Palliative Care Utilisation and Outcomes in Patients Admitted for Heart Failure in a Victorian Healthcare Service.

BACKGROUND: Heart failure (HF) has high mortality and healthcare utilisation. It has a complex and unpredictable trajectory, which is often interpreted as a barrier to guideline recommended early integration of palliative care (PC). In particular, lack of referral criteria and misconceptions around PC affect inpatient specialist PC referrals. AIMS: The main objective was to characterise the pattern and predictors of referral of HF patients to the specialist inpatient PC consultative service at our healthcare service. METHODS: A retrospective, single-centre cohort study was performed on consecutive patients admitted across the hospital with HF over a 12-month period (July 2019-June 2020). Mortality data were checked against state death registry data. RESULTS: The 502 patients admitted for HF were elderly (mean age 78±14 years), had high dependency (54% Australian-modified Karnofsky Performance Status (AKPS) 50-70, 29% AKPS 10-40), and high mortality (53% within median 32 months at death registry data linkage). Seven per cent (7%) were referred to inpatient specialist PC. AKPS 10-40 (62% of those referred vs 26% not referred, p<0.01), reliance on carers (65% vs 36%, p<0.01), and New York Heart Association (NYHA) class III-IV symptoms (86% vs 42%, p<0.01) were associated with referral, but two or more admissions in the last 12 months for HF were not (16% vs 10%, p=0.21). Many PC domains, such as symptom burden, distress, and preferred care, were not adequately assessed. CONCLUSIONS: Referral to inpatient specialist PC in hospitalised HF patients is low relative to the morbidity and mortality in these patients.

Concurrent Denosumab and Parenteral Iron Therapy Precipitating Severe Hypocalcemia and Hypophosphatemia.

Denosumab-induced hypocalcemia and iron infusion-related hypophosphatemia are both well described. We describe a case of severe hypocalcemia and hypophosphatemia following sequential denosumab and parenteral iron administration. This resulted in respiratory failure due to muscle weakness and cardiac arrhythmia, requiring noninvasive ventilation and urgent intravenous electrolyte replacement. This case highlights the severe dysregulation in calcium and phosphate homeostasis that can occur with denosumab and iron infusions when administered in quick succession. Given that these drugs are among the most common therapies prescribed across a range of specialties, we hope to alert clinicians to this potential serious drug-drug interaction and suggest strategies for monitoring and management of the electrolyte derangement.

Cognitive Dysfunction in Heart Failure: Pathophysiology and Implications for Patient Management.

PURPOSE OF REVIEW: There is increasing recognition of the prevalence and impact of cognitive dysfunction (CD) in heart failure (HF) patients. This contemporary review appraises the evidence for epidemiological association, direct pathophysiological links and emerging pharmacological and non-pharmacological interventions. Furthermore, we present evidence for care models that aim to mitigate the morbidity and poor quality of life associated with these dual processes and propose future work to improve outcomes. RECENT FINDINGS: CD disproportionately affects heart failure patients, even accounting for known comorbid risk factors, and this may extend to subclinical left ventricular dysfunction. Neuroimaging studies now provide evidence of anatomical and functional differences which support previously postulated mechanisms of reduced cerebral blood flow, micro-embolism and systemic inflammation. Interventions such as multidisciplinary ambulatory HF care, education and memory training improve HF outcomes perhaps to a greater degree in those with comorbid CD. Additionally, optimisation of standard heart failure care (cardiac rehabilitation, pharmacological and device therapy) may lead to additional cognitive benefits. Epidemiological, neuroimaging and intervention studies provide evidence for the causal association between HF and CD, although evidence for Alzheimer's dementia is less certain. Specific reporting of cognitive outcomes in HF trials and evaluation of targeted interventions is required to further guide care provision.