Opinion | Is ‘End-Stage’ Heart Failure Really The End? Not Anymore
Rapid advances in heart failure therapies over the past couple of decades mean that Stage D heart failure is no longer a death sentence — nor should it be considered truly "end-stage"
Before we delve into the topic of “end-stage" heart failure, let us first try to understand what is meant by heart failure. As you know, the heart is an organ that pumps blood to all other organs — from the very beginning of life in our mother’s womb until the end of life. It is essential for sustaining the function of all the tissues in the body.
Oxygenated blood from the lungs enters the left-sided chambers of the heart, from where it is pumped to the rest of the body. Similarly, deoxygenated blood from the body is returned to the right side of the heart and then pumped to the lungs.
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Heart failure, in simple terms, is the inability or reduced capacity of the heart to perform this vital function. This leads to a build-up of fluid in the lungs and other parts of the body, resulting in the classical symptoms of heart failure — such as breathlessness, fatigue, and swelling of the legs.
Heart failure does not mean that the heart has stopped working entirely (which is known as cardiac arrest), but rather that it is functioning inefficiently or may require support to do so.
Heart failure is generally a progressive disease, and depending on its underlying cause (aetiology), the rate of progression and potential for reversibility can vary. However, for practical purposes — particularly in guiding treatment decisions and prognosis — heart failure is categorised into four stages, from A to D, in order of increasing severity.
As for the term “end-stage" heart failure, it is now considered obsolete and is no longer recommended for use.
STAGES OF HEART FAILURE
In collaboration with the American College of Cardiology, the American Heart Association (AHA) has identified four stages of heart failure, as outlined in the table below:
Stage A: At risk for heart failure
People who are at risk of developing heart failure but do not yet have symptoms or evidence of structural or functional heart disease.
Risk factors for this stage include hypertension, coronary vascular disease, diabetes, obesity, exposure to cardiotoxic agents, certain genetic variants, and a family history of cardiomyopathy.
Stage B: Pre-heart failure
People without current or previous symptoms of heart failure, but with evidence of structural heart disease, increased filling pressures in the heart, or other predisposing risk factors.
Stage C: Symptomatic heart failure
People with current or previous symptoms of heart failure.
Stage D: Advanced heart failure
People with symptoms of heart failure that interfere with daily life or result in repeated hospitalisations.
Stage D, or advanced heart failure, was previously referred to as “end-stage heart failure" due to the poor prognosis associated with it. However, rapid advances in heart failure therapies over the past couple of decades mean that Stage D heart failure is no longer a death sentence — nor should it be considered truly “end-stage".
That said, survival rates for advanced heart failure remain worse than for many cancers, which makes prevention critically important. To that end, it is essential to address the common causes of heart failure. These include coronary artery disease, heart attacks, valvular heart disease, cardiomyopathy (including alcohol-induced), abnormal heart rhythms, systemic infections, severe anaemia, certain vitamin or mineral deficiencies, and congenital heart diseases, among others.
Heart failure is generally not completely reversible in most cases. However, with current potent therapies, it can be well controlled in the long term and is at least partially reversible. In certain conditions — such as thyroid disorders, vitamin or mineral deficiencies, anaemia, pregnancy-related heart failure, rhythm abnormalities, or stress-induced cardiomyopathy — a complete reversal of heart failure is possible.
As mentioned earlier, prevention remains the most effective approach in combating heart failure. However, for those with established heart failure, therapeutic options include lifestyle modifications, potent medical treatment (Guideline-Directed Medical Therapy), device therapy, and, in cases of advanced heart failure, interventions such as LVADs (Left Ventricular Assist Devices), artificial hearts, or heart transplantation — all of which have shown promising outcomes.
Dr Shyam Sasidharan is Consultant, Department of Cardiology, KIMSHEALTH, Thiruvananthapuram. Views expressed in the above piece are personal and solely those of the author. They do not necessarily reflect News18’s views.
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