Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited. Heart failure therapy: beyond the guidelines Keith A. Thompson, Parag Bharadwaj, Kiran J. Philip and Ernst R. Schwarz Heart failure is a chronic and debilitating disease responsible for high cardiac morbidity and mortality in the world and is associated with over 290 000 deaths in the United States each year. This article reviews palliative care and self-care, which are critical components of heart failure management that are inadequately defined in the current American College of Cardiology/American Heart Association Guidelines for the Diagnosis and Management of Heart Failure. Palliative care describes a multidisciplinary approach to the treatment of heart failure therapy that addresses both the symptomatic and psychosocial aspects of the disease. Self-care aims to maintain disease stability and prevent clinical decline through a variety of patient-based behavioral and lifestyle modifications. J Cardiovasc Med 11:919–927 Q 2010 Italian Federation of Cardiology. Journal of Cardiovascular Medicine 2010, 11:919–927 Keywords: heart failure, palliative care, self-care Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, California, USA Correspondence to Ernst R. Schwarz, MD, PhD, Division of Cardiology, Cedars Sinai Medical Center, 8700 Beverly Blvd., Suite 6215, Los Angeles, CA 90048, USA Tel: +1 310 423 1866; fax: +1 310 423 1498; e-mail: Ernst.Schwarz@cshs.org Received 6 February 2010 Revised 24 April 2010 Accepted 15 June 2010 Introduction The current American College of Cardiology (ACC)/ American Heart Association (AHA) Guidelines for the Diagnosis and Management of Heart Failure are intended to assist healthcare providers in clinical decision-making by describing a range of generally acceptable approaches for the diagnosis, management or prevention of this dis- ease [1]. Whereas these guidelines provide an exceptional evidence-based approach to the management of heart failure, they focus on the use of behavioral, pharmacologic and invasive therapies that have proven morbidity and mortality benefits; these include, for example, smoking cessation, lipid reduction, and the use of beta-blockers, angiotensin-converting enzyme inhibitors, loop diuretics, nitrates, hydralazine, implantable cardiac defibrillators, and biventricular pacemakers. Despite this, there are many aspects of heart failure therapy that are either not addressed or de-emphasized in the current guidelines. Two specific therapies that have received much attention in recent heart failure literature that remain somewhat under-represented in the guidelines are the fields of ‘palliative care’ and ‘self-care’. Palliative care is a practice that focuses on treating both the physical and psychosocial aspects of heart failure; it uses a multidisciplinary approach to patient care in order to address a wide variety of patient concerns. Self-care aims to prevent the progression of heart failure through a variety of patient-driven behavioral and lifestyle modifications; self-care also allows patients to initiate a therapeutic strategy when symptoms of heart failure exacerbation develop. This article will review the current concepts of both palliative care and self-care, which are essential aspects of comprehensive heart failure management. Palliative care In advanced stages of heart failure, the burden of physical and psychological symptoms in heart failure patients is similar to those with advanced cancer [2]. The role of palliative care in the treatment of heart failure is to recognize the extreme physical and psychological burden that heart failure may have on a patient, and provide a multidisciplinary team that can help treat all aspects of the disease. It is important to realize that the role of palliative care in heart failure therapy has been redefined in recent years and is no longer limited to end-of-life care. Instead, palliative care represents a variety of treatment strategies that should be initiated at the time of the diagnosis of heart failure and continued throughout the course of the disease. It is important to keep in mind that the involvement of palliative care is not dependent on prognosis, and thus can be delivered at the same time as the patient is pursuing all other appropriate treatments, including curative options [3]. The importance of pallia- tive care as an integral aspect of heart failure therapy was recently demonstrated in a state-of-the-art review article by Goodlin [4], who describes several aspects of palliative care; these include decision-making, communication, edu- cation, psychosocial and spiritual issues, and symptom management. Decision-making Decision-making is an integral part of heart failure care as both the physician and patient will be required to make a multitude of treatment-based decisions throughout the disease course. These include the choice of a patient- specific drug regimen and the decision to use inter- ventional therapies such as biventricular pacemakers, Review article 1558-2027 ß 2010 Italian Federation of Cardiology DOI:10.2459/JCM.0b013e32833d3566