Management of advanced and terminal heart failure in an elderly patient with reduced ejection fraction

Abstract Heart failure (HF), despite new therapeutic strategies, remains a condition characterized by an inauspicious prognosis and poor quality of life. The management of advanced and then terminal SC proves to be a current challenge, especially in elderly patients. A.C, 87 years old is autonomous and cognitively intact (BADL preserved 5/6, MMSE 28/30). In June ‘21 femur fracture complicated by cerebral hemorrhage (no relics) and anterior STEMI (FE 25%). Not performed coronarography (contraindication to antiplatelet therapy). Discharged to NYHA II with ARNI, MRA and beta blocker. After 1 month hospitalized for HF in the course of AF, performed infusion of levosimendan. In September ‘21 taken over by our "HF clinic" with progressive titration of therapy and insertion of SGLT2–i. In January ‘22 due to precarious clinical compensation (NYHA III–IV) progressive increase in furosemide dosage and undertaken sequential nephron blockade with metolazone, with good response. Given advanced–HF situation, performed Levosimendan infusions under DH regimen (8 h; 0.05–>0.2 mcg/Kg/min; three times every 2 weeks) with clinical stabilization. In April, hospitalization for decompensation flare–up with worsening creatinine (0.8 >>>2 mg/dL). On discharge, given the precarious compensation, activated the "Hospital–Territory Rapid Intervention Group" with home diuretic infusions and stabilization of the clinical picture and subsequent new referral from the "heart failure clinic" with monthly FU. By November 2022, clinical (NYHA IV with diuretic resistance), cognitive and functional (MMSE 22/30, BADL preserved 2/6) worsening. Evaluated as an end–stage scenario (in the absence of further treatment options), family interview was performed, home nursing service activated for infusions of furosemide, and referred to the palliative care service to assist the patient in the terminal phase of illness at home (Fig. 1). Conclusion in order to ensure the best quality of life in the terminal phase of the disease, the management of advanced SC in the elderly patient must involve individualization of the care pathway, through multidimensional assessment of the patient and sharing of goals at the different stages: from intensive FU with optimization of therapy in the early stages to early activation of home and palliative care services in the more advanced stages.