Expanding the Paradigm for Cardiovascular Palliative Care

Palliative Care and Advanced Cardiovascular Disease in Adults: Not Just End-of-Life Care: A Scientific Statement From the American Heart Association

Cardiovascular disease remains a leading cause of morbidity and mortality in adults despite recent scientific advancements. Although people are living longer lives, there may be an adverse impact on quality of life, necessitating a greater need for palliative care services and support. Palliative care for adults with advanced cardiovascular disease has the potential to significantly improve quality of life for individuals living with cardiovascular disease and their informal care partners. Effective communication, shared decision-making, age-friendly care principles, and advance care planning are vital components of palliative care and support comprehensive and holistic care throughout the advanced cardiovascular disease trajectory and across care settings. Current evidence highlights the benefits of palliative care in managing symptoms, reducing psychological distress, and supporting both people with cardiovascular disease and their care partners. However, significant gaps exist in palliative care research related to non-heart failure populations, care partner outcomes, and palliative care implementation in diverse populations. This scientific statement (1) discusses the application of effective communication, shared decision-making, age-friendly care, and advance care planning in advanced cardiovascular disease palliative care; (2) provides a summary of recent evidence related to palliative care and symptom management, quality of life, spiritual and psychological support, and bereavement support in individuals with advanced cardiovascular disease and their care partners; (3) discusses issues involving diversity, equity, and inclusion in cardiovascular disease palliative care; (4) highlights the ethical and legal concerns surrounding palliative care and implanted cardiac devices; and (5) provides strategies for palliative care engagement in adults with advanced cardiovascular disease for the care team.

Palliative and End-of-Life Care During Critical Cardiovascular Illness: A Scientific Statement From the American Heart Association

Cardiac intensive care units are witnessing a demographic shift, characterized by patients with increasingly complex or end-stage cardiovascular disease with a greater burden of concomitant comorbid noncardiovascular disease. Despite technical advances in care that may be offered, many critically ill cardiovascular patients will nevertheless experience significant morbidity and mortality during the acute decompensation, including physical and psychological suffering. Palliative care, with its specialized focus on alleviating suffering, aligns treatments with patient and caregiver values and improves overall care planning. Integrating palliative care into cardiovascular disease management extends the therapeutic approach beyond life-sustaining measures to encompass life-enhancing goals, addressing the physical, emotional, psychosocial, and spiritual needs of critically ill patients. This American Heart Association scientific statement aims to explore the definitions and conceptual framework of palliative care and to suggest strategies to integrate palliative care principles into the management of patients with critical cardiovascular illness.

Identifying Palliative Care Needs in Heart Failure Patients With Nurse-Led Screening

Patients with heart failure benefit from specialty palliative care but are often not evaluated for these services. The lack of standardized screening tools and limited nurse training for assessing palliative care needs are contributing factors. This quality improvement project aimed to improve the identification of unmet palliative care needs in patients with heart failure admitted to a progressive care unit by implementing a standardized nurse-administered palliative care screening tool. The nursing staff administered the Integrated Palliative Care Outcome Scale (IPOS) tool. The number of palliative consultations before project implementation was compared with those during the project. Spearman ρ was assessed for correlation between screening tool score and New York Heart Association (NYHA) heart failure class. Thirty-eight patients completed the screening tool. NYHA class was documented in 29% of patients. Among all patients, those categorized as NYHA III with heart failure with reduced ejection fraction demonstrated the highest need scores. Spearman ρ indicated a nonsignificant ( P > .05), very weak negative correlation between the IPOS scores and NYHA class ( rs = -0.18, P = .60). Implementing a nurse-administered screening tool effectively identified unmet palliative care needs among patients with heart failure with reduced ejection fraction and NYHA III. Despite low rates of palliative consults, standardization using IPOS could increase screening, contribute to institutional triggering palliative consultations, and improve awareness of unmet needs.

Advance Care Planning Challenges in Adult Congenital Heart Disease

Due to advances in congenital heart disease management, there are now more adults than children living with congenital heart disease in the United States. This population of over 1.4 million people is expected to continue to grow rapidly as a result of improving survival. However, patients with adult congenital heart disease continue to face increased rates of morbidity, hospitalizations, and medical interventions compared to the general population, in addition to elevated mortality. Therefore, comprehensive advance care planning is integral to caring for this patient population. Yet despite recommendations for early advance care planning in adult congenital heart disease, evidence suggests that it is rarely performed prior to patients' end-of-life. As demonstrated in this case, there are several challenges to advance care planning in this population which may account for this finding. Difficulty with accurate prognostication combined with the relatively young age of these patients has been reported to contribute to clinician hesitancy in initiating advance care planning prior to the onset of serious illness. Patients may have difficulty grasping their shortened life expectancy and may not feel ready to discuss serious illness care ahead of its onset. Furthermore, comorbid poor mental health and other psychosocial challenges are frequently prevalent in this population, further complicating matters. Therefore, patients with adult congenital heart disease may need more directed support with the advance care planning process, and early involvement with specialist Palliative Care can be invaluable. Further research specific to this population is needed to create a framework for successful palliative care delivery.

Preference for advance care planning in patients with pulmonary hypertension

Implementing advance care planning (ACP) is recommended in clinical guidelines. However, in pulmonary hypertension, patients' preference toward ACP remains unclear. We aimed to elucidate the preference of patients with pulmonary hypertension for ACP conversations and the association of ACP with important patient factors underlying treatment decision-making. We conducted a cross-sectional questionnaire-based study, assessing patients' preferred and actual participation in ACP conversations, as well as important patient factors underlying their treatment decision-making (including prognosis; patient values; physician recommendation; and symptom, financial, family, and social burdens). Univariate logistic regression analysis was conducted to identify patients with positive attitudes toward ACP conversations. Of 133 patients with pulmonary hypertension (median age, 60 years; mean pulmonary arterial pressure, 23 mmHg; female, 71.4%), 78.2% recognized the importance of ACP conversations. Regarding the patients' perception of appropriate ACP timing, 37.8% chose after repeated hospitalizations for worsening pulmonary hypertension and 22.4% chose during readmission for worsening pulmonary hypertension. Among these, 40.8% engaged in ACP conversations. A positive attitude toward ACP conversations was associated with marital status (married), having children, better oxygenation, and patients' preference toward physician recommendations in pulmonary hypertension treatment decision-making, but not with age, pulmonary hypertension etiology, or other patient preferences in treatment decision-making. Most patients with pulmonary hypertension preferred ACP conversations. A positive attitude toward ACP was associated with patients' preference toward physicians' recommendations in pulmonary hypertension treatment decision-making. Further research is required to establish an appropriate ACP approach that aligns with patient preference and physician recommendations for this patient population.

Navigating the Intersection of Heart Failure and Palliative Care: A Holistic Approach to Improving Quality of Life

Heart failure (HF) is a multifaceted, severe condition linked to significant emotional, physical, and social challenges that have an immense impact on the patient's quality of life. Notwithstanding the advancements in medical treatment, many HF patients experience recurrent hospitalizations, gradual functional decline, and various incapacitating symptoms. The integration of palliative care into the management of HF offers a holistic approach that addresses not only the physical symptoms but also the emotional, psychological, and spiritual needs of patients, their families, and caregivers. The integration of palliative care in HF management addresses the patients' holistic requirements, which enhances the quality-of-life outcomes for the patients through the provision of emotional and psychological support and aiding caregivers in managing the challenges associated with HF. Regardless of the acknowledged advantages of integrating PC into heart failure management, execution has largely remained poor in most healthcare services globally. The objective of this systematic review is to identify how the integration of palliative care into heart failure treatment interventions improves the quality of life for heart failure patients. To attain the set objective, we conducted an extensive search on references drawn from diverse online databases, such as Embase, PubMed, SCOPUS, Web of Science, and Google Scholar. Cross-over design studies randomized controlled trials (RCTs), systematic reviews and meta-analyses, and prospective cohort studies that focused on palliative care in heart failure patients were selected and subsequently included. From the search, 18 studies satisfied the inclusion criteria and were consequently included following evaluations using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The review disclosed that PC is effective in improving the quality of life (QoL) of heart failure patients.

Registry study of cardiovascular death in Sweden 2013-2019: Home as place of death and specialized palliative care are the preserve of a minority

Background

Palliative care needs in patients with cardiovascular diseases (CVD) are expected to increase. For the planning of equitable palliative care, it is important to understand where people with CVD die. The aim was to examine trends in place of death, associated factors including utilization of specialized palliative services, and to what extent longitudinal development is influenced by national policy.

Methods

A population-level registry study of place of death for adults deceased due to CVD (n = 209 671) in Sweden 2013-2019. Linear regression analysis was applied.

Results

The predominant place of death was nursing home (39.1 %) and hospital (37.6 %), followed by home (22.0 %). From 2013 to 2019 home deaths increased by 2.8 % and hospital deaths decreased by 3.0 %. An overall downward trend was found for dying in hospital compared to dying at home. With variations, this trend was seen in all healthcare regions and for all CVD types, except Stockholm and cerebrovascular disease, with no significant trend. Overall, but with cross-regional variations, 2.1 % utilized specialized palliative services, while 94.2 % had potential palliative care needs. Other variables significantly influencing the trend were age and having had an unplanned healthcare visit.

Conclusion

Despite a slight positive trend, only a minority of people with CVD die in their own home. Regional variations in place of death and the low and varied utilization of specialized palliative services indicate inequity in access to palliative care. Hence, the impact of current national policies is questionable and calls for strengthening through inclusion of early palliative care in specific CVD policies.

Use of Palliative Care Among Adults With Newly Diagnosed Heart Failure: Insights From a US National Insured Patient Sample

BACKGROUND

Despite the known benefits for individuals with heart failure (HF), incomplete data suggest a low use of palliative care (PC) for HF in the United States. We aimed to investigate the national PC use for adults with HF by determining when they received their first PC consultation (PCC) and the associations with clinical factors following diagnosis of HF.

METHODS AND RESULTS

We conducted a retrospective cohort study in a national all-payer electronic health record database to identify adults (aged ≥18 years) with newly diagnosed HF between 2011 and 2018. The proportion of those who received PCC within 5 years following a diagnosis of HF, and associations of time to first PCC with patient characteristics and HF-specific clinical markers were determined. We followed 127 712 patients for a median of 792 days, of whom 18.3% received PCC in 5 years. Shorter time to receive PCC was associated with diagnoses of HF in 2016 to 2018 (compared with 2010-2015: adjusted hazard ratio [aHR], 1.421 [95% CI, 1.370-1.475]), advanced HF (aHR, 2.065 [95% CI, 1.940-2.198]), cardiogenic shock (aHR, 2.587 [95% CI, 2.414-2.773]), implantable cardioverter-defibrillator (aHR, 5.718 [95% CI, 5.327-6.138]), and visits at academic medical centers (aHR, 1.439 [95% CI, 1.381-1.500]).

CONCLUSIONS

Despite an expanded definition of PC and recommendations by professional societies, PC for HF remains low in the United States. Racial and geographic variations in access and use of PC exist for patients with HF. Future studies should interrogate the mechanisms of PC underusage, especially before advanced stages, and address barriers to PC services across the health care system.

New Disease Trajectories of Heart Failure: Challenges in Determining the Ideal Timing of Palliative Care Implementation

Background: The disease trajectory of heart failure (HF), along with other organ failures, is still being elucidated. The trajectory is represented as a descending saw-tooth curve, indicating the frequent exacerbations and hospitalizations and slow progression to death. However, the clinical pattern of HF is no longer unique because of the definition of three distinct phenotypes, according to different values of ejection fraction (EF): HF with reduced EF (HFrEF), mildly reduced EF (HFmEF), and preserved EF (HFpEF). Patients with HFrEF have access to pharmacological and nonpharmacological treatments that have been shown to reduce mortality, unlike the other two classes for which no effective therapies are present. Therefore, their disease trajectories are markedly different. Methods: In this study, multiple new disease trajectories of HFrEF are being proposed, ranging from a complete and persistent recovery to rapid clinical deterioration and premature death. These new trajectories pose challenges to early implementation of palliative care (PC), as indicated in the guidelines. Results: From these considerations, we discuss how the improved prognosis of HFrEF because of effective treatment could paradoxically delay the initiation of early PC, especially with the insufficient palliative knowledge and training of cardiologists, who usually believe that PC is required only at the end of life. Conclusions: The novel therapeutic approaches for HF discussed in this study highlight the clinical specificity and peculiar needs of patients with HF. The changing model of disease trajectories of patients with HF will provide new opportunities for the early implementation of PC.

Design, Creation, and 13-Month Performance of a Novel, Web-Based Activity for Education in Primary Cardiology Palliative Care

Cardiovascular disease (CVD) clinicians who care for seriously ill patients frequently report that they do not feel confident nor adequately prepared to manage patients' palliative care (PC) needs. With the goal, therefore, of increasing PC knowledge and skills amongst interprofessional clinicians providing CVD care, the ACC's PC Workgroup designed, developed, and implemented a comprehensive PC online educational activity. This paper describes the process and 13-month performance of this free, online activity for clinicians across disciplines and levels of training, "Palliative Care for the Cardiovascular Clinician" (PCCVC). A key component of PCCVC is that it is tailored to the lifelong learner; users can choose and receive credit for the activities that meet their individual learning needs. This webinar series was well-subscribed, and upon completion of the modules, learners reported better self-perceived abilities related to palliative care competencies. We propose PCCVC as a model for primary PC education for clinicians caring for individuals with other serious or life-shortening illnesses.

Cuproptosis and copper deficiency in ischemic vascular injury and repair

Ischemic vascular diseases are on the rise globally, including ischemic heart diseases, ischemic cerebrovascular diseases, and ischemic peripheral arterial diseases, posing a significant threat to life. Copper is an essential element in various biological processes, copper deficiency can reduce blood vessel elasticity and increase platelet aggregation, thereby increasing the risk of ischemic vascular disease; however, excess copper ions can lead to cytotoxicity, trigger cell death, and ultimately result in vascular injury through several signaling pathways. Herein, we review the role of cuproptosis and copper deficiency implicated in ischemic injury and repair including myocardial, cerebral, and limb ischemia. We conclude with a perspective on the therapeutic opportunities and future challenges of copper biology in understanding the pathogenesis of ischemic vascular disease states.

When cardiovascular medicines should be discontinued

An integral component of the practice of medicine is focused on the initiation of medications, based on clinical practice guidelines and underlying trial evidence, which usually test the addition of novel medications intended for life-long use in short-term clinical trials. Much less attention is given to the question of medication discontinuation, especially after a lengthy period of treatment, during which patients age gets older and diseases may either progress or new diseases may emerge. Given the paucity of data, clinical practice guidelines offer little to no guidance on when and how to deprescribe cardiovascular medications. Such decisions are often left to the discretion of clinicians, who, together with their patients, express concern of potential adverse effects of medication discontinuation. Even in the absence of adverse effects, the continuation of medications without any proven effect may cause harm due to drug-drug interactions, the emergence of polypharmacy, and additional preventable spending to already strained health systems. Herein, several cardiovascular medications or medication classes are discussed that in the opinion of this author group should generally be discontinued, either for the prevention of potential harm, for a lack of benefit, or for the availability of better alternatives.