Failing the failing heart: a review of palliative care in heart failure.

Heart failure (HF) is the most common reason for hospital admission for patients older than 65 years. With an aging population and improving survival in heart failure patients, the number of people living with HF continues to grow. As this population increases, the importance of treating symptoms of fatigue, dyspnea, pain, and depression that diminish the quality of life in HF patients becomes increasingly important. Palliative care has been shown to help alleviate these symptoms and improve patients' satisfaction with the care they receive. Despite this growing body of evidence, palliative care consultation remains underutilized and is not standard practice in the management of HF. With an emphasis on communication, symptom management, and coordinated care, palliative care provides an integrated approach to support patients and families with chronic illnesses. Early communication with patients and families regarding the unpredictable nature of HF and the increased risk of sudden cardiac death enables discussions around advanced care directives, health care proxies, and deactivation of permanent pacemakers or implantable cardioverter defibrillators. Cardiologists and primary care physicians who are comfortable initiating these discussions are encouraged to do so; however, many fear destroying hope and are uncertain how to discuss end-of-life issues. Thus, in order to facilitate these discussions and establish an appropriate relationship, we recommend that patients and families be introduced to a palliative care team at the earliest appropriate time after diagnosis.

Pilot study of palliative care consultation in patients with advanced heart failure referred for cardiac transplantation.

BACKGROUND: Heart failure (HF) in its chronic form is an irreversible and progressive disease. Palliative care (PC) interventions have traditionally been focused on patients with advanced cancer. We performed a pilot study to assess the feasibility of implementing the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for early PC intervention in patients with advanced HF who were seeking or received potentially curative therapies. METHODS: Twenty consecutive patients with advanced HF referred to PC from the heart transplant service with stage D, New York Heart Association (NYHA) class III-IV symptoms were analyzed retrospectively in a tertiary care setting. Data were reviewed to assess the clinical impact of PC intervention. Feedback was obtained to assess satisfaction of the patients, their families, and the health care professionals. An independent assessment of the impact of the PC service in the care of each patient was performed by a cardiologist and PC physician by use of a scoring system. RESULTS: Twenty consecutive patients with HF were analyzed. PC consult was obtained for a variety of reasons. All patients complained of a high symptom burden. PC consultation resulted in a decrease in the use of opioids and increased patient satisfaction. Patients and their family members generally reported improved holistic care, continuity of care, more focused goals of care, and improved planning of treatment courses. The nonstandardized scoring system used to determine the impact of the PC service showed an average of moderate to significant impact when assessed by both a cardiologist and a PC physician. CONCLUSION: PC consultation appears to be beneficial in the treatment and quality of life of advanced HF patients, independent of their prognosis. This pilot study demonstrated feasibility and sufficient evidence of clinical benefit to warrant a larger randomized clinical trial assessing the benefit of standard involvement by PC in patients with advanced HF, independent of the patient's prognosis or treatment goals.

The potential effects of IGF-1 and GH on patients with chronic heart failure.

Heart failure (HF) is an important health concern with almost a quarter million deaths each year despite advances in medical therapy. Improvement of cardiac function has been shown to reduce morbidity and mortality in patients with HF. There has been recent interest in the growth hormone (GH) / insulin-like growth factor (IGF) pathway as a potential therapeutic target for patients with HF. Insulin-like growth factor 1 has been shown to augment cardiac function ex vivo and in animals. It was hypothesized that IGF-1/IGF-binding protein 3 levels might be able to provide prognostic benefits in patients with heart disease. Initial observational studies have shown significant benefits from GH supplementation including improved ejection fraction, increased exercise tolerance, and decreased New York Heart Association functional class. These results, however, were not replicated in randomized, controlled trials. Patients with advanced stages of HF might develop cachexia associated with a state of significant GH resistance. The lack of response to GH supplementation may be secondary to a deficiency in IGF-1, the effector hormone. Hypothetically, this group of patients could benefit from direct IGF-1 supplementation. Combined therapy with GH and IGF-1 is appealing; however, future trials in patients with advanced HF are warranted to prove this concept.

The effects of spirituality and religion on outcomes in patients with chronic heart failure.

Heart failure (HF) is a chronic progressive disease with marked morbidity and mortality. Patients enduring this condition suffer from fluctuations in symptom burden such as fatigue, shortness of breath, chest pain, sexual dysfunction, dramatic changes in body image and depression. As physicians, we often ask patients to trust in our ability to ameliorate their symptoms, but oftentimes we do not hold all of the answers, and our best efforts are only modestly effective. The suffering endured by these individuals and their families may even call into question one's faith in a higher power and portends to significant spiritual struggle. In the face of incurable and chronic physical conditions, it seems logical that patients would seek alternative or ancillary methods, notably spiritual ones, to improve their ability to deal with their condition. Although difficult to study, spirituality has been evaluated and deemed to have a beneficial effect on multiple measures including global quality of life, depression and medical compliance in the treatment of patients with HF. The model of HF treatment incorporates a multidisciplinary approach. This should involve coordination between primary care, cardiology, palliative care, nursing, patients and, importantly, individuals providing psychosocial as well as spiritual support. This review intends to outline the current understanding and necessity of spirituality's influence on those suffering from HF.

Philosophical implications of the systemic and patient-oriented management of chronic heart failure.

Chronic heart failure is a lifelong disease that involves a large variety of symptoms and, ultimately, the entire organism relatively early in the disease process. At least in part, this is in contrast to other chronic conditions such as diabetes, renal failure or cancer. Modern treatment of patients with chronic heart failure goes beyond the mere prescription of vasodilators or inotropes. The multitude of multi-organ involvements and associated symptoms unrelated to pure cardiac contractile failure, as well as the psychosocial burden for patients and their direct environment, calls for a re-engagement with the philosophical aspects of medical care. Such a process may well challenge the approach commonly taken by health care providers. We further suggest a broader and more holistic view of medical care--in this case in regard to heart failure--and one that is based on patients' and physicians' understanding of health and disease, autonomy, suffering, existential values and expectations that might positively affect treatment strategies and outcomes.

Persistent sexual dysfunction impairs quality of life after cardiac transplantation.

INTRODUCTION: The impact of sexual dysfunction (SD) on mental and physical health after heart transplantation (HTx) has not been established. AIM: We investigated the relationship of SD on quality of life (QoL), physical and mental health, and depressive symptoms after HTx. MAIN OUTCOME MEASURES: We evaluated SD according to the International Index of Erectile Dysfunction and the Female Sexual Function Index. QoL, physical and mental health were assessed using: 1) Short Form 12 Health Survey Questionnaire, 2) Quality of Life Enjoyment and Satisfaction Questionnaire--Short Form, and two depressive symptoms questionnaires: 1) Beck Depression Inventory-II and 2) Quick Inventory Depressive Symptomatology-Self Report. METHODS: We enrolled patients who were greater than 6 months post HTx. Patients unable to read English, had pelvic surgery or trauma, urogenital abnormalities, or sexually inactive were excluded. RESULTS: Out of 79 subjects that were screened, 33 men and 6 women participated (mean age 61.4 + 1.4). Response rates were at least 82% for all questionnaires. Overall prevalence of SD was 61%, with 78% of men being affected and 50% of women. There was no significant difference in measures between genders. HTx recipients with SD reported significantly worse QoL on measures of physical health when compared to those without SD. After HTx, patients suffering from SD had significantly worse general health (P = 0.02) and physical health (P = 0.02), including physical functioning (P = 0.01) and physical role limitation (P = 0.01). In contrast, mental health and depressive symptoms after HTx were not significantly different between those with and without SD. CONCLUSIONS: After HTx a high prevalence of SD remains among both men and women. Patients with SD had worse general and physical health but not depressive symptoms when compared to those without SD. The contributing factors may be more related to physical rather than psychological causes.

Erythropoiesis stimulating agents in heart failure patients with anemia: a meta-analysis.

BACKGROUND: Anemia is prevalent in patients with heart failure and an independent prognostic sign of poor outcome. The current report is a meta-analysis of published clinical trials assessing the use of erythropoeisis stimulating agents (ESA) in heart failure (HF) patients with anemia. METHODS: Literature and Medline search was performed to identify studies with control groups (case-control, cohort or randomized controlled trials) that examined the effect of ESA therapy in patients with HF and anemia. RESULTS: Seven prospective controlled trials met inclusion criteria (n = 663 subjects). The ESA studied was darbepoetin in 4 trials and erythropoietin in 3 trials. Mean follow up period ranged from 12 to 27 weeks. Compared to placebo ESA therapy was associated with improvement in six cardiovascular parameters assessed by at least three of the analyzed trials, including increase in hemoglobin levels 2.35(95% confidence interval [Cl], 1.76-2.93, P < 0.00001), increase in exercise duration 0.91(95% Cl, 0.08-1.73, P = 0.03), improvement in New York Heart Association functional class -1.46(95% Cl, -2.32 to -0.60, P = 0.0009), improvement in 6-minute walk test 1.42(95% Cl, 0.31-2.54, P = 0.01), decrease in B-type natriuretic peptide -0.54(95% Cl, -1.03 to -0.06, P = 0.03), and improvement in peak oxygen consumption 0.93(95% Cl, 0.52-1.34, P < 0.00001). CONCLUSION: In patients with heart failure and anemia, erythropoiesis stimulating agent therapy appears to have a positive effect on several important cardiovascular parameters, compared to control therapy. Large prospective randomized controlled trials are warranted to comprehensively evaluate the potential effects of erythropoiesis stimulating agents on clinical outcomes in heart failure patients with anemia.

Value of medical therapy in patients >80 years of age with heart failure and preserved ejection fraction.

Heart failure (HF) with preserved ejection fraction (EF) has a high prevalence in the geriatric population, and this cohort may be at risk of complications caused by polypharmacy. Effects of commonly used cardiac medications on long-term survival of patients >80 years with HF and preserved left ventricular EF were assessed. One hundred forty-two patients were evaluated. During a 5-year follow-up, 98 patients died (69%). There were no significant differences in baseline parameters in patients who died compared with those who survived at 5 years. None of the drug therapies appeared to make a significant difference in long-term survival, including beta blockers (p = 0.89), angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (p = 0.91), calcium channel blockers (p = 0.69), diuretics (p = 0.30), digoxin (p = 0.22), and statins (p = 0.32). In conclusion, based on the present data, it appears that use of certain common cardiac medications may not be associated with a significant effect on long-term survival in octogenarians with HF and preserved EF.