Palliative Care for Cardiovascular Disease

– Dr Eric Borges, Mumbai

The management of Cardiovascular Disease (CVD) using Palliative Care (PC) principles is in its infancy in India and is evolving worldwide. To commemorate ‘World Heart Day’, observed on 29th September, I am presenting my approach to this very complex field. 

The concept of Palliative Care was enunciated in the 1950’s in response to the terrible suffering that terminally ill cancer patients had to endure. It was termed end-of-life care or hospice care. This indication for PC did not change for more than 50 years until it was realized that the number of patients in the non-cancer space needing PC services, outnumbered those with cancer by a whopping 100:1.  This led to the birth of PC for patients suffering from diseases other than cancer. 

To qualify for PC, one must have an acute/chronic life limiting condition. If one reads the tea leaves, it becomes very difficult to classify or codify conditions in the Cardio Vascular (CV) disease spectrum that automatically qualifies one for PC. This is due to rapid advances in therapeutics and technology which are often game changers. 

Suffice it to say that there are 3 basic categories of CV disease that most often end up needing PC. 

  1. Heart failure due to a cause that cannot be corrected
  2. Severe coronary artery disease that produces intractable angina which is not amenable to any intervention or medical treatment 
  3. Intractable cardiac arrhythmia not responsive to any treatment with very poor quality of life (QoL)

Having classified these conditions, it must be said that every person with a serious illness should be considered as a potential candidate for palliative care which should be initiated early in the disease trajectory to get optimal results in QoL. 

The trajectory of CV diseases can be a long one and of one which is constantly extended by skilled cardiac specialists who deal with acute exacerbations which would have otherwise been fatal. These doctors often treat the disease and not the patient. 

Serious illnesses cause physical, emotional, social, financial and spiritual pain to the patient and the family. This “Total Pain” needs to be addressed by a Multi-disciplinary approach involving physicians, physiotherapists, dieticians, counsellors, occupation therapists, financial advisors and support groups. This is the essence of PC.

Individual cardiologists most often do not have the time or the training to be a palliative care physician though they could definitely be one if they so desired. 

The palliative care physician therefore becomes the hub and liaison between the patient and the specialist—conveying the wishes of the patient to the specialist and his team so that the approved plan of treatment is executed to perfection. 

This approach is common to all patients needing PC. 

I have chosen congestive heart failure (CHF) to be an index disease to illustrate and discuss PC in CVD. CHF is often associated with multiple co-morbid conditions like hypertension (HBP), Diabetes (DM), kidney disease (KD), severe anemia and so on. This makes the management more complex since these conditions need to be individually managed concomitantly with the CHF. 

Since CHF is a life limiting condition, the patient has to be educated about the disease and available therapeutic options at every stage of the disease. Realistic expectations of survival, QoL, and other important issues like emotional, spiritual and financial aspects need to be addressed. It is also very important to understand what the patient and family’s expectations and desires are, and these have to be conveyed to the PC team as their wishes should be an important component of the treatment plan. 

PC treatment can be divided into 3 different stages depending upon the severity of the CHF and symptom burden. 

Class A:

  • This patient has New York Heart Association (NYHA) I to 2 symptoms and mild to moderate Left Ventricular (LV) dysfunction.
  • This is the time to educate the patient about the disease, address co-morbid conditions, involve physiotherapists, yoga instructors, dieticians, counsellors and ensure that optimal goal directed medical therapy is initiated. 
  • It is vital to discuss the disease trajectory and the possibility of gradual deterioration or of sudden dips in the clinical condition necessitating modification of treatment protocols and goals. 

Class B:

  • The patient’s symptoms deteriorates to NYHA 2 to 3 along with a further deterioration of the LV function.
  • This may necessitate increase in medications, decrease in activities and initiation of Device Therapy in the form of Bi-ventricular Pacing to improve heart function in some patients and Implantable Converter Defibrillator (ICD) implantation to prevent sudden cardiac death (SCD).
  • The patient should be educated about the possibility of receiving shocks from the ICD and how to deal with them. Also, the issue of switching off the pacemaker and ICD should heart failure become worse and inappropriate shocks start disturbing the already compromised QoL. 

Class C:

  • Severe intractable heart failure NYHA 4 with symptoms of heart failure at rest, swelling all over the body and so on.
  • This is the stage at which for certain patients, left ventricular assist devices are recommended as a bridge to a heart transplant.
  • Needless to say that the pros and cons, the risks, QoL, life expectancy, financial implications and other issues need to be adequately addressed.
  • Despite of all these treatment modalities some patients reach end of life status. It is in this group that devices may be turned off.
  • These patients must be counselled and educated about a living will, and should be kept comfortable with oxygen and judicious use of morphine.

To conclude, I share the below take home messages:

  1. PC for CVD is complex and still evolving
  2. Start PC early in all cases
  3. Educate patients and their caregivers about realistic goals and understand their desires
  4. Take care of Total Pain
  5. Practice judicious use of devices and heart transplant
  6. Implement humane hospice care as required 

About the Author:

Dr Eric Borges is a Senior Interventional Cardiologist at Bombay Hospital, Mumbai, and the Chairman of the King George V Memorial Trust that started the Sukoon Nilaya Palliative Care Centre, Mumbai.

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