| 9 | Prognosis |
Diagnosis of heart failure (HF) carries a poor prognosis, often comparable with that of cancer. The annual mortality for mild-to-moderate HF (NYHA class II or III) is 24–28%, and increases to 50% in patients with severe NYHA class IV symptoms. Hospital admission with acute HF is a strong and independent predictor of worse prognosis, and is associated with 2–4% in-hospital and 5–15% 90-day mortality. Between 30% and 50% of patients with acute HF are readmitted within 6 months, although 50% of these readmissions are due to comorbidities, often associated with advanced age, rather than existing HF.
Prognosis of HF in individual patients is challenging as a number of independent variables must be considered, including symptoms, severity, etiology and type of HF. The fact that sudden death can occur at any stage of the disease makes the prognostic process even less predictable. In general, patients with NYHA class IV symptoms, and HF caused by infiltrative heart disease, HIV infection or anthracycline toxicity, with systolic left ventricular (LV) or biventricular dysfunction, have the worse prognosis.
Outcomes are poor when the intensity of HF treatment is low and the patient does not adhere to the medications prescribed. Comorbidities (e.g. renal disease, diabetes mellitus), advanced age, male sex and ethnicity all contribute to worse outcomes.
Several clinical and laboratory markers of poor prognosis have been validated (Table 9.1). Other identified factors of reduced survival in patients with HF include attenuated response to diuretics, low peak oxygen consumption (VO2max) or short distance in the 6-Minute Walk Test (6MWT), a large burden of ventricular ectopy and complex ventricular arrhythmia, significant pulmonary hypertension, new-onset atrial fibrillation and specific echocardiographic features (significant LV dyssynchrony, evidence of ongoing remodeling and a marked increase in left atrial volume).
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TABLE 9.1 Clinical and laboratory markers of poor prognosis* |
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Cardiac function • LVEF < 20% (mortality doubles when LVEF drops from 35% to 17%) |
• Abnormal RV systolic function |
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Hospitalization for heart failure • Almost threefold increase in risk of death within 12 months of discharge |
• Highest risk within 1 month of discharge |
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Hypotension • Low mean arterial blood pressure (a 10-mmHg decrease is associated with an 11% increase in risk) |
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Low eGFR and serum sodium level • Impaired renal function (e.g. cardiorenal syndrome and hyponatremia) |
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Conduction disease • Marked prolongation of QRS (> 150 ms) on surface ECG with evidence of LBBB morphology |
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Clinical findings • S3 gallop (a third heart sound) • Persistently elevated JVP |
• Elevated resting heart rate • Weight loss |
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Neurohormones • Chronically elevated plasma levels of norepinephrine (noradrenaline), epinephrine (adrenaline) and aldosterone |
• High plasma renin activity • Elevated BNP level • Elevated troponin levels |
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Autonomic dysfunction • Reduced heart rate variability • Poor baroreflex sensitivity • Increased central and peripheral chemoreflex activation |
• Activation of skeletal muscle ergoreceptors |
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Others • Depression • Hypoalbuminemia |
• Hyperuricemia • Hypocholesterolemia |
*Reduced survival or higher mortality. BNP, type B natriuretic peptide; eGFR, estimated glomerular filtration rate; JVP, jugular venous pressure; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; RV, right ventricular. |
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Initial assessment in patients with HF should include a review of the prognosis but, importantly, a search for reversible factors contributing to disease progression (Table 9.2). If any of these problems are identified, prompt and comprehensive treatment should improve HF symptoms, in many cases arrest disease progression and improve prognosis.
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TABLE 9.2 Reversible factors that contribute to disease progression |
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• Non-adherence to treatment • Cardiac arrhythmia • Myocardial ischemia • Arterial hypertension • Cardiac dyssynchrony |
• Thyroid disease • Alcohol abuse • Type 2 diabetes mellitus • Obstructive sleep apnea |
Palliative care improves the quality of life of patients and their families facing the problems associated with life-threatening illness. This is accomplished by the prevention and relief of symptoms, including early identification, assessment and treatment of pain and other physical, psychosocial and spiritual problems (Table 9.3).
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TABLE 9.3 The principles of palliative care |
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• Provides relief from pain and other distressing symptoms • Affirms life and regards dying as a normal process • Intends neither to hasten nor postpone death • Integrates the psychological and spiritual aspects of patient care • Offers a support system to help patients live as actively as possible until death • Offers a support system to help the family cope during the patient’s illness and in their own bereavement • Uses a team approach to address the needs of patients and their families • Enhances quality of life and positively influences the course of illness • Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life and includes those investigations needed to better understand and manage distressing clinical complications |
Adapted from the WHO 2004 definition of palliative care; available at www.who.int/cancer/palliative/en, last accessed 12 May 2017. |
The quality of life of patients with advanced HF refractory to optimal pharmacological and non-pharmacological strategies can be very poor and comparable with that of patients with terminal malignancies, with a case–fatality rate of 75% over 5 years overall.
In general, an illness trajectory for HF can provide a broad estimate of timeframe and help to predict patterns of need and interaction with health and social services (Figure 9.1).
Figure 9.1 Illness trajectory, showing the distinct stages of clinical heart failure. (1) The overall stable functional status of chronic disease management. (2) Palliative and supportive care, during which clinical exacerbation leads to progressive deterioration in physical functioning. (3) Terminal care. Adapted from Goodlin SJ. 2009.
In practical terms advanced HF can be divided into three distinct stages:
• chronic disease management
• palliative and supportive care
• terminal care.
Chronic disease management strategies include education, monitoring, prevention and effective therapy (see earlier chapters). They are used to prolong life, prevent HF hospitalization and provide symptomatic relief. Intervention should be delivered using the protocols of locally available HF management programs. Patients and their families (carers) should be fully informed about the nature of the disease including treatment and prognosis, with regular monitoring and appropriate review.
Palliative and supportive care may begin following readmission to hospital with HF. A careful review of the patient’s symptoms and all the available treatment options should be performed by the specialist in consultation with the patient’s family practitioner and a palliative care specialist, using robust clinical identifiers of poor prognosis (Table 9.4).
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TABLE 9.4 Identifiers of patients with advanced heart failure and poor prognosis |
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• Patient with consistent NYHA class IV HF – unable to undertake physical activity without discomfort – symptoms of chronic HF present at rest – severe chronic HF and • Not suitable for any further procedures, such as: – revascularization with coronary bypass surgery – coronary angioplasty – valve surgery – cardiac resynchronization therapy (biventricular pacing [BiV-P]) – heart transplantation plus, at least one of: • increasing HF symptoms despite maximum tolerated HF therapy, including diuretics, ACE inhibitors and beta-blockers, as indicated • worsening or irreversible end-organ damage (including cardiac cachexia) • repeated hospital readmissions with deteriorating HF, ventricular arrhythmias or cardiac arrest |
ACE, angiotensin-converting enzyme; HF, heart failure; NYHA, New York Heart Association. |
If the patient assessment indicates the need for palliative care, management should shift to symptom control (Table 9.5). Patients and their families or carers may require assistance in negotiating the change in goals of care from prolongation of life to improvement of quality of life by maximizing comfort and dignity. Time should be set aside to discuss the prognosis, course of the illness and palliative-care strategies in detail with the patient and carer. A program of care individualized to the needs of the patient and their family is extremely important. Palliative-care strategies should build on, rather than replace, multidisciplinary programs of care that optimize advanced HF management. Properly applied, they can cut the overall cost of care by reducing the amount of time patients spend in acute-care settings.
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TABLE 9.5 Management of symptoms in the palliative-care phase of advanced heart failure |
Dyspnea • Assess all causes and exclude reversible reasons • Involve physiotherapist in review of breathing techniques • Offer psychological support • Consider anxiety therapy • Include relaxation techniques • Provide fans and recliner beds • Use of home oxygen • Introduce opioids with oral morphine initially, 2–3 mg, and titrate according to response; initial use when required, may change to long-acting (always use prophylactic laxatives) • Set up nebulizers – with saline and bronchodilators • Consider glyceryl trinitrate and sublingual lorazepam |
Nausea and vomiting • Exclude drug(s) as a cause • If constant, start haloperidol, 1–3 mg orally, olanzapine or levomepromazine • If meal-related, introduce metoclopramide, 10 mg tds • Review delivery methods; administer subcutaneously if symptoms persist or patient is vomiting |
Pain • Perform full assessment of cause • Introduce an oral opioid with slow dose titration (use prophylactic laxatives) • Exclude and/or treat gout • Avoid NSAIDs |
Mood disorder/anxiety/insomnia • Consider antidepressants (sertraline, citalopram, mirtazapine) but avoid tricyclics • Use night sedation with lorazepam or temazepam (if indicated) • Start anxiolytics – lorazepam or diazepam if anxiety is a large component • Explore underlying psychosocial and spiritual issues |
Peripheral edema • Continue primary therapy with diuretics unless resistant to therapy • Use emollients for the involved skin • Consider bandaging with gradual pressure in massive edema • Involve OT techniques (appropriate posture and rest) and massage • Provide scrotal supports (if indicated) |
NSAID, non-steroidal anti-inflammatory drug. OT, occupational therapy; tds, three times daily. |
Clear communication with community-care providers and family members should always precede any changes in direction or content of care provided by the treating team. An advance care plan is often documented and the ways of managing future clinical deterioration discussed with the patient. Carers should be included in the management plans.
Advanced health directive. Recognizing that the outcomes of resuscitation in patients with advanced HF are dismal, individuals should be empowered to express their treatment preferences even when unable to speak for themselves. The existence and process of obtaining such a legal document should be discussed with the patient and their carers early in the course of advanced HF.
Medication withdrawal. As the patient’s condition deteriorates, the healthcare team should discuss any changes to the goals of medical therapy with the patient and family. This inevitably will include review of the current medical therapy and termination of non-essential drugs. The list includes but is not limited to statins, acetylsalicylic acid (ASA; aspirin) and warfarin, vasodilators and beta-blockers (especially in patients with low blood pressure), aldosterone antagonists, anti-anginals and other therapies for comorbidities.
Device deactivation. Automatic implantable cardiac defibrillators (ICDs) have become a common therapeutic option in suitable patients with severe HF. They can help prevent sudden cardiac death, but in advanced HF they can become a potential cause of distress when incessant ventricular rhythms develop. In these circumstances, the patient’s quality of life should be paramount, and in many instances deactivation of the device may need to be discussed. To prepare patients and their families for such meetings, many physicians explore these issues at the time of implantation and continue to monitor the patient’s status during follow-up visits. If progression to advanced HF becomes clear, it is suggested that discussion regarding deactivation of the ICD function should take place. In many instances the ‘not-for-resuscitation’ status and arrangements for terminal care are also reviewed at this time (see below).
Terminal care continues as the patient presents with intractable HF, with resting symptoms, poor appetite, weight loss, slow mental activity and low blood pressure with end-organ failure (e.g. kidney failure). Therapy for symptom control should continue. The patient’s resuscitation status should be reviewed with the patient and carer, and documented. Carers will require increased practical and emotional support, followed by bereavement support.
• Heart failure (HF) has a poor prognosis with an annual mortality of 25–50% depending on severity of symptoms and left ventricular (LV) systolic dysfunction.
• Poor prognostic signs include impaired renal function, marked prolongation of QRS, hypotension and hyponatremia.
• The search for reversible factors is always indicated.
• The model of palliative care for advanced HF needs to be very flexible, individualized to the needs of the patient and their family.
• Good communication skills are the key to effective palliative care delivery.
• Primary care, cardiology and palliative care teams should work in collaboration to deliver an effective phase-specific treatment in advanced HF.
• End-of-life planning and decision making are essential and should be discussed early in the process.
References
Ayach B, Malik A, Seifer C, Zieroth S. End of life decisions in heart failure: to turn off the intracardiac device or not? Curr Opin Cardiol 2017;32:224–8.
Goodlin SJ. Palliative care in congestive heart failure. J Am Coll Cardiol 2009;54:386–96.
Jaarsma T, Beattie JM, Ryder M et al. Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2009;11:433–43.
McIlvennan CK, Allen RA. Palliative care in patients with heart failure. BMJ 2016;358:1010.
Meyers DE, Goodlin SJ. End-of-life decisions and palliative care in advanced heart failure. Can J Cardiol 2016;32:1148–56.
Piepoli M. Diagnostic and prognostic indicators in chronic HF. [Editorial] Eur Heart J 1999;20:1367–9.
