(179) Outcomes for Patients With Substance Use History Evaluated for Advanced Cardiac Therapies

Background &

Introduction: Patients with advanced heart failure frequently present with complex medical, psychosocial, and substance-related histories that may influence eligibility for advanced cardiac therapist (ACT), such as left ventricular assist device (LVAD) implantation and transplantation. Substance use is a well-recognized consideration in organ transplant candidacy evaluations including heart transplantation, yet its impact on access to other ACT remains poorly understood. Active substance use is considered a contraindication to heart transplantation and LVAD implantation, while recent substance use typically requires 3–6 months of documented abstinence with random testing prior to listing. Professional society guidelines further recommend comprehensive psychosocial evaluation to assess substance use history, treatment engagement, periods of abstinence, and readiness for advanced therapies. While substance use policies are intended to optimize post-transplant outcomes, they may also unintentionally limit access to other life-prolonging therapies. This study examines the association between a documented history of substance use and receipt of ACT in a contemporary cohort undergoing evaluation at a tertiary care transplant center. Understanding how substance use history affects listing decisions, treatment pathways, and treatment outcomes is critical to identifying potential inequities, clarifying barriers to care, and informing future policy discussions surrounding ACT eligibility criteria.

Methods: We conducted a retrospective cohort study of 180 adult patients evaluated for advanced cardiac therapies between 2020 and 2025 at a single Midwest academic tertiary care facility. Patients were categorized by patient-reported substance use history documented in psychosocial evaluations, committee notes, and clinical records. Outcomes included receipt of ACT (LVAD or cardiac transplant), denial ACT due to substance use, denial of ACT for other reasons, or never being listed for transplant as of December 2025. Descriptive statistics were used to compare ACT evaluation outcomes based on substance use history. All patients were included in the analysis, including those with incomplete psychosocial evaluations or remote substance use histories, to reflect real-world clinical decision-making.

Results: Of 180 patients evaluated for advanced cardiac therapies (ACT), 123 (68%) had a documented history of substance use, including nicotine/tobacco, alcohol, cannabis, and stimulants. Among 123 patients with substance use, 35 (28.5%) ultimately received ACT, defined as left ventricular assist device (LVAD) implantation or heart transplantation. The most common outcome in this group was transplant denial related to substance use concerns (47 patients, 38%). An additional 41 (33%) were denied transplant for other medical or psychosocial reasons, and 49 (40%) were never listed for transplant, highlighting multiple overlapping barriers to candidacy.

Importantly, transplant denial did not uniformly preclude advanced therapy. Among patients with substance use denied transplant (n=47), 16 (34%) subsequently received LVAD support. Across the entire cohort, 32 (18%) patients were denied transplant but received LVAD, evenly divided between patients with and without substance use.

In contrast, among patients without substance use history, 31 of 57 (54.4%) received ACT. Patients with substance use were significantly less likely to receive ACT compared with those without substance use (RR 0.52; 95% CI 0.36–0.76; p=0.001). Mortality was higher among patients who did not receive ACT across both cohorts, with the highest mortality observed among patients with substance use who did not receive advanced therapy.

Conclusions &

Discussion: In this cohort, a documented history of substance use was associated with reduced receipt of advanced cardiac therapies. Although substance use concerns frequently contributed to transplant denial, candidacy decisions appeared multifactorial, reflecting overlapping medical, psychosocial, and substance-related considerations.

Notably, transplant denial did not universally preclude treatment, as a subset of patients subsequently received LVAD support, suggesting that alternative therapeutic pathways may remain available for selected patients. Despite the high prevalence of substance use in this population, access to addiction medicine resources during ACT evaluation was limited, highlighting an opportunity for greater integration of addiction-focused care into transplant evaluation processes.

This study is limited by its retrospective design and reliance on chart documentation to define substance use. Future research should examine the role of structured addiction treatment engagement, standardized biological substance use testing, and integration of addiction medicine consultation in ACT evaluation. These efforts may help clarify the relative contributions of substance use and other barriers to transplant candidacy and improve equitable access to life-prolonging therapies.

References:

Dew MA, DiMartini AF, Dobbels F, et al. The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support. J Heart Lung Transplant. 2018;37(7):803–823.

Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2023;82(9):833–955.

Dew MA, DiMartini AF, De Vito Dabbs A, et al. Adherence and substance use after transplantation. Am J Transplant. 2008;8(8):1616–1625.

Rodrigue JR, Hanto DW, Curry MP. Substance abuse treatment and its association with post-transplant outcomes. Liver Transpl. 2013;19(7):719–726.

Health Equity: This study addresses how substance use history influences access to advanced heart failure therapies, which are limited, life-prolonging resources. Substance use disorders disproportionately affect individuals from socioeconomically disadvantaged backgrounds and marginalized communities, placing these patients at increased risk for exclusion from transplant candidacy. Our findings demonstrate a significant disparity in receipt of advanced therapies among patients with substance use histories, raising concern for potential structural barriers embedded within transplant evaluation processes. By identifying patterns of denial, non-listing, and alternative treatment pathways, this work highlights opportunities to improve transparency, consistency, and fairness in transplant decision-making. Understanding these disparities is a critical step toward developing more equitable evaluation practices that address substance use as a treatable condition rather than a categorical exclusion criteria.