Heart failure occurs when the heart cannot pump enough blood to meet the body’s needs. End stage heart failure is the most severe form of heart failure.

This article will discuss end stage heart failure, including common signs and symptoms. It will also explain the causes of the condition and how to manage, treat, and help prevent it. It also explores the outlook of people with end stage heart failure.

Information for caregivers

As a person’s condition progresses, they may need help reading or understanding information regarding their circumstances. This article contains details that may help caregivers identify and monitor symptom progression, side effects of drugs, or other factors relating to the person’s condition.

A person with heart failure experiences weakening of the heart over time. Management and treatment options can help a person live with the symptoms that heart failure causes, but heart failure is chronic, and there is no cure.

In end stage heart failure, the body can no longer compensate for the lack of blood the heart pumps, and the heart has limited functional recovery. A person may find it difficult to breathe even when they are resting.

Stages or classes of heart failure

The final stage of heart failure is also known as the end stage of heart failure. Doctors classify heart failure into stages A–D and functional classes I–IV to label them in terms of severity and symptoms. These come from the classifications of the American College of Cardiology and the New York Heart Association (NYHA).

According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure, a person with end stage heart failure typically has stage D, NYHA class IV heart failure.

If a person has class IV heart failure, it means they:

  • cannot do much physical activity without experiencing discomfort
  • have symptoms of heart failure even when resting
  • experience increasing discomfort with any amount of physical activity

If a person has stage D heart failure, it means they:

  • have objective (observational) evidence of severe heart disease
  • have severe functional limitations
  • experience noticeable symptoms even when resting

Other signs and symptoms of end stage heart failure include frequent ventricular arrhythmias, worsening hypotension (low blood pressure) due to intolerance to beta-blockers, weakness and wasting of the heart muscle, deteriorating liver and kidney function, and repeated hospitalizations.

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A person with end stage heart failure may experience symptoms of cardiovascular disease.

Symptoms may include:

End stage heart failure can also cause a person to experience kidney or liver dysfunction.

A person may require regular hospitalization or depend on daily intravenous medications, and their condition may not respond well to treatment. This can worsen as the heart failure progresses.

Heart failure can be chronic and develop over time due to medical conditions that make the heart work harder than usual or damage it.

It may also be acute and develop due to conditions that cause sudden damage to the heart, such as heart attack or infection.

Over time, heart failure may progress to the point where medications no longer work. Ventricular assist devices and heart transplants may be an option for some people, but others may not be eligible due to chronic illnesses or certain medical conditions.

Heart failure tends to impact either the right or left side of the heart. But in both cases, heart failure causes the heart to be unable to pump blood correctly.

Many conditions can cause or contribute to heart failure, such as:

Learn more about cardiomyopathy due to drugs.

There is no cure for end stage heart failure. At this stage, people must decide how much treatment they would like without sacrificing their quality of life.

Some people may wish to seek palliative or hospice care when they are in the final stages of heart failure. This option can help provide great comfort in a person’s last weeks and days.

Medications

Medications may help people with advanced heart failure manage their symptoms. Medications include:

  • Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: These reduce levels or actions of angiotensin, which is a hormone that raises blood pressure.
  • Beta-blockers: This medication reduces heart rate and “cardiac work.”
  • Mineralocorticoid receptor antagonists: This medication reduces the harmful effects of aldosterone, a hormone that influences blood pressure by controlling salt and water levels.
  • Sacubitril/valsartan: This medication blocks the effects of the renin-angiotensin system that controls blood pressure and blood water levels.
  • SGLT2 inhibitors: These help reduce the risk of death or hospitalization in people with heart failure.
  • Diuretics: These medications increase urine output and remove fluid.
  • Hydralazine/isosorbide dinitrate: This helps relax blood vessels and reduce blood pressure.
  • Digoxin: This medication increases heart muscle contractions.
  • Inotropes: These can include milrinone and dobutamine, which are given via IV continuously for symptom management in advanced heart failure.

Sometimes, people with advanced heart failure cannot tolerate these medications due to side effects such as low blood pressure. Intolerance is usually a marker for advanced disease.

Learn more about heart failure medication.

Surgery

Some people may also undergo surgery to receive the following:

  • Ventricular assist device: This mechanical support device helps the heart pump blood. A person may need a left ventricular assist device, right ventricular assist device, or biventricular assist device.
  • Biventricular pacemaker: A pacemaker helps the heart pump more synchronously for more efficient blood delivery.
  • Implantable cardioverter defibrillator: This device assesses heart rate and delivers electrical pulses to correct abnormal heart rhythms.

They may also receive an artificial heart or a heart transplant.

Some people may get a peripherally inserted central catheter (PICC) line and receive IV medications at home to decongest the heart or to help support the heart’s pumping while waiting for a transplant.

Palliative care

Palliative care aims to improve the quality of life for someone experiencing a life threatening condition and typically has less than 6 months to live.

This may involve treatments to reduce symptoms and address the psychosocial, mental, emotional, or spiritual needs of patients, their caregivers, and their loved ones. It may involve treatments to extend life.

Hospice care

Hospice care does not aim to extend a person’s life. It seeks to manage their symptoms and relieve physical and emotional distress so people with end stage heart failure can live as fully as possible with dignity and in comfort at home or in a hospice facility.

Learn more about end-of-life planning.

There is no cure for end stage heart failure. The exact outlook can vary from person to person.

According to a 2018 review, those who have stage D heart failure usually experience a poor quality of life.

People can use medications and other therapies or strategies to help reduce the discomfort that end stage heart failure can cause.

Life expectancy for someone with end stage heart failure

The life expectancy for a person with end stage heart failure will depend on the severity of the condition and how they have responded to treatment.

Once heart failure progresses to stage D, people experience poor quality of life and high symptom burden and face a median life expectancy of only 6–12 months.

According to a 2019 review, the average survival rates of people with heart failure are as follows:

  • 86.5% of people with heart failure survive for 1 year
  • 72.6% of people with heart failure survive for 2 years
  • 56.7% of people with heart failure survive for 5 years
  • 34.9% of people with heart failure survive for 10 years.

The overall 5-year survival rate for people with heart failure is around 60%.

A 2019 analysis indicated that 91% of people who receive a heart transplant live for at least 1 year. However, the median survival rate post-transplant is 12–13 years.

According to a small single study, the survival rates for people who receive a left ventricular assist device after 2, 3, and 4 years are approximately 71%, 62%, and 45%.

The best way to help prevent heart failure is to make lifestyle changes or establish habits that reduce the risk of developing conditions that cause or contribute to heart failure.

The American Heart Association’s Life’s Essential 8 checklist highlights ways to help prevent heart failure. These include:

Learn more about how to improve heart health.

Caring for a loved one with end stage heart failure can be challenging but rewarding. It may require a caregiver to provide practical and emotional support. Practical support, for example, may entail helping the person wash or dress.

When caring for someone at the end of their life, the caregiver may find it helpful to:

  • ask the person’s doctor what they can expect as the illness progresses
  • ask the doctor about how to manage symptoms
  • keep contact details for the doctor or healthcare team somewhere accessible or easy to find
  • keep a record of out-of-hours numbers to contact on evenings and weekends
  • check what support may be available for them, for example, financial aid or support groups

Caregivers may also wish to discuss hospice care with their loved ones and their healthcare team.

Signs that someone with heart failure is near the end of life

Some physical signs that a person is near the end of their life may include:

  • breathlessness on rest or minimal exertion
  • pain
  • persistent cough
  • fatigue or extreme tiredness
  • limited physical activity
  • fluid retention
  • cognitive impairment, like problems with memory, language, speech, or even sudden confusion
  • nausea and loss of appetite

People with end stage heart failure can experience many different feelings and emotions. They may experience:

  • sadness
  • anger
  • anxiety
  • depression
  • helplessness or as if they have no control over their life
  • unable to deal with the reactions of others

If a person is experiencing depression or anxiety, they may wish to seek treatment from a mental health professional. Treatments may include cognitive behavioral therapy (CBT).

End stage heart disease is the most severe form of heart disease. A person with this condition will need medical intervention to stay alive, often involving a mixture of medications, procedures, or medical devices.

The symptoms of end stage heart disease include trouble breathing, exhaustion, weight loss, changes in skin color, swelling, and abdominal pain all or most of the time. These can progressively worsen.

Caring for someone with end stage heart failure may involve providing physical and emotional support. Talk with family members about seeking hospice care.