The term "advanced heart failure" is often used to characterise heart failure patients with severe symptoms, recurrent episodes of decompensation and severe cardiac dysfunction (Metra et al., 2007). Typically, the patient’s clinical condition deteriorates progressively despite maximal therapy, with worsening of symptoms and severe impairment of functional capacity, although this may take years. Hard data on the epidemiology of advanced heart failure has been difficult to obtain because the condition lacked a uniform definition, but it was previously suggested that about 6 million people have this condition in the USA (Norton et al., 2011).

To overcome this, the Heart Failure Association of the European Society of Cardiology (HFA-ESC) have published proposed criteria to define advanced heart failure (Table 1).

Advanced heart failure is defined by the presence of all the following criteria despite optimal guideline-directed treatment.

Table 1. HFA-ESC updated definition of advanced heart failure (Crispo-Leiro et al., 2018).
Criteria Definition


Severe and persistent symptoms of heart failure (NYHA Class III (advanced) or IV)


Severe cardiac dysfunction defined by a reduced LVEF ≤30%, isolated RV failure (e.g. ARVC) or non-operable severe valve abnormalities or congenital abnormalities or persistently high (or increasing BNP or NT-proBNP values and data of severe diastolic dysfunction or LV structural abnormalities according to the ESC definition of HFpEF and HFmrEF


Episodes of pulmonary or systemic congestion requiring high-dose intravenous diuretics (or diuretic combinations) or episodes of low output requiring inotropes or vasoactive drugs or malignant arrhythmias causing >1 unplanned visit or hospitalisation in the last 12 months


Severe impairment of exercise capacity with inability to exercise or low 6MWTD (<300 metres) or pVO2 (<12–14 mL/kg/min), estimated to be of cardiac origin

Extra-cardiac organ dysfunction due to heart failure (e.g. cardiac cachexia, liver or kidney dysfunction) or type 2 pulmonary hypertension may be present but are not required.
ARVC, arrhythmogenic right ventricular cardiomyopathy; BNP, B-type natriuretic peptide; HFmrEF, heart failure with mid-range ejection fraction; HFpEF, heart failure with preserved ejection fraction; LV, left ventricular; LVEF, left ventricular ejection fraction; NT-proBNP, N-terminal pro-B-type natriuretic peptide; NTHA, New York Heart Association; pVO2, peak exercise oxygen consumption; RV, right ventricular; 6MWTD, 6-minute walking test distance.

Various estimations of the prevalence of advanced heart failure have given figures from 6–25% of the total heart failure population, but the true prevalence of advanced heart failure remains uncertain (Nohria et al., 2002). More recently, it has been estimated to comprise a lower, but still substantial, 1–10% of the overall heart failure population (Crespo-Leiro et al., 2018).

It can be assumed that in the coming years the number of patients classified as having advanced heart failure will increase. This is the consequence of an ageing population and improved survival due to compliance with current chronic heart failure medications (Fruhwald et al., 2016).