Palliative Care Underused Among Acute MI Patients

Only about 1% of acute MI patients in the United States receive palliative care, with low rates seen even in those at highest risk of poor prognosis and death, a new analysis shows.

“Palliative care can help alleviate some of the physical and psychological discomfort of sick patients and their families, and several studies have investigated the patterns of palliative care utilization in other critical illnesses such as heart failure and stroke, but not for acute myocardial infarction,” lead author Islam Y. Elgendy, MD (Massachusetts General Hospital, Boston, MA), told TCTMD in an email. “We know from other national registries that in-hospital mortality due to acute myocardial infarction is about 5%, so our findings suggest that palliative care is underutilized in patients with acute myocardial infarction.”

Using data from the National Inpatient Sample from 2002 to 2016, Elgendy and colleagues did note an increase in penetration of palliative care over the study period for both STEMI and NSTEMI patients. But the numbers remained small overall, at just 3.9% for STEMI patients in 2016 and 2.7% for NSTEMI. Most of the increase was seen in patients who died during hospitalization. Nearly one-third of those who died in the hospital had a palliative care encounter in 2016 compared with just 1.5% in 2002 (P < 0.001).

The research was published today in the Journal of the American College of Cardiology.

Some Positive Signs

While overall rates of referral for palliative care remain low among high-risk patients, use has been slowly increasing, particularly among those with cardiogenic shock (from 0.6% in 2002 to 14% in 2016; P for trend < 0.001). This increase was accompanied by a decrease in rates of in-hospital mortality among acute MI patients, both in those with cardiogenic shock and in the overall cohort. But among the individuals who received palliative care, 53.7% died while in the hospital as compared to 5.2% of people who received no palliative care (P < 0.001), indicating it is likely being reserved for the most critically ill patients.

Still, Elgendy said the increased penetration of palliative care in acute MI is reassuring, “suggesting that there is increasing awareness among treating physicians.” The overall decreases in in-hospital mortality over time for acute MI, he added, may be a sign that palliative care is more frequently being offered to relatively lower risk patients now than it was a decade ago.

Multivariable analyses identified a number of patient-related and hospital-related factors that predicted the likelihood that acute MI patients would receive a palliative encounter.

“We found that [it] was mostly offered to older patients with multiple comorbidities (sicker patients), suggesting that the treating physicians are recognizing these ‘higher-risk’ patients and are referring them to palliative care,” Elgendy said. “We also found that palliative care was mostly utilized in larger hospitals and in urban locations, possibly since smaller and rural hospitals have no or only limited access to palliative care services.”

Other factors that influenced palliative care use were being treated with an intra-aortic balloon pump or percutaneous ventricular assist device, requiring mechanical ventilation, and not receiving PCI or systemic thrombolysis.

“We hope that this analysis would generate interest among the cardiology community to better understand the reasons and barriers behind the low utilization rates for palliative care, and how to improve this,” Elgendy observed.

In their paper, Elgendy and colleagues note that some of those barriers highlighted in previous research include lack of palliative care knowledge and skills among treating physicians, a view that intensive care and palliative care are sequential and mutually exclusive, and unrealistic expectations of patients, families, and physicians regarding treatment.