine output and edema
  • Documents related to transplantation or devices (LVAD, pacemaker, etc.), and information on medical devices currently in use
  • A caregiver's contact information and information about the living environment (availability of support)
• Examples of questions that patients and caregivers should record in advance for the outpatient visit
  • When symptoms began and their pattern of worsening (when and under what circumstances they worsen)
  • Recent weight changes (how much weight was gained over how many days), and changes in urination and urine output
  • Changes in medication use (whether medications were stopped or changed) and experience of side effects
  • Any recent infections, surgery, or trauma

Examples of General Questions to Ask the Doctor

• "What side effects can occur with the medications I am currently receiving? What should I watch for with each medication?"
• "In my situation, are standard treatments (ARNI, beta-blocker, MRA, SGLT2 inhibitor, etc.) being used sufficiently?"
• "If I visit the hospital or emergency room, what symptoms (such as a +3 kg weight gain or worsening dyspnea) mean that I should contact you immediately?"
• "What is my expected prognosis, and what can I expect in terms of improving survival and quality of life?"
• "How should I adjust driving, daily activities, and exercise (type and intensity)?"

Examples of Disease-Specific Questions

• Regarding LVAD and transplantation
  • "Do I meet the criteria for being a candidate for heart transplantation (including contraindications)? Are there circumstances in which an LVAD should be considered as a bridge?"
  • "If I undergo LVAD surgery, what will the hospitalization period, complications (infection, thrombosis, bleeding), and rehabilitation process be like? What can I expect regarding my long-term prognosis (daily life and survival)?"
• Regarding worsening symptoms and emergencies
  • "My dyspnea has recently become worse at night. Based on my current symptom pattern, how do you determine whether hospitalization and administration of injectable diuretics are necessary?"

(Organizing the items to prepare and questions before the appointment can help communication between the doctor and patient and treatment decisions during the outpatient visit.)