Congestive Heart Failure:Not for the Weak of Heart: Palliation

1
Congestive Heart Failure (Not for the) Weak of
Heart Palliation

• Glen Drobot, MD, FRCPC
• Assistant Professor, Department of Internal
  Medicine, University of Manitoba St. Boniface
  General Hospital
• Co-director consultant WRHA Heart Failure Clinic

Annual Scientific Assembly 2006, Manitoba College
of Family Physicians
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Objectives

• Define heart failure (HF), end stage HF
• Define palliative care
• Outline measures for palliation of end-stage HF
  patients

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Definition of Heart Failure

• Heart Failure is a clinical syndrome where
• Heart and circulation are unable to meet the
  demands of the body
• Includes situations where metabolic demands are
  elevated (i.e. high output HF from anemia)
• Or only able to do so at an abnormally elevated
  diastolic volume

4
Stages of Heart Failure

• American College of Cardiology defines stages of
  heart failure
• Differs from New York Heart Association classes
  of symptoms (I IV)
• Akin to stages of renal disease
• Stage A high risk for developing HF
• Stage B asymptomatic LV dysfunction
• Stage C past or current symptoms of HF
• Stage D end-stage HF

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Stages of Heart Failure

• Progressive nature of LV dysfunction
• Progress in one direction due to cardiac
  remodeling
• Patient can move between NYHA classes

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• Stage A emphasizes preventability
• Stage B is asymptomatic LV dysfunction

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• typical patient is in Stage C
• Increasing numbers of patients with Stage D
• Palliation is appropriate

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Scope of the problem of HF

• 1 in 100 Canadians suffer from HF
• Prevalence steadily increased since 1970
• Most common cause for hospitalization among
  patients over age 65
• HF contributes to 9 of all deaths in Canada

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Palliative Care (WHO)

• Approach that improves the quality of life of
  patients and families facing life-threatening
  illness
• Prevention and relief of suffering
• Early identification and assessment
• Treatment of pain and other problems physical,
  psychosocial and spiritual

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Palliative Care (WHO)

• Components of palliative care
• Relief from pain and other distressing symptoms
• Affirms life, regards dying as a normal process
• Integrates the psychological and spiritual
  aspects of patient care
• Offers a support system to patients/families
• Uses a team approach
• Applicable early in course of illness, in
  conjunction with other therapies

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Palliative Care and HF

• Emphasizes goal of improving quality of life (not
  necessarily quantity)
• Decrease symptoms
• Reduce rates of hospital admissions
• Both Canadian and American HF guidelines have
  sections devoted to end-of-life issues

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Prognosis of HF

• Difficult to predict time of death
• Challenging in HF due to
• Cyclical nature of disease
• Complexity of care
• Recent advances, especially in the area of
  medical devices
• Implantable defibrillators
• Biventricular pacemakers (cardiac
  resynchronization)

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Prognosis of HF

• Mechanism of death in HF
• Sudden cardiac death
• Brady- or tachyarrhythmias
• Progressive heart failure
• Varies depending on NYHA class
• NYHA class II higher risk of sudden death or
  drop
• NYHA class IV increasing dyspnea/ orthopnea,
  decreased BP LOC or drown

Arnold et al. CCS Can J Cardiol 2006
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Case of Mr. K.

• 60-year-old male
• Ischemic cardiomyopathy, EF 20, AFib
• DM 2 x 10 years
• Some degree of hepatic cirrhosis
• Systolic BP 100 mm Hg, RR 20
• Initial investigations
• Na 130, urea 25 (maximum 21 for model)
• Hgb 143 g/L

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General Measures in End-stage HF

• Meticulous identification and control of fluid
  retention, including avoidance of certain
  medications
• NSAIDs, celecoxib
• non-dihydropyridine CCBs (verapamil, diltiazem if
  low EF)
• Thiazolidinediones (TZDs) (rosiglitazone,
  pioglitazone)
• Metformin in CRF
• Most antiarrythmics (? risk sudden death)

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General Measures in End-stage HF

• Referral of patients to HF program with expertise
  in management of refractory HF
• Options for end-of-life care discussed with
  patients and family
• Patients with refractory HF and ICDs should
  receive information about the option to
  inactivate defibrillation
• (continuous IV positive inotrope)
• (cardiac transplant, LV assist device)

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Management of Fluid Status

• Many patients have symptoms of congestion (versus
  low-output, ie. fatigue)
• Increasing doses of loop diuretic
• Addition of 2nd diurectic, eg. Metolazone
• Hospitalization for IV medications
• Accept elevations of urea creatinine
• Discharge after stable/effective diuretic regimen
  established
• Close to euvolemia

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Step-wise Approach
Hauptman and Havranek. Arch Intern Med 2005
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Step-wise Approach
Hauptman and Havranek. Arch Intern Med 2005
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Evidence for general measures?

• ACC/AHA give levels of evidence for many aspects
  of medical management (eg. ACE-I, beta blockers,
  continuous outpatient support with inotropes)
• Paucity of recommendations/data for other aspects
  of care
• Palliation of dyspnea and fatigue
• Treatment of depression
• Communication re advance care planning, course
  of illness

Goodlin et al. J Card Failure 2004
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Evidence for specific measures?

• Oxygen therapy
• No studies in advanced HF
• Small studies in mild-moderate, stable HF
• Variable improvement in symptoms
• More than just correction of hypoxemia
• Adverse effects
• Restriction of activities
• Psychological dependence to have oxygen on at all
  times
• Hypercapneic respiratory failure
• Difficult to withdraw when not needed

Booth et al. Resp Med 2003
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Evidence for specific measures?

• Opiates
• Commonly used in palliative care for pain and
  dyspnea
• Studied in acute LV dysfunction, but less so in
  chronic setting
• Morphine has sedative, hemodynamic, neurohormonal
  and ventililatory effects

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Morphine in Chronic HF

• small (n10), randomized, double-blind, crossover
  pilot study
• NYHA Class III/IV, males
• Active arm 4 days of morphine 5mg qid
• 2 day wash-out
• Switch to other arm
• 6/10 patients had improvement in breathlessness
  score (visual analog scale)
• Sedation increased, 4/10 had constipation
• In placebo group, no significant difference in
  breathlessness or sedation, 1 had constipation

Johnson et al. Eur J Heart Failure 2001
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Back to Mr. K.

• Frequent hospitalizations for dyspnea
• Rapid accumulation of ascites
• Persistent large (R) pleural effusion
• (possible hepatic hydrothorax)
• Variable degree of renal insufficiency
• Mild encephalopathy ?hepatic
• Admitted about 75 of the time over past 3 months
• What would your approach be?

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Plans with Mr. K.

• Expressed desire to have everything done on a
  few occasions
• Wife and daughter (who is a nurse) didnt agree
  with this approach, but respected his decision
• HF clinic physician and ward physician ? frank
  discussion about probable lack of benefit with
  resuscitation given poor prognosis
• Agreed to change from ACP plan 4 ? 3

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Plans with Mr. K.

• Elective, outpatient abdominal paracentesis to
  decrease chance of hospitalization
• Chest medicine consulted ? no benefit to
  pleurodesis as fluid would accumulate
• Home oxygen therapy at 2L for mild resting
  hypoxemia
• Plan to consult pain and symptom control clinic
  readdress goals of therapy

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Palliative Care in WRHA

• Interdisciplinary program
• In-hospital, at home, at PCH residence
• Estimate prognosis lt 1month, 1-3 months, 3-6
  months
• Difficult in HF unless very imminent
• Can be guided by frequency of hospitalizations
• In U.S., hospice guidelines for lt 6 mos. were
  only 50 accurate

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Palliative Care in WRHA

• Pain and symptom control service for inpatients
  or outpatients
• Within HF clinic, liase with primary care
  physician when prognosis appears to be getting
  worse
• Support in clinic to continue appropriate
  medications within palliative care mode

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Summary

• Most patients progress to later stages of
  symptomatic HF
• Prognosis may be difficult to determine, as very
  fluctuating course
• Frequent reassessment of goals of therapy is
  necessary
• Palliative care does not preclude ongoing,
  intensive management of HF

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Palliative Care in WRHA

• Interdisciplinary program
• In-hospital, at home, at PCH residence
• Estimate prognosis lt 1month, 1-3 months, 3-6
  months
• Difficult in HF unless very imminent
• Can be guided by frequency of hospitalizations
• In U.S., hospice guidelines for lt 6 mos. were
  only 50 accurate

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Discussion Questions

• hungry monkey, Taiping, Malaysia

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Bibliography

• Arnold JMO et al. Canadian Cardiovascular Society
  consensus conference recommendations on heart
  failure 2006. Can J Cardiol 2006 22(1) 23-45.
• Hunt SA et al. ACC/AHA 2005 guideline update for
  the diagnosis and management of chronic heart
  failure in the adult. J Am Coll Cardiol 2005 46
  1116-43.
• Charette SL. The next step palliative care for
  advanced heart failure. J Am Med Dir Assoc 2006
  11(1) 63-4.
• Goodlin SJ et al. Consensus statement palliative
  and supportive care in advanced heart failure. J
  Card Failure 2004 10(3) 200-9.

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Bibliography

• Pantilat SZ, Steimle AE. Palliative care for
  patients with heart failure. JAMA 2004 291(20)
  2476-82, e1.
• Hauptman PJ, Havranek EP. Integrating palliative
  care into heart failure care. Arch Intern Med
  2005 165 374-8.
• Booth S et al. The use of oxygen in the
  palliation of breathlessness. A report of the
  expert working group of the scientific committee
  of the association of palliative medicine. Resp
  Med 2003 98 66-77.
• Johnson MJ et al. Morphine for relief of
  breathlessness in patients with chronic heart
  failure a pilot study. Eur J Heart Failure
  2001 4 753-6.
• http//www.ccort.ca/CHFriskmodel.asp