Heart Failure Devices: Treatment Options, Underutilization, and a Proposed Trigger System for Patient Referral and Evaluation.

The use of guideline-directed medical therapy (GDMT) has substantially prolonged and improved the livelihoods of patients with heart failure (HF). Nevertheless, adherence rates remain suboptimal. Even when successfully maximized and adhered to, there is a substantial residual risk of recurrent HF hospitalization and death. In light of this, there is a strong need for effective interventions that can reduce the high residual risk seen in patients with HF. Several device options exist which are approved by the FDA and which have been shown to reduce morbidity and/or mortality in patients among whom GDMT was maximized. These include valvular interventions (aortic valve replacement, mitral valve repair, and tricuspid valve repair/replacement), cardiac resynchronization, cardiac contractility modulation, remote hemodynamic monitoring, and baroreceptor activation therapy. The pivotal trials for each of these interventions, and the patient populations for which they have been approved, are discussed. Current rates of device use in clinical practice remain very low. For many device classes, the vast majority of eligible patients are not offered or prescribed the device. Several reasons may explain this mismatch, foremost of which is a lack of clinical awareness about when to escalate therapy, identify patients requiring more than GDMT, and access to centers with sufficient experience. To aid the appropriate uptake of device therapy in clinical practice, we propose a simple mnemonic for use by clinicians that can prompt the early identification and prompt referral of patients with HF who likely merit consideration of additional device-based therapy in addition to GDMT.