Dr Lee GrahamConsultant Cardiologist/

Electrophysiologist

Yorkshire Heart CentreThe General Infirmary, Leeds

Cardiological issues in palliative care

TopicsTopics

Heart failureHeart failure

Implantable defibrillatorsImplantable defibrillators

Atrial fibrillationAtrial fibrillation

AnginaAngina

Pericardial effusionPericardial effusion

Anything else you want to knowAnything else you want to know

Heart failureHeart failure

Burden of heart failureBurden of heart failureFor the United KingdomFor the United Kingdom**

63000 new cases/year63000 new cases/year-34000 men-34000 men-29000 women-29000 women

875000 people have definite/probable heart failure875000 people have definite/probable heart failure: 473000 men: 473000 men: 405000 women: 405000 women

Annual cost for the NHS is about £625 millionAnnual cost for the NHS is about £625 million

*based on age-sex-specific estimates for the year 2000 UK population.Coronary Heart Disease Statistics: Heart Failure SupplementBritish Heart Foundation/University of Oxford, 2002

Spectrum of symptoms in end stage Spectrum of symptoms in end stage heart failure patientsheart failure patients

Dying from Heart DiseaseDying from Heart DiseaseRetrospective review of 600 cardiac deaths from 20 Retrospective review of 600 cardiac deaths from 20 English Health districts (1990)English Health districts (1990)

Symptoms reported by informal carersSymptoms reported by informal carersPainPain 78%78% AnorexiaAnorexia 43%43%DyspnoeaDyspnoea 61%61% ConstipationConstipation 37%37%Low moodLow mood 59%59% Nausea/vomitingNausea/vomiting 32%32%InsomniaInsomnia 45%45% Urinary incontinenceUrinary incontinence 29%29%AnxietyAnxiety 30%30% Faecal incontinenceFaecal incontinence 16%16%Mental confusionMental confusion 27%27%

McCarthy et al, J. Roy. Coll. Phys Lond., (30) 325, 1996

Depression in heart failureDepression in heart failure

Clinically significant Clinically significant

depression in 21%depression in 21%

Rates much higher with Rates much higher with

increasing NYHA class increasing NYHA class

(42% in NYHA IV) (42% in NYHA IV)

Increased readmission Increased readmission

ratesrates

Increased mortalityIncreased mortality

Rutledge et al., JACC 2006

Are we contributing to the problem?Are we contributing to the problem?

ACE inhibitor coughACE inhibitor cough

Digoxin toxicityDigoxin toxicity

Over diuresisOver diuresis

Fluid restrictionFluid restriction

Diuretic induced incontinenceDiuretic induced incontinence

Beta-blocker lethargyBeta-blocker lethargy

Opiate related constipationOpiate related constipation

Spectrum of symptoms in end stage Spectrum of symptoms in end stage heart failure patientsheart failure patients

Are we good at alleviating symptoms?Are we good at alleviating symptoms?

Symptom Relief Symptom Relief CompleteComplete PartialPartial NoneNone Pain Pain 23%23% 34%34% 34%34% Dyspnoea Dyspnoea 36%36% 39%39% 24%24%

McCarthy et al, J. Roy. Coll. Phys Lond., (30) 325, 1996

State of the art heart failure therapyState of the art heart failure therapy

Medication Complex ‘chemotherapy’ £54.08m (2000)

Intervention

Revascularisation - PCI - CABGCRTICD’sLVADSTransplantationStem cells

Implications of “high technology” Implications of “high technology” cardiology practicecardiology practice

Promotes superspecialisation - cardiologists increasingly removed from mainstream general medicine

Palliative care physicians - anxious about technical aspects

General physicians - deskilling - high readmission rates

Patients disempowered

End of life care for heart failure End of life care for heart failure patientspatients

Heart failure patients much more likely to die Heart failure patients much more likely to die

in hospital than are cancer patientsin hospital than are cancer patients

More likely to receive invasive interventions in More likely to receive invasive interventions in

the last few days of lifethe last few days of life

HF patients have special palliative care needsHF patients have special palliative care needs

Compared to Lung CancerCompared to Lung Cancer

““Cardiac patients received less Cardiac patients received less health,social and palliative care services health,social and palliative care services and care was often poorly coordinated.” and care was often poorly coordinated.”

““Most people with heart failure do not Most people with heart failure do not understand the cause or prognosis of their understand the cause or prognosis of their disease and rarely discuss end of life disease and rarely discuss end of life issues with their carers” issues with their carers”

Murray et al., BMJ 2002

Why has end of life care for heart Why has end of life care for heart failure patients been inadequate?failure patients been inadequate?

Access to resourcesAccess to resources

Reliance on cancer based charitiesReliance on cancer based charities

Sheer scale of the problemSheer scale of the problem

Lack of interaction between cardiologist & Lack of interaction between cardiologist &

palliative care physicianpalliative care physician

Difficulty in predicting disease trajectoryDifficulty in predicting disease trajectory

Heart failure trajectoryHeart failure trajectory

Reasons for difficulty in predicting Reasons for difficulty in predicting prognosisprognosis

Many different clinical scenariosMany different clinical scenarios

Unpredictable response to treatmentUnpredictable response to treatment

Worries that:Worries that:

– A precipitant has been overlookedA precipitant has been overlooked

– Alternative drug combinations might helpAlternative drug combinations might help

High incidence of sudden deathHigh incidence of sudden death

Sudden Cardiac Death (SCD)Sudden Cardiac Death (SCD)

NYHA II

NYHA IV

NYHA III

64%

12%

24%

56%

33%

11%

26%

15%

59%

Sudden DeathCHFOther

Deaths = 103 Deaths = 232

Deaths = 27MERIT-HF investigators, Lancet 1999

Palliative care in advanced heart failurePalliative care in advanced heart failure

Frameworks of careFrameworks of care

Gold standard Gold standard

framework (GSF)framework (GSF)

Liverpool care Liverpool care

pathway (LCP)pathway (LCP)

Triggers for Heart Failure Integrated Triggers for Heart Failure Integrated Care Pathway ActivationCare Pathway Activation

CHD collaborativeCHD collaborative

NYHA III-IVNYHA III-IV

Patient thought to be in last year of lifePatient thought to be in last year of life

Repeated hospitalisation with HF Repeated hospitalisation with HF symptomssymptoms

Refractory physical/psychosocial Refractory physical/psychosocial symptoms despite optimal therapysymptoms despite optimal therapy

Triggers for Heart Failure Integrated Triggers for Heart Failure Integrated Care Pathway ActivationCare Pathway Activation

Liverpool care pathwayLiverpool care pathway

Patient bed boundPatient bed bound

Semi-comatoseSemi-comatose

Only able to take sips of fluidOnly able to take sips of fluid

No longer able to take tabletsNo longer able to take tablets

Not responding to maximal therapyNot responding to maximal therapy

Leeds adapted LCP for inpatients Leeds adapted LCP for inpatients with heart failurewith heart failure

Criteria for useCriteria for useKnown irreversible life-threatening illnessKnown irreversible life-threatening illnessReversible causes for current deterioration Reversible causes for current deterioration considered and appropriately managedconsidered and appropriately managedICU/resus inappropriate. ICD deactivation ICU/resus inappropriate. ICD deactivation discusseddiscussedDay by day deteriorationDay by day deteriorationPatient or team elected to withdraw from Patient or team elected to withdraw from active treatmentactive treatment

Leeds adapted LCP for inpatients Leeds adapted LCP for inpatients with heart failurewith heart failure

Non essential medication discontinuedNon essential medication discontinued– StatinsStatins– Antiarrhythmics e.g. amiodaroneAntiarrhythmics e.g. amiodarone– Anti-anginalsAnti-anginals

Essential medication continued for symptomsEssential medication continued for symptoms– DiureticsDiuretics– DigoxinDigoxin– Vasodilators e.g. ISMN, ACE-IVasodilators e.g. ISMN, ACE-I

Continuous sc infusion if appropriateContinuous sc infusion if appropriate

Leeds adapted LCP for inpatients Leeds adapted LCP for inpatients with heart failurewith heart failure

PRN sc medication PRN sc medication – PainPain– Nausea & vomitingNausea & vomiting– AgitationAgitation– Respiratory secretionsRespiratory secretions– DyspnoeaDyspnoea

Discontinue inappropriate interventionsDiscontinue inappropriate interventions– Blood testsBlood tests– AntibioticsAntibiotics– TelemetryTelemetry

Leeds adapted LCP for inpatients Leeds adapted LCP for inpatients with heart failurewith heart failure

Insight into condition Insight into condition – Awareness of diagnosisAwareness of diagnosis– Recognition of dyingRecognition of dying

GP practice aware of patients conditionGP practice aware of patients condition

Plan of care discussedPlan of care discussed– PatientPatient– CarerCarer

Religious/spiritual needsReligious/spiritual needs

Identify how family/carers informed of deathIdentify how family/carers informed of death

Implantable defibrillatorsImplantable defibrillators

Implantable DefibrillatorsImplantable Defibrillators

Expanding indications for implantationExpanding indications for implantation

Increasingly common in HF patientsIncreasingly common in HF patients

Over 20% patients may receive a shock in the Over 20% patients may receive a shock in the last month of life (Goldstein 2004)last month of life (Goldstein 2004)

Increasing relevance of device deactivationIncreasing relevance of device deactivation

Whilst almost all physicians agree that Whilst almost all physicians agree that conversations about deactivation should occur, conversations about deactivation should occur, they rarely do so (Goldstein 2008)they rarely do so (Goldstein 2008)

Why discussions about ICD Why discussions about ICD deactivation may not occur deactivation may not occur

Lack of timeLack of time

Concern over taking away hopeConcern over taking away hope

Raise concerns about deathRaise concerns about death

Concern over withdrawing therapyConcern over withdrawing therapy

May not result in patient death May not result in patient death “immediately”“immediately”

Small “innocuous” deviceSmall “innocuous” device

Goldstein et al., 2008

ICD deactivationICD deactivation

“When you start talking about ... turning it off, then you are sort of shutting off the hope.”

“I think that one thing is that people don’t think about [turning it off] because it’s internalized.”

“Well, I think it’s different than a ventilator, for example, because it’s, you know, it’s not like you turn [the ICD] off and the person dies.”—female electrophysiologist”

Goldstein et al., 2008

ICD specialist nurseICD specialist nurse

3 consultant electrophysiologists3 consultant electrophysiologists

All patients seen pre-implantAll patients seen pre-implant

End of life discussions had with all patients End of life discussions had with all patients before procedurebefore procedure

Further discussions surrounding Further discussions surrounding deactivation if and when appropriatedeactivation if and when appropriate

ICD deactivation Leeds perspectiveICD deactivation Leeds perspective

How to deactivate an ICDHow to deactivate an ICD

Placing a magnet over the device will Placing a magnet over the device will

deactivate all tachy therapies (ATP, deactivate all tachy therapies (ATP,

shocks) without affecting pacing functionshocks) without affecting pacing function

Contact cardiology SpR or on-call pacing Contact cardiology SpR or on-call pacing

technician for support if required technician for support if required

Atrial fibrillationAtrial fibrillation

Atrial fibrillationAtrial fibrillation

Atrial fibrillationAtrial fibrillation

Assess your patientAssess your patient– SymptomsSymptoms– Haemodynamic upset/ ventricular rateHaemodynamic upset/ ventricular rate– Heart failureHeart failure

Is there an underlying causeIs there an underlying cause– InfectionInfection– Electrolyte disturbanceElectrolyte disturbance– pericardial infiltration or effusionpericardial infiltration or effusion

Atrial fibrillation-acute managementAtrial fibrillation-acute management

Correct underlying cause if appropriateCorrect underlying cause if appropriate

Control ventricular rateControl ventricular rate– Beta blocker e.g. bisoprolol 2.5-5mgBeta blocker e.g. bisoprolol 2.5-5mg– Diltiazem (long acting) alternativeDiltiazem (long acting) alternative– Digoxin if signs of heart failureDigoxin if signs of heart failure

Aspirin if appropriateAspirin if appropriate

Treat any associated heart failureTreat any associated heart failure

Phone a friend if in doubtPhone a friend if in doubt

AnginaAngina

AnginaAngina

Medical management of anginaMedical management of anginaAspirinAspirin 75-300mg daily 75-300mg dailyClopidogrelClopidogrel alternative if aspirin sensitive alternative if aspirin sensitiveBeta-blockersBeta-blockers– Bisoprolol 2.5 - 10mg dailyBisoprolol 2.5 - 10mg daily– Metoprolol 25-50mg bdMetoprolol 25-50mg bd

Long acting nitratesLong acting nitrates– ISMN 30 -120mg daily ISMN 30 -120mg daily

Calcium antagonistsCalcium antagonists– Rate limiting e.g. diltiazem LA 2-300mg dailyRate limiting e.g. diltiazem LA 2-300mg daily– Non-rate limiting e.g. amlodipine 5 – 10mg dailyNon-rate limiting e.g. amlodipine 5 – 10mg daily

Potassium channel openersPotassium channel openers– Nicorandil 10 - 30mg bdNicorandil 10 - 30mg bd

Patients unable to take oral Patients unable to take oral medication/tabletsmedication/tablets

Sublingual or buccal nitratesSublingual or buccal nitrates

Nitrate patches – remove at nightNitrate patches – remove at night

Beta-blocker syrups e.g. atenolol syrupBeta-blocker syrups e.g. atenolol syrup

OpiatesOpiates

Pericardial effusionPericardial effusion

Pericardial effusionPericardial effusion

Often insidious and chronic in malignancyOften insidious and chronic in malignancy

Patients often remarkably asymptomaticPatients often remarkably asymptomatic

CT often overestimates sizeCT often overestimates size

Clinical features of tamponade are lateClinical features of tamponade are late

ECHO signs of tamponade earlyECHO signs of tamponade early

Pericardial effusionPericardial effusion

Physical signs of tamponadePhysical signs of tamponade

Raised JVPRaised JVP

Low blood pressureLow blood pressure

Pulsus paradoxus (>10mmHg)Pulsus paradoxus (>10mmHg)

Soft heart soundsSoft heart sounds

OedemaOedema

Chronic asymptomatic effusions can be Chronic asymptomatic effusions can be

managed conservativelymanaged conservatively

Pericardiocentesis & drainage generally Pericardiocentesis & drainage generally

straightforward and safestraightforward and safe

? Pericardial window? Pericardial window

Pericardial effusion- managementPericardial effusion- management