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