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Palliative Care In
Heart Failure
Dr Chi-Chi CheungConsultant in Palliative Medicine
19th March 2015
Overview• When does heart failure become palliative?• Heart failure therapies• Cardiac devices• Pharmacological management • Prescribing at the end of life
Follow the general principles
Heart failure admissions
• Represent 5% of all emergency admissions
• High readmission rate
• 1.8% total NHS budget • 70% of cost of heart failure care = hospital admissions
• 33% mortality at 1 year (NYHA III/IV)• 15% mortality within 30 days of hospital admission (9% in
hospital, 6% post-discharge)
End stage disease trajectory
Contrasting Dying Trajectories for (A) Obvious late decline of cancer; (B) End stage heart or lung disease with episodic crises; and (C) Dwindling course of dementia
Predictors of Poor Prognosis
• NYHA grade• Blood pressure• Diuretic resistance• Poor exercise tolerance• Inability to take ACE or ARB
• Hyponatraemia• Uraemia• Renal failure
Significant conversations
Cardiac Device Therapy
CRT = cardiac resynchronisation therapy
Deactivating ICD/CRT-D devices
But…
Medication
If rationalising meds in final phase of life, consider stopping:•Statins•Anti-platelet agents•Ca channel blockers•Nitrates
Consider switching furosemide to
bumetanide, or combining loop with thiazide
Renal Failure and Heart Failure• 17% of patients with Heart Failure have CKD stage 1
(GFR>90mls/min)• 27% have CKD stage 2 (GFR 60-89mls/min)• 40% have CKD stage 3 (GFR 30-59mls/min)• 16% have CKD stage 4 or 5 (GFR<30mls/min)
Circulation. 2004;109:1004-1009.
• A 30% rise in creatinine is expected with diuretics and ACE inhibitors
• A 50% rise in creatinine may be satisfactory• An even greater fall in GFR is expected• Therefore seek cardiology advice if uncertain
Common Symptoms• Breathlessness• Fatigue• Oedema• Postural hypotension• Pain • Poor appetite• Depression• Poor energy levels• Nausea• Cough• Fear• Syncope
NB Treat cause where
possible
Specific symptoms• Breathlessness: Morphine (reduce dose or frequency in
renal impairment, e.g. oramorph 2.5mg tds instead of 4 hourly)
• Pain: Avoid NSAIDs, pregabalin, TCAs• Nausea/vomiting: Avoid cyclizine• Depression: Avoid TCAs, venlafaxine
• Remember non-pharmacological modes of treatment• Remember laxatives with opioids!
End of life prescribing
Notes: 1. Opioid analgesic, sedative, anti-emetic, antisecretory2. Range for 24hr CSCI drugs
3. PRN drugs mirror CSCI drugs 4. PRN opioids are usually ⅙ of 24hr dose – reduce frequency in renal impairment
5. Subcutaneous furosemide may be an option
Take home messages