The diagnosis of advanced heart failure is generally based on the following symptoms, signs, and haemodynamic assessments in patients with NYHA functional class III–IV (Metra et al., 2007):

  • Episodes of fluid retention (systemic or pulmonary) or reduced cardiac output (peripheral hypoperfusion).
  • Severe cardiac dysfunction (at least one of the following):
    • left ventricular ejection fraction <30%
    • pseudonormal or restrictive left ventricular filling pattern
    • pulmonary capillary wedge pressure >16 mmHg or right atrial pressure >12 mmHg
    • high serum BNP or NT-proBNP levels.
  • Severe impairment of functional capacity (at least one of the following):
    • inability to exercise
    • 6-minute walking test distance <300 m
    • peak maximal oxygen uptake <12–14 ml/kg/min
    • at least one hospitalisation for heart failure during the last 6 months.

The presence of these findings despite attempts to optimise treatment for heart failure, including diuretic, renin–angiotensin–aldosterone blocker, beta-blocker (unless not tolerated) and cardiac resynchronisation therapy (where indicated), demonstrate advanced heart failure. A summary of the NYHA classification is shown below.

New York Heart Association (NYHA) functional classification (Dolgin, 1994).


I – No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or dyspnoea.

II – Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnoea.

III – Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnoea. 

IV – Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.

Objective assessment:

A – No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity.

B – Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest.

C – Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only at rest.

D – Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest.

Despite the above classifications, many patients with advanced heart failure receive a late referral for therapies such as transplantation and left ventricular assist devices (LVADs). Late referral increases the risk of right heart failure, renal and liver dysfunction, pulmonary hypertension and cardiac cachexia and resultantly, risks the patient becoming too unwell to receive advanced heart failure therapies (Baumwol, 2017).

The ‘I Need Help’ mnemonic includes risk factors associated with all-cause mortality in heart failure patients and has been developed to support timely referral of patients as they progress from stable to advanced heart failure (Table 1). Contact with an advanced heart failure service should be initiated if a patient has any of the below risk factors.

Table 2. ‘I Need Help’ mnemonic developed by J Baumwol (2017) for the timely referral for treatment of patients with advanced heart failure.
I Inotropes Previous or ongoing requirement for dobutamine, milrinone, dopamine or levosimendan
N NYHA Class/Natriuretic peptides Persisting NYHA III or IV and/or persistently high BNP or NT-ProBNP
E End-organ dysfunction Worsening renal or liver dysfunction in setting of heart failure
E Ejection fraction Very low ejection fraction <20%
D Defibrillator shock Recurrent appropriate defibrillator shocks
H Hospitalisations >1 hospitalisation with heart failure in last 12 months
E Edema/Escalating diuretics Persisting fluid overload and/or increasing diuretic requirement
L Low blood pressure Consistently low blood pressure with systolic <90–100 mmHg
P Prognostic medication Inability to up-titrate (or need to decrease/cease) ACE inhibitors, beta-blockers, angiotensin receptor neprilysin inhibitors or mineralocorticoid receptor antagonist