Management Issues

What is known

Palliative care may be helpful in addressing different needs throughout the heart failure trajectory. However, the transition from stable to unstable symptoms and worsening performance state may highlight the need for palliative care. As a patient with stable heart failure decompensates, symptoms may escalate dramatically. However, pharmacological management of acute decompensated heart failure is based largely on expert opinion, as most guidelines relate to chronic stable systolic heart failure. [1] Clinical decision tools such as the Seattle Heart Failure Model are available to help to estimate the benefit of adding medications or devices in the care of an individual patient. These tools are useful for individualising care decisions in advanced heart failure patients who have multiple comorbidities, and may help identify opportunities for palliative care input. [2-3]

When adjusting medications, dose-benefit balance is a major consideration. Tolerability may be affected by age and comorbidities, and the tendency is to reduce doses in older patients. Nonetheless, therapeutic benefit can still be associated with reduced doses. [4] Specific adverse effects, especially those related to elderly patients, should be monitored – including postural hypotension, renal dysfunction, electrolyte disturbances, and drug interactions. [5] Monitoring with ambulatory blood pressure is appropriate to help optimise therapy and may also provide prognostic information [6] and a six minute walk test is potentially useful as a maximal exercise test in advanced heart failure. [7] B-natriuretic protein (BNP) or NT-proBNP may also be of value for monitoring effectiveness of treatment in advanced heart failure. [8]

Opioids for palliation of dyspnoea have been well studied. They are a safe and effective approach for patients with both malignant and non-malignant causes of dyspnoea, although it has not been specifically studied in heart failure. [9-11]

A systematic review has identified evidence to support some specific non-pharmacological options for managing dyspnoea, although the studies have been predominantly done in a COPD population. [12] Options include breathing training and use of walking aids, (moderate evidence) neuro-electrical muscular stimulation and chest wall vibration (high level evidence). However there is not much evidence for acupuncture / acupressure, distractive auditory stimuli (music) relaxation, fan, counselling and support +/- breathing relaxation training, case management, or psychotherapy. [12] There is no evidence that relates to symptomatic dyspnoea management specifically in heart failure. [11] The role of oxygen in treating dyspnoea in non-hypoxic patients is also being studied, however further investigation is needed. [13]

The benefit of implantable cardiac defibrillators for primary prevention of mortality has not been not established for women with heart failure. [14] However cardiac resynchronisation therapy (biventricular pacing) has been shown to improve symptoms, exercise tolerance, and health related quality of life, [15] and to reduce all cause mortality, but not sudden cardiac death. [16]

Implications for practice

  • Evidence based guidance for managing heart failure should be used to optimise treatment. However, in the palliative context treatment must also be individualised for each patient, in terms of the benefits and burdens of whatever is offered, the goals of care and wishes of the patient, and the person’s likely prognosis and comorbidities. As the end of life approaches, the approach to care should be to avoid those treatments which may detract from a peaceful death, and this includes clarifying the patient’s resuscitation status.
  • Heart failure treatments used for primary disease management and life prolongation also have an impact on symptoms, and should generally be continued into the palliative phase for as long as they can be tolerated. Palliative care management strategies offer additional approaches to symptom management for many of the problems that occur commonly in advanced heart failure (eg the use of opioids for dyspnoea). Patients with difficult symptoms (physical or psychosocial) can benefit significantly from referral for palliative care.
  • Potential treatment options such as non-invasive ventilation and left ventricular assist devices may be part of the spectrum of palliation for some patients, and shared protocols for managing such treatments and negotiating goals of care are needed. The use of implantable cardioverter defibrillators raises the issue of inactivation to prevent “ICD storm” in a dying patient. Again, shared protocols between heart failure and palliative care services are needed.
  • Sharing of care between heart failure specialists and palliative care specialists will result in a wider range of treatment options for patients with advanced heart failure, and a broadening of the skills on both sides, with significant improvements in care for patients as a result. The well established model of collaboration between oncology and palliative care specialists in caring for patients with advanced cancer provides an example of how such collaboration can work in practice.
  1. Mehta R, Feldman D. Acute decompensated heart failure: best evidence and current practice. Minerva Cardioangiol. 2005 Dec;53(6):537-47.
  2. 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.
  3. Stuart B. Palliative care and hospice in advanced heart failure. J Palliat Med. 2007 Feb;10(1):210-28.
  4. Dobre D, Haaijer-Ruskamp FM, Voors AA, van Veldhuisen DJ. Beta-Adrenoceptor antagonists in elderly patients with heart failure: a critical review of their efficacy and tolerability. Drugs Aging. 2007;24(12):1031-44.
  5. Cheng JW, Nayar M. A review of heart failure management in the elderly population. Am J Geriatr Pharmacother. 2009 Oct;7(5):323-49.
  6. Goyal D, Macfadyen RJ, Watson RD, Lip GY. Ambulatory blood pressure monitoring in heart failure: a systematic review. Eur J Heart Fail. 2005 Mar 2;7(2):149-56.
  7. Olsson LG, Swedberg K, Clark AL, Witte KK, Cleland JG. Six minute corridor walk test as an outcome measure for the assessment of treatment in randomized, blinded intervention trials of chronic heart failure: A systematic review. Eur Heart J. 2005 Apr;26(8):778-93. Epub 2005 Mar 17.
  8. Balion C, McKelvie RS, Reichert S, Santaguida P, Booker L, Worster A, et al. Monitoring the response to pharmacologic therapy in patients with stable chronic heart failure: Is BNP or NT-proBNP a useful assessment tool? Clin Biochem. 2008 Mar;41(4-5):266-76. Epub 2007 Oct 16.
  9. Jennings AL, Davies AN, Higgins JP, Gibbs JS, Broadley KE. A systematic review of the use of opioids in the management of dyspnoea. Thorax. 2002 Nov;57(11):939-44.
  10. Qaseem A, Snow V, Shekelle P, Casey DE Jr, Cross JT Jr, Owens DK et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008 Jan 15;148(2):141-6.
  11. Lorenz KA, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA, et al. Evidence for improving palliative care at the end of life: a systematic review. [see comment]. Ann Intern Med. 2008 Jan 15;148(2):147-59.
  12. Bausewein CS, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD005623.
  13. Cranston JM, Crockett A, Currow D. Oxygen therapy for dyspnoea in adults. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD004769.
  14. Ghanbari H, Dalloul G, Hasan R, Daccarett M, Saba S, David S, et al. Effectiveness of implantable cardioverter-defibrillators for the primary prevention of sudden cardiac death in women with advanced heart failure: a meta-analysis of randomized controlled trials. Arch Intern Med. 2009 Sep;169(16):1500-6.
  15. Turley AJ, Raja SG, Salhiyyah K, Nagarajan K. Does cardiac resynchronisation therapy improve survival and quality of life in patients with end-stage heart failure? Interact Cardiovasc Thorac Surg. 2008 Dec;7(6):1141-46. Epub 2008 Jun 9.
  16. Rivero-Ayerza M, Theuns DA, Garcia-Garcia HM, Boersma E, Simoons M, Jordaens LJ. Effects of cardiac resynchronization therapy on overall mortality and mode of death: A meta-analysis of randomized controlled trials. Eur Heart J. 2006 Nov;27(22):2682-8. Epub 2006 Sep 11.

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Last updated 16 May 2017