Palliative Care Is Sorely Underused for Patients With Severe Heart Failure

Fewer than one in 10 patients with severe heart failure receive palliative care, according to newly published data from the Veterans Affairs (VA) health system.

Though it’s hard to know for sure what the right percentage would be, what is clear is that a holistic approach to treating patients with heart failure who have no remaining options is currently underused, senior author Deepak L. Bhatt, MD (Brigham and Women’s Hospital, Boston, MA), told TCTMD.

The reason for that underuse is twofold, he said: lack of awareness about palliative care’s benefits and fear of giving up too soon on patients who might survive.

Cardiologists predominately aim “to save lives,” Bhatt commented. “That’s terrific—frankly, that’s what drew me to cardiology—but it’s important to realize that not everybody is going to be saved. And for people where it seems like there isn’t much more to offer in the way of really advanced therapies, palliative care is a way of making sure that their final months are comfortable.

“In the case of somebody with end-stage heart failure, whatever the etiology, . . . it’s not a particularly pleasant way to go,” he continued. “Those folks oftentimes have really marked dyspnea and really marked limitations of daily living, and focusing on making their final months or weeks comfortable is often of great solace not only to the patients but also to their families.”

Importantly, he stressed, referral doesn’t have to be “an absolutely final decision.” It can instead be a chance for a “second set of experienced eyes looking at that patient,” Bhatt said. “Sometimes doctors think, ‘What if I’m pulling the trigger too soon?’ That’s okay, because that palliative care physician will make an independent assessment about the next best step.”

Fewer Than 10% Got Palliative Care

For the paper, published as a research letter online July 6, 2016, ahead of print in JAMA Cardiology, Bhatt, lead author Anant Mandawat, MD (Duke University Medical Center, Durham, NC), and colleagues studied the trajectories of 4,474 patients with severe heart failure who were treated within the VA system over a 7-year period from 2007 to 2013. All but 1% of the patients were men.

Within 1 year of their index hospitalization, 51.2% had died and 7.6% had received palliative care. Those who received the more holistic approach were similar in age to those who did not, and the percentage of patients with LVEF less than 35% was equivalent in the two groups. Mean brain-type natriuretic peptide level was higher for the palliative care patients.

There was a significant trend over time toward increased palliative care use, rising from approximately 5.5% in 2007 to slightly more than 10% in 2013. Use was “specific,” with 72.8% of patients given palliative care dying within 1 year, Mandawat et al report, but it was “not very sensitive”—only 10.7% of patients who died within 1 year had received the added care.

Prior research has shown palliative care to be used at a rate of 17% among patients with cancer, they note.

Fellows at the Forefront

To TCTMD, Bhatt said that the study’s message likely extends beyond the VA setting. Though the exact percentage of patients receiving palliative care might vary, the overall pattern of underuse “would likely be generalizable to other populations, including those with women,” he commented. Still, Bhatt stressed, it is important to investigate the issue more broadly and in greater depth.

Palliative care specific to cardiology is likely to garner more research and attract more clinicians, as has been seen for the specialty of cardio-oncology, Bhatt predicted, adding, “A good signal a lot of times on what the future [holds] is what fellows in training are interested in doing.” Just this past year, he reported, two or three applicants to the cardiology fellowship program at Brigham and Women’s expressed interest in palliative care. “That’s something 5 years ago, I wouldn’t have heard of,” he said. “Ten years ago, I wouldn’t have even thought of that.”

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  • Mandawat A, Heidenreich PA, Mandawat A, Bhatt DL. Trends in palliative care use in veterans with severe heart failure using a large national cohort. JAMA Cardiol. 2016;Epub ahead of print.

  • Mandawat reports no relevant conflicts of interest.
  • Bhatt reports serving on the advisory boards of Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; on the board of directors of Boston VA Research Institute, Society of Cardiovascular Patient Care; as chair of the AHA Quality Oversight Committee; on the data monitoring committees of Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, and Population Health Research Institute; as site co-investigator of Biotronik, Boston Scientific, and St. Jude Medical; and as a trustee of the American College of Cardiology (ACC). He also reports receiving honoraria from the ACC (Senior Associate Editor, Clinical Trials and News,, Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), and WebMD (CME steering committees); research funding from Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Forest Laboratories, Ischemix, Medtronic, Pfizer, Roche, Sanofi Aventis, and The Medicines Company; and royalties from Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease). He additionally reports being involved in unfunded research with FlowCo, PLx Pharma, and Takeda.

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