16, 2013 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary October 15, 2013:1495 539 6.4. Stage D See Table 18 for the European Society of Cardiology de nition of advanced HF and Table 19 for clinical events and ndings useful for identifying patients with advanced HF. 6.4.1. Water Restriction CLASS IIa 1. Fluid restriction (1.5 to 2 L/d) is reasonable in stage D, especially in patients with hyponatremia, to reduce congestive symptoms. (Level of Evidence: C) 6.4.2. Inotropic Support See Table 20 for inotropic agents used in HF management and Table 21 for a summary of recommendations from this section. CLASS I 1. Until de nitive therapy (e.g., coronary revascularization, MCS, heart transplantation) or resolution of the acute precipitating problem, patients with cardiogenic shock should receive tempo- rary intravenous inotropic support to maintain systemic perfusion and preserve end-organ performance. (Level of Evidence: C) CLASS IIa 1. Continuous intravenous inotropic support is reasonable as bridge therapy in patients with stage D HF refractory to GDMT and device therapy who are eligible for and awaiting MCS or cardiac transplantation (275,276). (Level of Evidence: B) CLASS IIb 1. Short-term, continuous intravenous inotropic support may be reasonable in those hospitalized patients presenting with documented severe systolic dysfunction who present with low blood pressure and signi cantly depressed cardiac output to maintain systemic perfusion and preserve end-organ performance (277 279). (Level of Evidence: B) 2. Long-term, continuous intravenous inotropic support may be considered as palliative therapy for symptom control in select patients with stage D HF despite optimal GDMT and device therapy who are not eligible for either MCS or cardiac transplantation (280 282). (Level of Evidence: B) Table 17. 