End of Life Issues in Heart Failure Setting the Scene

1
End of Life Issues in Heart FailureSetting the
Scene

• Guy A. MacGowan
• Consultant Cardiologist with Major Interest in
  Heart Failure
• Freeman Hospital

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Heart Failure

• Incidence
• Prognosis
• Clinical Course
• Need for Palliative Care

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Summary Statistics

• 63,000 New cases/year
• 878,000 have definite or probable heart failure
  in UK at present
• 40 patients diagnosed with heart failure die
  within 1 year
• 5 of total deaths are due to heart failure
• 2 of all inpatient bed days
• Expected 50 increase in admissions over next 25
  years
• lt50 patients are treated with ACE inhbitors
• 10 treated with b-blockers
• Annual cost to health service of 625 million

Coronary Heart Disease Heart Failure Supplement
2002
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One-year survival rates, heart failure and major
cancers compared, mid-1990's, England and Wales
ONS (2001) Cowie MR et al (2000) Heart 83
505-510
www.heartstats.org
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Incidence of heart failure, by sex and age,
1995/96, Hillingdon
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Average length of hospital admission by main
diagnosis, National Health Service hospitals,
2002/03, England
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Prognosis in Heart Failure

• Many factors are related to prognosis in heart
  failure including ejection fraction,
  functional capacity, age, race, presence of
  co-morbidities
• NYHA class is a useful marker of prognosis
• Prognosis will vary widely based on degree of
  functional limitation.
• Prognosis can be significantly improved with
  evidence based therapies ACE inhibitors,
  b-blockers

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COMPANION Trial

• n 1,520 Randomized
• NYHA Class III or IV, EF lt 35, QRS gt 120 msec

Design Open-label, prospective, multi-center,
randomized Stratification To ensure equal
distribution of ?-blocker use (gt 3
months) Diuretic ACEi/ARB, Spironolactone
Randomization/ Stratification
CRT Cardiac resynchronization therapy ICD
Implantable cardioverter-defibrillator
Late Breaking Trials HFSA Sept 24, 2003 Bristow
MR, Feldman AM,
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(No Transcript)
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REMATCH

• Long-Term Use of a Left Ventricular Assist Device
  for End-Stage Heart Failure
• N Engl J Med 2001 3451435-1443,
• Nov 15, 2001

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REMATCH Eligibility Criteria

• NYHA Class IV for at least 90 days despite
  maximal medical therapy
• LVEF lt 25
• Peak VO2 ? 12 ml/kg/min or IV inotrope dependent
• Had to pass gatekeeper
• Ineligible for cardiac transplantation

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Kaplan-Meier Survival of Left Ventricular Assist
Support vs Optimal Medical Management
P0.001 OMM vs LVAS
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Sudden Cardiac Death vs Progressive Heart Failure

• COMPANION Trial NYHA Class 3-4 Heart Failure
  44 Pump failure vs 27 SCD (Carson et al, JACC
  2005)
• Risk of ICD shocks increased in patients with
  class 3 CHF with low ejection fraction (Whang et
  al, Circulation 2004)

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SCD HEFT TrialAmiodarone vs Placebo vs ICD in
mild-moderate heart failure
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Worse functional class may not benefit from ICD
(death less often due to sudden cardiac death)
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Therapies Proven to Improve Survival in Heart
Failure

• ACE inhibitors/Angiotensin Receptor Blockers
• B-blockers
• Spironolactone
• Biventricular Pacemakers
• ICDs
• Left Ventricular Assist Devices
• Transplantation
• Diuretics do not improve survival, but are
  essential in controlling symptoms

Overall we do a poor job of giving proven
therapies to patients with heart failure
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Percentage of patients with heart failure
prescribed ACE inhibitors and beta-blockers, by
age and sex, 1998, England and Wales
Ellis C et al (2001) Health Statistics Quarterly
11 17-24
www.heartstats.org
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Progression of Heart Failure
INCREASING NEUROHUMORAL ACTIVATION
Left Ventricle
Terminal Decline
Time
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Deficiencies in Cardiac Care for Heart Failure

• Despite all the advances prognosis remains poor
  and symptoms debilitating in many cases
• Recurrent hospital admissions do little to
  address the impending death of the patient

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Symptoms of Advanced Heart Failure

• Breathlessness
• pain
• abdominal fullness
• nausea
• early meal satiety
• easily fatigued, leg weakness, lack of energy,
  persistent cough, weight loss, sleep problems,
  memory problems, oedema
• anorexia
• cachexia
• ascites
• depression

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NICE Heart Failure Guidelines, 2003

• R90 Issues of sudden death and living with
  uncertainty are pertinent to all patients with
  heart failure. The opportunity to discuss these
  issues should be available at all stages of care
• R91 The palliative needs of patients and carers
  should be identified, assessed and managed at the
  earliest opportunity
• R92 Patients with heart failure and their carers
  should have access to professionals with
  palliative skills within the heart failure team

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Palliative Care Collaborative

• Northern Network of Cardiac Care
• NHS End of Life Care Programme
• Department of Health