Abstract
Purpose of Review
The prevalence of cardiovascular disease (CVD) increases with increasing age, and most patients with CVD are older. Death is more common in older than that in younger patients with CVD.CVD is responsible for significant disability, particularly in older patients.
Findings
Older persons have many comorbidities that complicate palliative care. We summarize available information about palliative care in CVD and specifically in heart failure. We address many misconceptions about palliative care in patients with CVD, including the notion that palliative care and hospice are synonymous, that palliative care should be reserved for the end of life, and that it can only be delivered by dedicated palliative care providers. Palliative care for older persons with CVD includes therapies addressing the neurohormonal disarray and cytokine activation that accompany CVD, and other therapies that provide symptom relief.
Summary
Palliative care should be delivered throughout the course of illness, by all clinicians involved in care. Communication should incorporate patient values into goals of care which should be revisited throughout the course of cardiovascular care.
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References
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World Health Organization (WHO). Available at http://www.who.int. Accessed August 2016.
Mozzafarian D, Benjamin EJ, Go AS, et al. On behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016;133:e38–e360. doi:10.1161/CIR.0000000000000350.
Lloyd-Jones D, Adams RJ, Brown T, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121:e46–215. doi:10.1161/CIRCULATIONAHA.109.192667.
Incidence and prevalence. Chart book on cardiovascular and lung diseases. Bethesda, Maryland, USA: National Institute of Health, National Heart, Lung and Blood Institute, 2006;73.
Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980–2000. N Engl J Med. 2007;356:2388–98. doi:10.1056/NEJMsa053935.
Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the United States. Circulation. 2005;111:1233–41. doi:10.1161/01.CIR.0000158136.76824.04.
Caffrey C, Sengupta M, Moss A, Harris-Kojetin L, Valverde R. Home health care and discharged hospice care patients: United States, 2000 and 2007. National Health Statistics Reports, No 38. Hyattsville, MD: National Center for Health Statistics; 2011.
• Evangelista LS, Lombardo D, Malik S, Ballard-Hernandez J, Motie M, Liao S. Examining the effects of outpatient palliative care consultation on symptoms burden, depression, and quality of life in patients with symptomatic heart failure. J card Fail. 2012;18:894–9. doi:10.1016/j.cardfail.2012.10.019. This study showed that an outpatient palliative care consultation leads to reduced symptom burden and depression and improved quality of life in patients with heart failure.
Rabow M, Kvale E, Barbour L, et al. Moving upstream: a review of the evidence of the impact of outpatient palliative care. J Palliat Med. 2013;16:1540–9. doi:10.1089/jpm.2013.0153.
Schwartz ER, Baragnoush A, Morrisey RP, et al. Pilot study of palliative care consultation in patients with advanced heart failure referred for cardiac transplantation. J Palliat Med. 2012;15:12–5. doi:10.1089/jpm.2011.0256.
• Sidebottom AC, Jorgenson A, Richards H, Kirven J, Sillah A. Inpatient palliative care for patients with acute heart failure: outcomes from a randomized trial. J Palliat Med. 2015;18:134–42. doi:10.1089/jpm.2014.0192. This study showed that an inpatient palliative care consultation improves symptom burden, quality of life, and depression in patients with heart failure.
Smith S, Brick A, O’Hara S, Normand C. Evidence on the cost and cost-effectiveness of palliative care: a literature review. Palliat Med. 2014;28:130–50. doi:10.1177/0269216313493466.
May P, Normand C, Morrison RS. Economic impact of hospital inpatient palliative care consultation: review of current evidence and directions for future research. J Palliat Med. 2014;17:1054–63. doi:10.1089/jpm.2013.0594.
Laribi S, Aouba A, Nikolaou M, GREAT network, et al. Trends in death attributed to heart failure over the past two decades in Europe. Eur J Heart Fail. 2012;14:234–9. doi:10.1093/eurjhf/hfr182.
Smith TJ, Coyne P, Cassel B, Penberthy L, Hopson A, Hager MA. A high-volume specialist palliative care unit and team may reduce in-hospital end-of-life care costs. J Palliat Med. 2003;6:699–705. doi:10.1089/109662103322515202.
Tse DM, Chan KS, Lam WM, Leu K, Lam PT. The impact of palliative care on cancer deaths in Hong Kong: a retrospective study of 494 cancer deaths. Palliat Med. 2007;21:425–33. doi:10.1177/0269216307079825.
Gozalo P, Plotzke M, Mor V, Miller SC, Teno JM. Changes in Medicare costs with the growth of hospice care in nursing homes. N Engl J Med. 2015;372:1823–31. doi:10.1056/NEJMsa1408705.
Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail. 2008;10(2008):933–89. doi:10.1093/eurheartj/ehn309.
Fang JC, Ewald GA, Allen LA, et al. Advanced (stage D) heart failure: a statement from the Heart Failure Society of America Guidelines Committee. J Card Fail. 2015;21:519–34. doi:10.1016/j.cardfail.2015.04.013.
Lindenfeld J, Albert NM, Boehmer JP, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2010;16:e1–e194. doi:10.1016/j.cardfail.2010.04.004.
McKelvie RS, Moe GW, Cheung A, et al. The 2011 Canadian Cardiovascular Society heart failure management guidelines update: focus on sleep apnea, renal dysfunction, mechanical circulatory support, and palliative care. Can J Cardiol. 2011;27:319–38. doi:10.1016/j.cjca.2011.03.011.
•• Whellan DJ, Goodlin SJ, Dickinson MJ, et al. End-of-life care in patients with heart failure. J Card Fail. 2014;20:121–34. doi:10.1016/j.cardfail.2013.12.003. This paper includes a detailed discussion of end-of-life care in patients with heart failure.
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128:e240–327. doi:10.1016/j.jacc.2013.05.019.
• Kavalieratos D, Mitchell EM, Carey TS, et al. “Not the ‘grim reaper service’”: an assessment of provider knowledge, attitudes, and perceptions regarding palliative care referral barriers in heart failure. J Am heart Assoc. 2014;3, e000544. doi:10.1161/JAHA.113.000544. This paper discusses some of the barriers to palliative care in patients with heart failure.
Feldman D, Pamboukian SV, Teutenberg JJ, International Society for Heart and Lung Transplantation, et al. The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant. 2013;32:157–87. doi:10.1016/j.healun.2012.09.013.
Gohler A, Januzzi JL, Worrell SS, et al. A systematic meta-analysis of the efficacy and heterogeneity of disease management programs in congestive heart failure. J Card Fail. 2006;12:554–67. doi:10.1016/j.cardfail.2006.03.003.
Grady KL, Dracup K, Kennedy G, et al. Team management of patients with heart failure: a statement for healthcare professionals from The Cardiovascular Nursing Council of the American Heart Association. Circulation. 2000;102:2443–56. doi:10.1161/01.CIR.102.19.2443.
Beattie JM. Palliative care for heart failure: challenges and opportunities. Eur J Cardiovasc Nurs. 2014;13(2):102–4. doi:10.1177/1474515114521697.
Periyakoil VS, Neri E, Kraemer H. No easy talk: a mixed methods study of doctor reported barriers to conducting effective end-of-life conversations with diverse patients. PLoS One. 2015;10:e0122321. doi:10.1371/journal.pone.0122321.
Virdun C, Luckett T, Davidson PM, Phillips J. Dying in the hospital setting: a systematic review of quantitative studies identifying the elements of end-of-life care that patients and their families rank as being most important. Palliat Med. 2015;29:774–96. doi:10.1177/0269216315583032.
•• LeMond L, Allen L. Palliative care and hospice in advanced heart failure. Prog Cardiovasc Dis. 2011;54(2):168–78. doi:10.1016/j.pcad.2011.03.012. This article provides a comprehensive review of the use of palliative care and hospice in patients with heart failure.
•• Goodlin SJ. Palliative care in congestive heart failure. J Am Coll Cardiol. 2009;54:386–96. doi:10.1016/j.jacc.2009.02.078. This paper details the pathophysiology of heart failure and describes why early involvement of palliative care in patients with heart failure is important.
Vollman MW, LaMontagne LL, Hepworth JT. Coping and depressive symptoms in adult living with heart failure. J Cardiovasc Nurs. 2007;22(2):125–30.
Zimmermann C, Riechelmann R, Krzyzanowska M, et al. Effectiveness of specialized palliative care. JAMA. 2008;299:1698–709. doi:10.1001/jama.299.14.1698.
• Evangelista L, Liao S, Motie M, De Michelis N, Lombardo D. On-going palliative care enhances perceived control and patient activation and reduces symptom distress in patients with symptomatic heart failure: a pilot study. Eur J Cardiovasc Nurs. 2014;13(2):116–23. doi:10.1177/1474515114520766. This study shows that palliative care interventions lead to enhanced perceived control and activation in patients with heart failure, promoting their readiness and willingness to manage their care.
• Caboral MF, Evangelista LS, Whetsell MV. Hope in elderly adults with chronic heart failure. Concept analysis. Investigacion y educacion en enfermeria. 2012;30(3):406–11. This paper discusses the importance of hope in older adults with heart failure.
Clark AL. Origin of symptoms in chronic heart failure. Heart. 2006;92:12–6. doi:10.1136/hrt.2005.066886.
•• Beniaminowitz A, Land CC, LaManca J, Mancini DM. Selective low level leg muscle training alleviates dyspnea in patients with heart failure. J Am Coll Cardiol. 2002;40:1602. doi:10.1016/S0735-1097(02)02342-2. This showed that thigh muscle strengthening can reduce dyspnea and fatigue in symptomatic patients with heart failure.
Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA. 1995;273:1450–63. doi:10.1001/jama.1995.03520420066040.
Captopril Multicenter Research Group. A placebo-controlled trial of captopril in refractory congestive heart failure. J Am Coll Cardiol. 1983;2:755–63. doi:10.1016/S0735-1097(83)80316-7.
•• Goodlin SJ, PAIN-HF Investigators, et al. Investigating pain in heart failure patients: the pain assessment, incidence, and nature in heart failure (PAIN-HF) Study. J Cardiac Fail. 2012;18:776–83. doi:10.1016/j.cardfail.2012.07.007. This is a landmark study that described the prevalence, etiology, location, and treatment of pain in patients with heart failure.
Breitbart W, Rosenfeld B, Passik SD, McDonald MV, Thaler H, Portenoy RK. The undertreatment of pain in ambulatory AIDS patients. Pain. 1996;65:243–9.
Cleeland CS, Gonin R, Hatfield AK, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994;330:592–6. doi:10.1056/NEJM199403033300902.
Chua TP, Harrington D, Ponikowski P, Webb-Peploe K, Poole-Wilson PA, Coats AJ. Effects of dihydrocodeine on chemosensitivity and exercise tolerance in patients with chronic heart failure. J Am Coll Cardiol. 1997;29:147–52. doi:10.1016/S0735-1097(96)00446-9.
Williams SG, Wright DJ, Marshall P, et al. Safety and potential benefits of low dose diamorphine during exercise in patients with chronic heart failure. Heart. 2003;89:1085–6. doi:10.1136/heart.89.9.1085.
Setoguchi S, Glynn RJ, Stedman M, et al. Hospice, opiates, and acute care service use among the elderly before death from heart failure or cancer. Am Heart J. 2010;160:1390144. doi:10.1016/j.ahj.2010.03.038.
Coxib and traditional NSAID Trialists’ (CNT) Collaboration, Bhala N, Emberson J, et al. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013;382:769. doi:10.1016/S0140-6736(13)60900-9.
Page J, Henry D. Consumption of NSAIDs and the development of congestive heart failure in elderly patients: an underrecognized public health problem. Arch Intern Med. 2000;160:777–84. doi:10.1001/archinte.160.6.777.
Rutledge T, Reis VA, Linke SE, et al. Depression in heart failure a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. J Am Coll Cardiol. 2006;48:1527–37. doi:10.1016/j.jacc.2006.06.055.
Gottlieb SS, Kop WJ, Thomas SA, et al. A double-blind placebo-controlled pilot study of controlled-release paroxetine on depression and quality of life in chronic heart failure. Am Heart J. 2007;153(5):868–73. doi:10.1016/j.ahj.2007.02.024.
Kuchibhatla MN, Fillenbaum GG. Trajectory classes of depression in a randomized depression trial of heart failure patients: a reanalysis of the SADHART-CHF trial. Am J Geriatr Pharmacother. 2011;9(6):483–94. doi:10.1016/j.amjopharm.201.
McGrath L, Mudd J, Chien C, Lee C, Miller R, Gelow J. Patient reported symptoms of depression improve with treatment of acute heart failure: a pilot study. J Card Fail. 2016;22(8):S104. doi:10.1016/j.cardfail.2016.06.331.
Notarius CF, Morris B, Floras JS. Caffeine prolongs exercise duration in heart failure. J Card Fail. 2006;29:525. doi:10.1016/j.cardfail.2005.12.005.
• Ades PA, Keteyian SJ, Balady GJ, et al. Cardiac rehabilitation exercise and self-care for chronic heart failure. JACC Heart Fail. 2013;1:540. doi:10.1016/j.jchf.2013.09.002. This study showed that exercise can improve functional status, depression, quality of life, and clinical outcomes in patients with heart failure.
Saczynski JS, Go AS, Magid DJ, et al. Patterns of comorbidity in older adults with heart failure: the Cardiovascular Research Network PRESERVE study. J Am Geriatr Soc. 2013;61:26–33. doi:10.1111/jgs.12062.
Meyers DE, Goodlin SJ. End-of-life decisions and palliative care in advanced heart failure. Can J Cardiol. 2016;32:1148–56. doi:10.1016/j.cjca.2016.04.015.
Oudejans I, Mosterd A, Zuithoff NP, Hoes AW. Comorbidity drives mortality in newly diagnosed heart failure: a study among geriatric outpatients. J Card Fail. 2012;18:47–52. doi:10.1016/j.cardfail.2011.10.009.
•• Khan H, Kalogeropoulos AP, Georgiopoulo V, et al. Frailty and risk for heart failure in older adults: the health, aging, and body composition study. Am Heart J. 2013;166(5):887–94. doi:10.1016/j.ahj.2013.07.032. This article shows that frailty is an independent risk factor for poor outcomes in older adults with all types of cardiovascular disease.
Afilalo J, Alexander KP, Mack MJ, et al. Frailty assessment in the cardiovascular care of older adults. J Am Coll Cardiol. 2014;63:747–62. doi:10.1016/j.jacc.2013.09.070.
Cacciatore F, Abete P, Mazzella F, et al. Frailty predicts long-term mortality in elderly subjects with chronic heart failure. Eur J Clin Invest. 2005;35:723–30. doi:10.1111/j.1365-2362.2005.01572.x.
Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146–56. doi:10.1093/gerona/56.3.M146.
Afilalo J, Kim S, O’Brien S, et al. Gait speed and operative mortality in older adults following cardiac surgery. JAMA Cardiol. 2016;1(3):314–21. doi:10.1001/jamacardio.2016.0316.
• Dodson JA, Truong T, Towle V, et al. Cognitive impairment in older adults with heart failure: prevalence, documentation, and impact on outcomes. Am J Med. 2013;126:120–6. doi:10.1016/j.amjmed.2012.05.029. This article discusses the high prevalence of cognitive impairment in older patients with heart failure and shows that cognitive impairment is associated with worse outcomes in these patients.
Bradley TD, Logan AG, Fimoff RJ, et al. Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med. 2005;252:2025. doi:10.1056/NEJMoa051001.
Dev S, Abernethy AP, Rogers JG, O’Connor CM. Preferences of people with advanced heart failure—a structured narrative literature review to inform decision making in the palliative care setting. Am Heart J. 2012;164:313–319.e315. doi:10.1016/j.ahj.2012.05.023.
Parker SM, Clayton JM, Hancock K, et al. A systematic review of prognostic/end-of-life communication with adults in the advanced stages of a life-limiting illness: patient/caregiver preferences for the content, style, and timing of information. J Pain Symptom Manage. 2007;34:81–93. doi:10.1016/j.jpainsymman.2006.09.035.
Hauptman PJ, Goodlin SJ, Lopatin M, Costanzo MR, Fonarow GC, Yancy CW. Characteristics of patients hospitalized with acute decompensated heart failure who are referred for hospice care. Arch Intern Med. 2007;167:1990–7. doi:10.1001/archinte.167.18.1990.
Goldstein NE, Mehta D, Siddiqui S, et al. “That’s like an act of suicide” patients’ attitudes toward deactivation of implantable defibrillators. J Gen Intern Med. 2008;23 suppl 1:7–12. doi:10.1007/s11606-007-0239-8.
•• Westerdahl A, Sjöblom J, Mattiasson A, et al. Implantable cardioverter-defibrillator therapy before death: high risk for painful shocks at end of life. Circulation. 2014;129:422–9. doi:10.1161/CIRCULATIONAHA.113.002648. This paper showed the high rates of ICD shocks at the end of life.
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Dr. McGrath and Dr. Goodlin declare they have no conflicts of interests to declare.
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McGrath, L., Goodlin, S.J. Palliative Care in Older Adults with Cardiovascular Disease: Addressing Misconceptions to Advance Care. Curr Cardiovasc Risk Rep 11, 6 (2017). https://doi.org/10.1007/s12170-017-0530-0
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DOI: https://doi.org/10.1007/s12170-017-0530-0