by EBSCO Medical Review Board


Advanced heart failure is heart failure that has symptoms even with treatment. Symptoms are present even at rest. This is the final stage of heart failure.


Heart failure starts because of a weakened heart. Over time the increased workload on the weaker heart leads to more heart damage. The weaker heart causes advanced heart failure.

It may be a natural progression of the disease. Other factors that make heart failure worse include:

  • Problems with the treatment plan
  • Uncontrolled high blood pressure
  • A buildup of fluids and sodium

Risk Factors

You have a higher risk of advanced heart failure if you have:

  • High blood pressure
  • Obesity or are overweight
  • Kidney problems
  • Taken certain medicines, such as non-steroidal anti-inflammatory drugs (NSAIDs)
  • A diet that is high in salt and fat


Advanced heart failure has a worsening of heart failure symptoms, such as:

  • Shortness of breath that happens with activity, when lying flat, or when bending down
  • Coughing or wheezing
  • Lack of energy
  • Weight gain from a backup of fluids
  • Swelling of the feet, ankles, and legs
  • Swollen belly


You will be asked about your symptoms and history of heart failure. A physical exam will be done. Your blood and urine will be tested to look for changes in other organs like kidneys.

Tests will be done to view your heart and see how it is working. This can be done with:

An echocardiogram will be done to measure your ejection fraction. This is a measure of how well your heart is pumping out blood. Advanced heart failure will often have an ejection fraction of 40% or below.


You and your medical care team will need to make a new care plan. It will be based on your overall goals. You may choose aggressive treatment or focus on comfort measures only. These can be hard decisions. Talk to your care team and family about your concerns and decisions.

Medicine and healthy habits will need to be continued. This may include:

  • Medicine such as:
    • Diuretics to remove excess fluid in your body
    • Nitrates to dilate blood vessels
    • Digoxin to help your heart pump
    • Beta-blockers to slow your heart rate and lower blood pressure
    • Calcium channel blockers to lower blood pressure
    • ACE inhibitors to widen blood vessels
  • Healthy Habits such as:
    • Not drinking alcohol.
    • Quitting smoking.
    • Eating healthful foods. Choose one that are low in fat and sodium.
    • Tracking your fluid intake.

Note: Nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen can worsen your condition. Talk to your doctor about other medicines you may be able to take.


Surgery is not an option for everyone. It can be dangerous for people with weak hearts. Some options that may be needed include:

  • Coronary artery bypass (CABG) surgery—to relieve severe blockages in blood vessels. These blood vessels deliver blood to the heart muscle.
  • Devices may be needed to support your heart—left ventricular assist device (LVAD) is one option. It takes over the work of the heart. LVAD is implanted in the upper belly. It may be permanent or short term.
  • Heart transplant—will depend on your overall health. A donor heart will also need to be available.

Care Decisions

Work with your care team to understand your options. Your choice may change over time. Palliative care can help support you throughout your illness. They can also help you communicate your goals to your medical care team. This may include advanced directives that the medical team will follow if you are unable to instruct them.

Hospice care may be needed. The hospice care team specializes in easing pain and suffering from heart failure that can no longer be treated. It may be provided at home or in a care center.


Advanced heart failure cannot always be prevented once heart failure has begun. Following your care plan and healthy habits can delay it.


American Heart Association 

Heart Failure Association of America 


Health Canada 

Heart and Stroke Foundation of Canada 


Acute heart failure. EBSCO DynaMed website. Available at: . Updated February 20, 2019. Accessed April 24, 2019.

Heart failure: rehabilitation. EBSCO Nursing Reference Center website. Available at: Updated November 9, 2018. Accessed May 1, 2019.

Case management: the patient with heart failure. American Heart Association website. Available at: Updated April 30, 2017. Accessed April 24, 2019.

Revision Information

  • Reviewer: EBSCO Medical Review Board Peter Oettgen, MD
  • Review Date: 05/2020
  • Update Date: 07/10/2020