Introduction
In addition to treatments aimed at improving cardiac function and physical well-being, advanced care planning, decision making and psychological support can help patients with advanced HF. Data on the symptom burden and the potential need for psychological support in patients with HF are needed to improve this aspect of integrated HF care.

Purpose
We assessed symptom burden, psychological distress and palliative care (PC) needs in advanced HF in- and outpatients.

Methods
Demographic and clinical characteristics were assessed in a prospective cohort of HF patients seen at the UHZ, a large tertiary care center providing advanced HF therapy including transplantation. The projected survival was estimated using the Seattle Heart Failure Model. Subjective symptom burden and psychological distress were self-assessed by the MIDOS (Minimal Documentation System for Patients in Palliative Care) questionnaire and Distress Thermometer (DT). PC needs were subsequently estimated using the physician-directed Palliative Care Screening Tool for Heart Failure Patients (PCST).

Results
We enrolled 259 advanced HF patients in an inter-disciplinary explorative pilot study (mean age 62.7±8.3 years, 71.8% male, non-ischemic etology in 72.2%, over 50% NYHA III or higher, severe comorbidities in 62.2%). 137 patients (52.9%) were seen as inpatients in a specialized heart failure unit (HFU) and 122 (47.1%) treated on an outpatient basis at the specialized HF clinic (OC) of a tertiary care hospital. Patients seen as inpatients were older and more often suffered from non-ischemic forms of HF. Diabetes, peripheral artery disease, malignancies, chronic kidney disease and atrial fibrillation showed a higher incidence in hospitalized patients, while the other assessed comorbidities were evenly distributed (Table). The projected survival was higher in outpatients, each at one (92.8±6.6% vs. 90.7±9.5%, p=0.041), two (86.4±11.3% vs. 83.3±13.7%, p=0.056) and five years (68.9±20.6% vs 64.1±23%. p=0.083).
Symptom burden was pronounced, and clinically relevant psychological distress was seen in two thirds (171, 66%) of all patients. Hospitalized patients had more symptoms (mean MIDOS score 8.0±4.7 vs. 5.4±4.6, max. 30 points, p<0.001) and had a higher level of distress (mean DT scores 6.0±2.3 vs. 4.8±2.3, max. 10 points, p<0.001). “Clinically relevant” distress (DT score≥5 ) was present in 75.7% of HFU patients, compared to 56.7% of OC patients (p=0.001).
PC needs in the physician-directed screening was higher among hospitalized patients (mean PCST scores 6.6±2.1 vs. 4.8±1.8, max. 12 points, p<0.01). As indicated by PCST scores≥5, 82% of inpatients (113/137) and 52% of outpatients (64/122) may require palliative support (Figure).

Conclusions
The symptom burden and psychological distress in patients hospitalized for advanced HF is tremendous, and up to 4 out of 5 patients fulfil criteria for specialized PC. Early detection of unmet needs and access to specialized multi-professional treatment approaches is of central importance.