Cardiological issues in palliative care

1. Cardiological issues in palliative care Dr Lee Graham Consultant Cardiologist/ Electrophysiologist Yorkshire Heart Centre The General Infirmary, Leeds

2. Topics • Heart failure • Implantable defibrillators • Atrial fibrillation • Angina • Pericardial effusion • Anything else you want to know

3. Heart failure

4. Burden of heart failure For the United Kingdom* 63000 new cases/year -34000 men -29000 women 875000 people have definite/probable heart failure : 473000 men : 405000 women Annual 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 Supplement British Heart Foundation/University of Oxford, 2002

5. Spectrum of symptoms in end stage heart failure patients Dying from Heart Disease Retrospective review of 600 cardiac deaths from 20 English Health districts (1990) Symptoms reported by informal carers Pain 78% Anorexia 43% Dyspnoea 61% Constipation 37% Low mood 59% Nausea/vomiting 32% Insomnia 45% Urinary incontinence 29% Anxiety 30% Faecal incontinence 16% Mental confusion 27% McCarthy et al, J. Roy. Coll. Phys Lond., (30) 325, 1996

6. Depression in heart failure • Clinically significant depression in 21% • Rates much higher with increasing NYHA class (42% in NYHA IV) • Increased readmission rates • Increased mortality Rutledge et al., JACC 2006

7. Are we contributing to the problem? • ACE inhibitor cough • Digoxin toxicity • Over diuresis • Fluid restriction • Diuretic induced incontinence • Beta-blocker lethargy • Opiate related constipation

8. Spectrum of symptoms in end stage heart failure patients Are we good at alleviating symptoms? Symptom Relief CompletePartialNone Pain 23%34%34% Dyspnoea 36%39%24% McCarthy et al, J. Roy. Coll. Phys Lond., (30) 325, 1996

9. State of the art heart failure therapy Medication Complex ‘chemotherapy’ £54.08m (2000) Intervention Revascularisation - PCI - CABG CRT ICD’s LVADS Transplantation Stem cells

10. Implications of “high technology” cardiology 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

11. End of life care for heart failure patients • Heart failure patients much more likely to die in hospital than are cancer patients • More likely to receive invasive interventions in the last few days of life • HF patients have special palliative care needs

12. Compared to Lung Cancer • “Cardiac patients received less health,social and palliative care services and care was often poorly coordinated.” • “Most people with heart failure do not understand the cause or prognosis of their disease and rarely discuss end of life issues with their carers” Murray et al., BMJ 2002

13. Why has end of life care for heart failure patients been inadequate? • Access to resources • Reliance on cancer based charities • Sheer scale of the problem • Lack of interaction between cardiologist & palliative care physician • Difficulty in predicting disease trajectory

14. Heart failure trajectory

15. Reasons for difficulty in predicting prognosis • Many different clinical scenarios • Unpredictable response to treatment • Worries that: • A precipitant has been overlooked • Alternative drug combinations might help • High incidence of sudden death

16. Sudden Cardiac Death (SCD) NYHA II NYHA III 12% 26% 59% 24% 64% NYHA IV 15% Deaths = 103 Deaths = 232 33% Sudden Death CHF Other 56% 11% MERIT-HF investigators, Lancet 1999 Deaths = 27

17. Palliative care in advanced heart failure Frameworks of care • Gold standard framework (GSF) • Liverpool care pathway (LCP)

18. Triggers for Heart Failure Integrated Care Pathway Activation CHD collaborative • NYHA III-IV • Patient thought to be in last year of life • Repeated hospitalisation with HF symptoms • Refractory physical/psychosocial symptoms despite optimal therapy

19. Triggers for Heart Failure Integrated Care Pathway Activation Liverpool care pathway • Patient bed bound • Semi-comatose • Only able to take sips of fluid • No longer able to take tablets • Not responding to maximal therapy

20. Leeds adapted LCP for inpatients with heart failure Criteria for use • Known irreversible life-threatening illness • Reversible causes for current deterioration considered and appropriately managed • ICU/resus inappropriate. ICD deactivation discussed • Day by day deterioration • Patient or team elected to withdraw from active treatment

21. Leeds adapted LCP for inpatients with heart failure • Non essential medication discontinued • Statins • Antiarrhythmics e.g. amiodarone • Anti-anginals • Essential medication continued for symptoms • Diuretics • Digoxin • Vasodilators e.g. ISMN, ACE-I • Continuous sc infusion if appropriate

22. Leeds adapted LCP for inpatients with heart failure • PRN sc medication • Pain • Nausea & vomiting • Agitation • Respiratory secretions • Dyspnoea • Discontinue inappropriate interventions • Blood tests • Antibiotics • Telemetry

23. Leeds adapted LCP for inpatients with heart failure • Insight into condition • Awareness of diagnosis • Recognition of dying • GP practice aware of patients condition • Plan of care discussed • Patient • Carer • Religious/spiritual needs • Identify how family/carers informed of death

24. Implantable defibrillators

25. Implantable Defibrillators • Expanding indications for implantation • Increasingly common in HF patients • Over 20% patients may receive a shock in the last month of life (Goldstein 2004) • Increasing relevance of device deactivation • Whilst almost all physicians agree that conversations about deactivation should occur, they rarely do so (Goldstein 2008)

26. Why discussions about ICD deactivation may not occur • Lack of time • Concern over taking away hope • Raise concerns about death • Concern over withdrawing therapy • May not result in patient death “immediately” • Small “innocuous” device Goldstein et al., 2008

27. ICD deactivation “When you start talking about ... turning it off, then you are sort of shutting off the hope.” “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” “I think that one thing is that people don’t think about [turning it off] because it’s internalized.” Goldstein et al., 2008

28. ICD deactivation Leeds perspective • ICD specialist nurse • 3 consultant electrophysiologists • All patients seen pre-implant • End of life discussions had with all patients before procedure • Further discussions surrounding deactivation if and when appropriate

29. How to deactivate an ICD • Placing a magnet over the device will deactivate all tachy therapies (ATP, shocks) without affecting pacing function • Contact cardiology SpR or on-call pacing technician for support if required

30. Atrial fibrillation

31. Atrial fibrillation

32. Atrial fibrillation • Assess your patient • Symptoms • Haemodynamic upset/ ventricular rate • Heart failure • Is there an underlying cause • Infection • Electrolyte disturbance • pericardial infiltration or effusion

33. Atrial fibrillation-acute management • Correct underlying cause if appropriate • Control ventricular rate • Beta blocker e.g. bisoprolol 2.5-5mg • Diltiazem (long acting) alternative • Digoxin if signs of heart failure • Aspirin if appropriate • Treat any associated heart failure • Phone a friend if in doubt

34. Angina

35. Angina

36. Medical management of angina • Aspirin 75-300mg daily • Clopidogrel alternative if aspirin sensitive • Beta-blockers • Bisoprolol 2.5 - 10mg daily • Metoprolol 25-50mg bd • Long acting nitrates • ISMN 30 -120mg daily • Calcium antagonists • Rate limiting e.g. diltiazem LA 2-300mg daily • Non-rate limiting e.g. amlodipine 5 – 10mg daily • Potassium channel openers • Nicorandil 10 - 30mg bd

37. Patients unable to take oral medication/tablets • Sublingual or buccal nitrates • Nitrate patches – remove at night • Beta-blocker syrups e.g. atenolol syrup • Opiates

38. Pericardial effusion

39. Pericardial effusion

40. Pericardial effusion • Often insidious and chronic in malignancy • Patients often remarkably asymptomatic • CT often overestimates size • Clinical features of tamponade are late • ECHO signs of tamponade early

41. Physical signs of tamponade • Raised JVP • Low blood pressure • Pulsus paradoxus (>10mmHg) • Soft heart sounds • Oedema

42. Pericardial effusion- management • Chronic asymptomatic effusions can be managed conservatively • Pericardiocentesis & drainage generally straightforward and safe • ? Pericardial window