心力衰竭（HF）是死亡的主要原因，住院治疗,生活质量下降和医疗保健系统的主要负担。进展到HF晚期的患者数量正在增长。这些患者中只有有限的比例可以接受心脏移植或机械循环支持。这篇综述的目的是总结晚期HF患者的医疗管理。首先,必须实施循证口腔治疗,尽管通常不耐受.对于这些患者来说，新的治疗选择可能很快成为可能。第二个目标是通过缓解充血和改善血流动力学来减轻症状负担。一些作用于心脏功能的新疗法可以满足这两种需求。通过增加细胞内钙起作用的肌力药物通常增加死亡风险。然而,在最近的全球方法中，通过改善心力衰竭的收缩性来降低不良心脏结果（GALACTIC-HF）试验，与安慰剂相比，omecamtivmecarbil在减少心血管死亡或HF事件的主要结局方面是安全有效的（风险比，0.92；95%置信区间，0.86-0.99；P=0.03），在左心功能更严重的患者中，其影响更大。接受omecamtivmecarbil治疗的重度HF患者经历了显著的治疗获益，而没有严重HF的患者则没有（相互作用P=0.005）。最后,临床医生应该通过适当的多学科方法来处理生命的终结.因此，先进的HF的医学治疗仍然是一项重大挑战，也是进一步研究的广阔领域。
Heart failure (HF) is a major cause of mortality, hospitalizations, and reduced quality of life and a major burden for the healthcare system. The number of patients that progress to an advanced stage of HF is growing. Only a limited proportion of these patients can undergo heart transplantation or mechanical circulatory support. The purpose of this review is to summarize medical management of patients with advanced HF. First, evidence-based oral treatment must be implemented although it is often not tolerated. New therapeutic options may soon become possible for these patients. The second goal is to lessen the symptomatic burden through both decongestion and haemodynamic improvement. Some new treatments acting on cardiac function may fulfil both these needs. Inotropic agents acting through an increase in intracellular calcium have often increased risk of death. However, in the recent Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC-HF) trial, omecamtiv mecarbil was safe and effective in the reduction of the primary outcome of cardiovascular death or HF event compared with placebo (hazard ratio, 0.92; 95% confidence interval, 0.86-0.99; P = 0.03) and its effects were larger in those patients with more severe left ventricular dysfunction. Patients with severe HF who received omecamtiv mecarbil experienced a significant treatment benefit, whereas patients without severe HF did not (P = 0.005 for interaction). Lastly, clinicians should take care of the end of life with an appropriate multidisciplinary approach. Medical treatment of advanced HF therefore remains a major challenge and a wide open area for further research.
