Heart disease is the leading cause of death by disease. Many forms of heart disease result in sudden death; however, the disease progression of heart failure is protracted yet unpredictable. Advanced heart failure (class III-IV or stage C or D) is characterized by persistent symptoms that limit activities of daily living despite optimal drug therapy. Common symptoms include fatigue, breathlessness, anxiety, fluid retention, and pain. In heart failure, standard medication management is intended to reduce the progression of cardiac remodeling and is considered disease modifying (Fig. 4-2). However, with the exception of cholesterol-lowering agents, these same cardiac medications are also palliative and should not be discontinued prematurely without cause. Exacerbations of heart failure symptoms should be aggressively treated as long as the patient is responsive to therapy and wishes to receive treatment. In hospice, this can often be accomplished through medication manipulation in the patient's home without the need for hospitalization (see Chap. 6).
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