Aligning Pill Burden and Palliative Care Needs in Late-Stage CVD: AHA

The first scientific statement from the American Heart Association (AHA) that focuses specifically on pharmacotherapy considerations in the palliative management of patients with CVD urges a patient-centered, compassionate approach to de-escalating and deprescribing.

While prior scientific statements and some guidelines have delved into the palliative care arena when discussing the management of ACS in patients 75 and older, patients with valvular heart disease, and those with advanced heart failure (HF), the writing committee for the newest statement felt it was important to look specifically at ways of handling medication decisions from a palliative perspective across a range of common cardiovascular conditions and to provide resources to help clinicians make these decisions, said writing committee chair Katherine E. Di Palo, PharmD (Montefiore Medical Center, New York, NY).

In addition to shedding light on how and when to start deprescribing and de-escalating common cardiovascular drugs, the statement discusses palliative drugs for pain, shortness of breath, and appetite in the context of CVD, which Di Palo said the committee identified as a gap in knowledge given that much of the evidence for these drugs comes from patients with serious illnesses like cancer. Two comprehensive tables outline CVD therapies and common palliative drugs along with considerations for rational prescribing.

“We hope that the tables are a practical resource that clinicians can use,” Di Palo told TCTMD. “We wanted to really stress which cardiovascular drugs can be used to manage symptoms, even when prolonging life is no longer a priority. Also, specialty aligned palliative care is limited and not all patients may have access to specialty teams, but there are certain drugs that clinicians should be comfortable prescribing as primary palliative care.”

The scientific statement was published this week in Circulation: Cardiovascular Quality and Outcomes.

Important Takeaways

Di Palo and colleagues note that palliative care complements cardiovascular care in several important ways, including reducing physical symptom burden, managing emotional and spiritual distress, providing sufficient support for caregivers, and helping patients choose treatment in line with their goals for care.

At the end of the day, it's about patient permission and patient awareness around their trajectory. Katherine E. Di Palo

A growing concept is specialty-aligned palliative care (SAPC), which allows for comanagement by interprofessional subspecialty teams that partner with primary care physicians or other specialty clinicians. As the writing committee notes, SAPC is distinct from hospice, which in the United States is restricted to end-of-life care for those whose life expectancy is 6 months or less.

“Differentiating between patients with advanced CVD that is amenable to interventions (valve replacement, mechanical circulatory support, transplantation) and end-stage CVD (ESCVD), for which these interventions are unlikely to provide symptomatic benefit or are no longer indicated because of advanced frailty and noncardiovascular comorbidities, is also an important consideration,” they write.

When patients opt to forgo life-sustaining therapies or invasive interventions, ongoing discussions about goals and symptom relief are crucial to maintaining appropriate pharmacology and initiating palliative therapy. In some cases, patients or their families may prioritize quality of life issues such as pain, dyspnea, fatigue, mood, sleep issues, and/or appetite.

“Shared decision-making is always the key and also setting expectations with patients because medication management may change [but] it shouldn't be necessarily perceived as a sign of giving up,” Di Palo said. “At the end of the day, it's about patient permission and patient awareness around their trajectory.”

A few things that may prompt discussion about medication deprescribing include polypharmacy that triggers side effects, nonadherence, or hospital admissions; excessive out-of-pocket costs or financial toxicity; and complex drug regimens that put patients at risk for drug-drug interactions, drug-disease interactions, and medication errors.

Recognizing that some clinicians may see certain CVD drugs as too essential to deprescribe, the committee notes that in some cases these drugs “may no longer have value when continued for prevention in the setting of a limited lifespan or for an emergency issue that is now resolved.”

In addition to HF, the document addresses palliative care for transthyretin cardiac amyloidosis and hypertrophic cardiomyopathy, coronary heart disease, arrythmias, and pulmonary arterial hypertension.

Another section of the document discusses depression, anxiety, and insomnia, offering specific drug suggestions and timing. Also a common issue but one that may vex clinicians is nausea, which the committee says may affect up to half of all patients with end-stage CVD. Suggested medications and diet changes are provided.

Thirst, another frequent complaint, particularly among those with HF, is also addressed, as is the use of appetite-promoting agents for patients with lack of appetite/anorexia.

With all of these issues, Di Palo said having patients tell their clinicians what matters most to them and which symptoms are most bothersome is the key to aligning their goals with those of their healthcare team.

“For example, many CVD therapies cause drowsiness and tiredness, so if those symptoms are preventing them from doing things they love . . . we may want to taper back,” she said.

To TCTMD, Di Palo added that more research is needed to understand the intricacies of dealing with palliative care needs in a variety of CVD patient populations. But hope is high that ongoing studies coupled with patients living longer with chronic CV conditions will help fill those gaps, she said.