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Heart Failure

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Heart Failure
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Key messages

  • Heart failure is an eventually fatal condition which is becoming more prevalent, and is associated with severe symptom distress and high rates of mortality
  • Patients with advanced heart failure benefit from receiving, in parallel, active disease management and a personalised palliative approach to their care
  • Palliative care
    • affirms life and treats dying as a normal process;
    • neither hastens nor postpones death;
    • provides relief from pain and other distressing symptoms;
    • integrates the physical, psychological, social, emotional and spiritual aspects of care, with coordinated assessment and management of each person’s needs;
    • offers a support system to help people live as actively as possible until death; and
    • offers a support system to help the family cope during the person’s
      illness and in their own bereavement.
      Source: Department of Health Palliative Care webpage

Background

Heart failure is the only cardiac disease which is increasing in prevalence. This is largely due to the long-term effects of common conditions that affect the heart’s pump function – particularly hypertension and coronary artery disease. [1] Improving long-term survival from cardiac conditions and also from heart failure itself has increased the numbers of people living with the condition, and changed its demography. It is now a disease mainly of older people, especially of older women, and it is estimated to affect at least 10% of Australians aged 65 years and older. [2] Survival ranges from 80% at 2 years for those without fluid overload, to less than 50% survival at 6 months for patients with refractory symptoms. [3]

Despite continuing improvements in treatment which can prolong and improve the lives of heart failure patients, it remains a terminal condition with a heavy burden of symptoms, especially in the advanced stages. There are many different trajectories which range from sudden cardiac death at any point during the illness (decreasing due to ICDs and beta blockers), to either alternating periods of stability with periods of loss of control of symptoms, or prolonged periods of disability and distress with poor quality of life. [1] Mortality and severity of symptoms in advanced heart failure are comparable to those in cancer [4, 5] although this is generally not understood by either patients or clinicians. Hence the palliative care approach is not always identified as an essential part of the continuum of care for patients with heart failure [4, 6] - although this is now starting to change. [7]

A palliative approach systematically addresses issues that are important for patients with a terminal disease [8] such as:

  • providing timely prognostic information to help patients and families plan for their future and deal with end of life issues
  • referring to and integrating palliative care with usual care
  • providing holistic supportive care for disabling and distressing symptoms
  • providing carer support
  • reducing unnecessary or unwanted hospitalisation and
  • individualised consideration of the benefit versus burden of any interventions that are offered. [4]

Approaches to end-of-life care, including how and when to de-escalate treatment and inactivate devices, as well as treatment of refractory symptoms, are particularly important in the palliative management of heart failure patients. 

Topics to be covered here summarise the current evidence about the palliative care of patients with advanced heart failure. They are:

Prognostic Issues
Symptoms & Patients’ Experiences
Management Issues
Carers and Families
Service Issues

Active research areas/controversies

  • Predicting prognosis continues to be an area of research interest. The information needs of patients and carers in relation to prognosis are also being explored.
  • Shortness of breath affects palliative care patients with a range of conditions, including advanced heart failure. Issues that are being explored in various studies include the use of opioids for dyspnoea (efficacy and titration of different opioids), and the role of oxygen in managing dyspnoea in non-hypoxic patients. Measuring dyspnoea is a methodological problem for researchers which is also being studied. [9, 10] 
  • Improvements in the medical management of heart failure continue to be relevant in the palliative phase, and new treatment modalities are evolving – these include cytokine and immunomodulation therapies [11] calcium sensitizers [12] and cell based therapies. [13]
  • Many different populations are affected by heart failure, and they may have very different needs. Little specific research is available to improve the care of Indigenous patients, of those from different cultural backgrounds or of women as specific needs groups. The elderly in particular are usually excluded from clinical trials, despite being the most common age group affected by heart failure. [14]

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References

  1. Connolly M, Beattie J, Walker D, Dancy M. End of life care in heart failure: A framework for implementation. Leicester: National End of Life Care Program, NHS; 2010.
  2. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand (Chronic Heart Failure Guidelines Expert Writing Panel), Guidelines for the prevention, detection and management of chronic heart failure in Australia 2006. Canberra: National Heart Foundation of Australia; 2006. See also 2011 Update.
  3. Nohria A, Lewis E, Stevenson LW. Medical management of advanced heart failure. JAMA. 2002;287(5):628-40.
  4. Jaarsma T, Beattie JM, Ryder M, Rutten FH, McDonagh T, Mohacsi P, et al. Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2009 May;11(5):433-43.
  5. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006 Jan;31(1):58-69.
  6. Stuart B. Palliative care and hospice in advanced heart failure. J Palliat Med. 2007 Feb;10(1):210-28.
  7. National Heart Foundation of Australia. Multidisciplinary care for people with chronic heart failure: Principles and recommendations for best practice. Canberra: National Heart Foundation of Australia; 2010.
  8. Stuart B. The nature of heart failure as a challenge to the integration of palliative care services. Curr Opin Support Palliat Care. 2007 Dec;1(4):249-54.
  9. Dorman S, Byrne A, Edwards A. Which measurement scales should we use to measure breathlessness in palliative care? A systematic review. Palliat Med. 2007 Apr;21(3):177-91. Epub 2007 Mar 15.
  10. Johnson MJ, Oxberry SG, Cleland JG, Clark AL. Measurement of breathlessness in clinical trials in patients with chronic heart failure: the need for a standardized approach: a systematic review. Eur J Heart Fail. 2010 Feb;12(2):137-47.
  11. El-Menyar AA. Cytokines and myocardial dysfunction: state of the art. J Card Fail. 2008 Feb;14(1):61-74.
  12. Parissis JT. Andreadou I, Bistola V, Paraskevaidis I, Filippatos G, Kremastinos DT. Novel biologic mechanisms of levosimendan and its effect on the failing heart. Expert Opin Investig Drugs. 2008 Aug;17(8):1143-50.
  13. Podesser BK, Bauer M, Liao R. Evolving cell-based therapies for heart failure patients. Curr Treat Options Cardiovasc Med. 2008 Aug:10(4):358-67.
  14. Imazio M, Cotroneo A, Gaschino G, Chinaglia A, Gareri P, Lacava R, et al. Management of heart failure in elderly people. Int J Clin Pract. 2008 Feb;62(2):270-80. Epub 2007 Dec 7.

Last updated 25 March 2011*