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, though 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 has been previously suggested that about 6 million people are affected in the USA (Norton et al., 2011).

The Heart Failure Association of the European Society of Cardiology (HFA-ESC) first attempted to define heart failure in 2007 (Metra et al., 2007). This definition was updated in 2018 (Table 1) (Crispo-Leiro et al., 2018). The updated version emphasises the role of comorbidities, including tachyarrhythmias, and the role of heart failure with preserved ejection fraction (Metra et al., 2019).

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).

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

Various estimations of the prevalence of advanced heart failure have ranged from 6% to 25% of the total heart failure population and 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 is very likely that the number of patients classified as having advanced heart failure will increase, asa consequence of an ageing population and of improved survival due to compliance with current chronic heart failure medications (Fruhwald et al., 2016).