Table 40: Managing the symptoms of advancing HF
	Pharmacological	Nonpharmacological
Dyspnea	Optimized CCS HF guideline therapy Inotropic agents or mechanical circulatory support devices if consistent with advance care plans (inotropes may hasten death) Subcutaneous furosemide (observational data) Psychotropic First line: low dose opioids Second- line: benzodiazepines	Rehabilitation/physical activity Energy conservation Positioning Supplemental oxygen if hypoxia Fan to circulate air
Fatigue	Optimized CCS HF guideline therapy	Rehabilitation/physical activity Consider depression, sleep disordered breathing or other comorbidities
Edema	Optimized CCS HF guideline therapy	Attention to skin care
Disability	Optimized CCS HF guideline therapy	Rehabilitation/physical activity Occupational therapy, Social work
Pain	Apply WHO ladder (avoiding NSAIDs) Opioids	Physical therapy, occupational therapy, massage If related to ICD discharge, consider adjusting settings or deactivation
Gastrointestinal	Consider ascites, digoxin toxicity
Nausea	pro-motility agents (e.g. metoclopramide 10 mg po/sc tid with meals) target chemoreceptor trigger zone: Haloperidol 0.5 mg q12h; ondansetron 4 mg	Small frequent meals
Constipation	Stimulant laxative: Sennosides	Relax fluid restriction Prune juice
Depression	Optimized CCS HF guideline therapy Selective serotonin reuptake inhibitors (sertraline, citalopram) Avoid tricyclic antidepressants	Psychotherapy Cognitive behaviour therapy Rehabilitation/physical activity
Anxiety	Consider and treat concomitant depression Benzodiazepines	Supportive / psychotherapy Breathing exercises Relaxation therapy
Sleep disturbance	Optimized CCS HF guideline therapy Consider and treat concomitant depression, anxiety, agitated delirium, nocturia, sleep apnea	Attention to sleep hygiene
Agitated delirium	Consider underlying precipitants (e.g. HF or other cardiac event, metabolic disturbance, infection or medication side-effect) Minimize anticholinergic drugs Low dose antipsychotic if symptoms lead to risk to patient or caregivers	Senior friendly approaches, including attention to vision and hearing impairment, cognitive stimulation and reorientation, physical activity and mobilization, nutrition and hydration
Considerations at the end-of-life Myoclonus, seizures	Consider discontinuation of medications no longer consistent with goals of care, e.g. statins Consider and treat underlying precipitants Terminal sedation	Consider discontinuation of shock therapies, inotropic agents, or Mechanically Assisted Circulation

Disclaimer: This table is intended to provide practical tips or examples of medications that might provide symptom relief. It should be used by clinicians with an understanding of the medication characteristics and their patients’ specific clinical conditions and limitations inherent in the location of care. These suggestions are not intended to replace specialist consultation for physicians unfamiliar with the use of these therapies.

CCS, Canadian Cardiovascular Society;
HF, heart failure.