Palliative Care In Heart Failure Dr Chi-Chi Cheung Consultant in Palliative Medicine

1. Palliative Care In Heart Failure Dr Chi-Chi Cheung Consultant in Palliative Medicine 19th March 2015

2. Overview • When does heart failure become palliative? • Heart failure therapies • Cardiac devices • Pharmacological management • Prescribing at the end of life

3. Follow the general principles

4. 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)

5. 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

6. NYHA grade Blood pressure Diuretic resistance Poor exercise tolerance Inability to take ACE or ARB Hyponatraemia Uraemia Renal failure Predictors of Poor Prognosis

8. Significant conversations

9. Cardiac Device Therapy CRT = cardiac resynchronisation therapy

10. Deactivating ICD/CRT-D devices

11. But…

12. Medication Consider switching furosemide to bumetanide, or combining loop with thiazide • If rationalising meds in final phase of life, consider stopping: • Statins • Anti-platelet agents • Ca channel blockers • Nitrates

13. 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 Renal Failure and Heart Failure

14. Breathlessness Fatigue Oedema Postural hypotension Pain Poor appetite Depression Poor energy levels Nausea Cough Fear Syncope Common Symptoms NB Treat cause where possible

15. 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!

16. End of life prescribing Notes: 1. Opioid analgesic, sedative, anti-emetic, antisecretory 2. 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

17. Take home messages