Inability to exercise b. 6-Minute walk distance 300 m c. Peak _ 5. History of 1 HF hospitalization in past 6 mo 6. Presence of all the previous features despite attempts to optimize therapy, including diuretics and GDMT, unless these are poorly tolerated or contraindicated, and CRT when indicated BNP indicates B-type natriuretic peptide; CRT, cardiac resynchronization therapy; ESC, European Society of Cardiology; GDMT, guideline-directed medical therapy; HF, heart failure; LVEF, left ventricular ejection fraction; NT-proBNP, N-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association; PA, pulmonary artery; PCWP, pulmonary capillary wedge pressure; and RAP, right atrial pressure. Adapted from Metra et al. (33). Table 19. Clinical Events and Findings Useful for Identifying Patients With Advanced HF Repeated (2) hospitalizations or ED visits for HF in the past year Progressive deterioration in renal function (e.g., rise in BUN and creatinine) Weight loss without other cause (e.g., cardiac cachexia) Intolerance to ACE inhibitors due to hypotension and/or worsening renal function Intolerance to beta blockers due to worsening HF or hypotension Frequent systolic blood pressure <90 mm Hg Persistent dyspnea with dressing or bathing requiring rest Inability to walk 1 block on the level ground due to dyspnea or fatigue Recent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose over 160 mg/d and/or use of supplemental metolazone therapy Progressive decline in serum sodium, usually to <133 mEq/L Frequent ICD shocks ACE indicates angiotensin-converting enzyme; BUN, blood urea nitrogen; ED, emergency department; HF, heart failure; and ICD, implantable cardioverter- defibrillator. Adapted from Russell et al. (274). Yancy et al. JACC Vol. 62, No. 16, 2013 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary October 15, 2013:1495 539 CLASS III: HARM 1. 