Key elements of palliative care consist of overseeing medications, involving patients in decision-making, and focusing on specific care goals.
Incorporating patient-centered palliative care treatments, such as prescribing, adjusting, or stopping medications as necessary, can assist in symptom control and enhancing the quality of life for individuals with heart conditions. This guidance comes from the “Palliative Pharmacotherapy for Cardiovascular Disease” scientific statement by the American Heart Association, featured in the journal Circulation: Cardiovascular Quality and Outcomes.
The scientific statement assesses current data on the advantages and disadvantages of cardiovascular and crucial palliative drugs. It offers suggestions for healthcare professionals to include palliative techniques as part of a comprehensive medication management plan at all stages of a patient’s health issues, emphasizing shared decision-making and goal-focused care.
Palliative care is specialized medical assistance aimed at alleviating symptoms and improving the quality of life for individuals dealing with health difficulties caused by severe illnesses. This strategy can be beneficial for patients with cardiovascular diseases like coronary heart disease, valvular heart disease, pulmonary arterial hypertension, and heart failure — conditions that significantly affect the quality of life, require ongoing treatment, and are often progressive, with high mortality rates. The progression of many conditions, from chronic to advanced and end-stage, can be uncertain and marked by worsening symptoms that lead to recurrent hospital visits.
Palliative care works alongside standard cardiovascular care by managing physical symptoms, handling emotional distress, and supporting patients in making decisions aligned with their care goals. This approach can be integrated into the medication management plan for patients at any phase of heart disease, whether they are dealing with chronic, stable heart disease or advanced and end-stage cardiovascular disease. Additionally, palliative care promotes a more patient-focused, goal-oriented treatment approach.
Research shows that incorporating palliative care interventions into evidence-based care enhances patients’ quality of life, functional status, alleviates depression and anxiety, and improves spiritual well-being. It also reduces the likelihood of hospital readmissions for patients with advanced heart disease compared to standard clinical care. Despite these advantages, fewer than 20% of individuals with end-stage heart disease receive palliative care.
Despite significant advancements in cardiovascular care, disparities in care and outcomes persist based on race, ethnicity, gender, and social determinants of health. Patients with heart failure referred to palliative care are primarily white, have higher socioeconomic status, and are more likely to seek care at academic medical centers. Conversely, patients from underrepresented racial and ethnic backgrounds are less likely to access palliative care, leading to inferior outcomes and a higher risk of premature death.
“It is crucial for patients to be fully aware of their diagnosis and how medication management may evolve as the disease progresses so they have adequate time to establish and communicate their care goals,” commented Katherine E. Di Palo, Pharm.D., M.B.A., M.S., FAHA, chair of the statement writing group. Di Palo is the senior director of Transitional Care Excellence at Montefiore Medical Center and an assistant professor of medicine at Albert Einstein College of Medicine in New York City. “These goals often involve reducing symptoms like shortness of breath, fatigue, and pain, while also enhancing sleep, mood, and appetite.”
To achieve these objectives, medications that help alleviate symptoms, such as diuretics for managing fluid retention in heart failure, should be prioritized for patients with advanced heart disease. Introducing palliative drugs alongside evidence-based cardiovascular treatments can complement symptom management and optimize quality of life. Common palliative medications include antidepressants, opioids for pain relief and managing breathing difficulties, and anti-nausea drugs.
“Given the complexities of managing medications in individuals with heart disease, a team-based approach is essential. Collaborating across primary care, cardiology, and palliative care disciplines is necessary to provide effective, person-centered care,” Di Palo added.
Since patients’ health can change rapidly, ongoing discussions are critical to ensuring treatment plans align with their preferences and priorities. Clinicians should consistently assess — and clearly communicate — potential risks, benefits, and expected benefits of each medication to patients and their families.
Deprescribing and de-escalating medications are vital parts of palliative medication management for individuals with heart issues. Deprescribing involves tapering off, discontinuing, or stopping a medication to improve outcomes. De-escalating medications focuses on reducing the dosage or switching to another medication based on the patient’s response.
“Deprescribing strategies that target medications offering limited benefits or posing an increased risk of adverse effects can be safely implemented with patient consent,” Di Palo explained.
The statement highlights instances where deprescribing medications might be appropriate, such as when the time needed for a medication to show its benefits surpasses the patient’s life expectancy. For instance, although anticoagulants may be prescribed to reduce blood clot risks, certain medications could elevate bleeding risks, especially in older patients over 75, who are more susceptible to falls. Discontinuing nonsteroidal anti-inflammatory drugs (NSAIDs) might also be considered for end-stage heart disease patients due to increased bleeding and fluid retention risks. Despite beta-blockers being common for managing high blood pressure and heart failure, they may contribute to fatigue and functional decline in end-stage heart disease. Gradually tapering off these medications can help avoid sudden increases in blood pressure or withdrawal symptoms when abruptly stopped.
Other reasons for considering deprescribing medications include polypharmacy, where individuals take five or more medications daily. This raises the chances of adverse reactions, not adhering to medication schedules, hospital readmissions, and mortality rates. High out-of-pocket medication costs could also warrant the need for deprescribing some medications.
Further research is necessary to identify the most effective ways to provide timely and personalized access to palliative medication management, especially for patients with advanced heart disease from underrepresented racial and ethnic groups facing barriers to accessing palliative care.
