Timothy J. Fendler

Team-based Palliative and End-of-life Care for Heart Failure

Clinical practice guidelines endorse the use of palliative care in patients with symptomatic heart failure. Palliative care is conceptualized as supportive care afforded to most patients with chronic, life-limiting illness. However, the optimal content and delivery of palliative care interventions remains unknown and its integration into existing heart failure disease management continues to be a challenge. Therefore, this article comments on the current state of multidisciplinary care for such patients, explores evidence supporting a team-based approach to palliative and end-of-life care for patients with heart failure, and identifies high-priority areas for research.

Frequency of Poor Outcome (Death or Poor Quality of Life) After Left Ventricular Assist Device for Destination Therapy Results From the INTERMACS Registry

Background—A left ventricular assist device (LVAD) improves survival and quality of life for many, but not all, patients with end-stage heart failure who are ineligible for transplantation. We sought to evaluate the frequency of poor outcomes using a novel composite measure that integrates quality of life with mortality. Methods and Results—Within the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) national registry, poor outcome was defined as death or an average Kansas City Cardiomyopathy Questionnaire <45 during the year after LVAD (persistently limiting heart failure symptoms and poor quality of life). Among 1638 patients with LVAD, 29.7% had a poor outcome, with death in 22.4% and persistently poor quality of life in 7.3%. Patients who had a poor outcome were more likely to have higher body mass indices (29.3 versus 28.2 kg/m2; P=0.007), lower hemoglobin levels (11.1 versus 11.4 g/dL; P=0.005), previous cardiac surgery (47.8% versus 39.8%; P=0.004), history of cancer (13.8% versus 9.7%; P=0.025), severe diabetes mellitus (15.6% versus 11.5%; P=0.038), and poorer quality of life preimplant (Kansas City Cardiomyopathy Questionnaire scores: 29.8 versus 35.3; P<0.001). Conclusions—Nearly one third of patients die or have a persistently poor quality of life during the year after LVAD. We identified several factors associated with a poor outcome, which may inform discussions before LVAD implantation to enable more realistic expectations of recovery.

Incidence and Predictors of Cognitive Decline in Patients with Left Ventricular Assist Devices

Background—After left ventricular assist device (LVAD) placement for advanced heart failure, increased cerebral perfusion should result in improved cognitive function. However, stroke (a well-known LVAD complication) and subclinical cerebral ischemia may result in transient or permanent cognitive decline. We sought to describe the incidence and predictors of cognitive decline after LVAD using a valid, sensitive assessment tool. Methods and Results—Among 4419 patients in the Interagency Registry for Mechanically Assisted Circulatory Support who underwent LVAD implantation between May 2012 and December 2013, cognitive function was assessed in 1173 patients with the Trail Making B Test before LVAD and at 3, 6, and 12 months. The test detects several forms of cognitive impairment, including subclinical stroke. Cognitive decline was defined as a clinically important increase during follow-up using a moderate Cohen d effect size of 0.5×baseline SD (32 s). The cumulative incidence of cognitive decline in the year after LVAD implantation, treating death and transplantation as competing risks, was 29.2%. In adjusted analysis, older age (≥70 versus <50 years; hazard ratio, 2.24; 95% confidence interval 1.46–3.44; Ptrend<0.001) and destination therapy (hazard ratio, 1.42; 95% confidence interval, 1.05–1.92) were significantly associated with greater risk of cognitive decline. Conclusions—Cognitive decline occurs commonly in patients in the year after LVAD and is associated with older age and destination therapy. These results could have important implications for patient selection and improved communication of risks before LVAD implantation. Additional studies are needed to explore the association between cognitive decline and subsequent stroke, health status, and mortality in patients after LVAD.

Use of Heart Failure Medical Therapies Among Patients With Left Ventricular Assist Devices: Insights From INTERMACS

BACKGROUND Use of left ventricular assist devices (LVADs) for treatment of advanced heart failure has expanded significantly over the past decade. However, concomitant use of heart failure medical therapies after implant is poorly characterized. METHODS AND RESULTS We examined the use of heart failure medications before and after LVAD implant in adult patients enrolled in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) between 2008 and 2013 (N = 9359). Using logistic regression, we examined relationships between patient characteristics and medication use at 3 months after implant. Baseline rates of heart failure therapies before implant were 38% for angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), 55% for β-blockers, 40% for mineralocorticoid receptor antagonists (MRAs), 87% for loop diuretics, 54% for amiodarone, 11% for phosphodiesterase inhibitors, 22% for warfarin, and 54% for antiplatelet agents. By 3 months after implant, the rates were 50% for ACE inhibitors or ARBs, 68% for β-blockers, 33% for MRAs, 68% for loop diuretics, 42% for amiodarone, 21% for phosphodiesterase inhibitors, 92% for warfarin, and 84% for antiplatelet agents. In general, age, preimplant INTERMACS profile, and prior medication use were associated with medication use at 3 months. CONCLUSIONS Overall use of neurohormonal antagonists was low after LVAD implant, whereas use of loop diuretics and amiodarone remained high. Heart failure medication use is highly variable, but appears to generally increase after LVAD implantation. Low neurohormonal antagonist use may reflect practice uncertainty in the clinical utility of these medications post-LVAD.

Association of Smoking Status With Health-Related Outcomes After Percutaneous Coronary Intervention

Background—Patients who smoke at the time of percutaneous coronary intervention (PCI) would ideally have a strong incentive to quit, but most do not. We sought to compare the health status outcomes of those who did and did not quit smoking after PCI with those who were not smoking before PCI. Methods and Results—A cohort of 2765 PCI patients from 10 US centers were categorized into never, past (smoked in the past but had quit before PCI), quitters (smoked at time of PCI but then quit), and persistent smokers. Health status was measured with the disease-specific Seattle Angina Questionnaire and the EuroQol 5 dimensions, adjusted for baseline characteristics. In unadjusted analyses, persistent smokers had worse disease-specific and overall health status when compared with other groups. In fully adjusted analyses, persistent smokers showed significantly worse health-related quality of life when compared with never smokers. Importantly, of those who smoked at the time of PCI, quitters had significantly better adjusted Seattle Angina Questionnaire angina frequency scores (mean difference, 2.73; 95% confidence interval, 0.13–5.33) and trends toward higher disease specific (Seattle Angina Questionnaire quality of life mean difference, 1.97; 95% confidence interval, −1.24 to 5.18), and overall (EuroQol 5 dimension visual analog scale scores mean difference, 2.45; 95% confidence interval, −0.58 to 5.49) quality of life when compared with persistent smokers at 12 months. Conclusions—Smokers at the time of PCI have worse health status at 1 year than those who never smoked, whereas smokers who quit after PCI have less angina at 1 year than those who continue smoking.

Palliative Care Clinicians Caring for Patients Before and After Continuous Flow-Left Ventricular Assist Device

Left ventricular assist devices (LVADs) are an available treatment option for carefully selected patients with advanced heart failure. Initially developed as a bridge to transplantation, LVADs are now also offered to patients ineligible for transplantation as destination therapy (DT). Individuals with a DT-LVAD will live the remainder of their lives with the device in place. Although survival and quality of life improve with LVADs compared with medical therapy, complications persist including bleeding, infection, and stroke. There has been increased emphasis on involving palliative care (PC) specialists in LVAD programs, specifically the DT-LVAD population, from the pre-implantation process through the end of life. Palliative care specialists are well poised to provide education, guidance, and support to patients, families, and clinicians throughout the LVAD journey. This article addresses the complexities of the LVAD population, describes key challenges faced by PC specialists, and discusses opportunities for building collaboration between PC specialists and LVAD teams.

PREDICTING THE LIKELIHOOD FOR CORONARY ARTERY BYPASS GRAFTING IN NON ST ELEVATION MYOCARDIAL INFARCTION PATIENTS

Current ACC/AHA guidelines recommend dual antiplatelet therapy (DAPT) on presentation in patients with non ST elevation myocardial infarction (NSTEMI). This practice, however, can complicate coronary artery bypass (CABG) procedures, required in 8% to 25% of NSTEMI patients, and lead to delays in

Individualized Risk Estimates From Population Data: Should We Stop Creating Models and Start Engaging Patients?

The creation and use of disease-specific risk models to assign prognosis and predict outcomes for individual patients has pervaded health services research in the last decade. Development of such models has been driven by the increased availability of data and the need for tailoring treatment to risk, as underscored by the Institute of Medicine’s vision for patient-centered care and shared decision-making. However, despite a surplus of validated, published risk models for various disease states, and a culture of medicine that claims to emphasize transparency with patients, there is a paucity of data evaluating the implementation and clinical utility of these models from patients’ perspectives. In this issue of the Journal of Cardiac Failure, Narayan et al present a qualitative study of patients’ desires for, and reactions to, estimates of their predicted survival based upon the Seattle Heart Failure Survival Model (SHFM). Though the SHFM was created over a decade ago, to our knowledge this study represents the first attempt to assess how valuable a personalized estimate of prognosis is to patients. The authors should be lauded for their efforts, since a primary goal for all predictive models should be to inform patients of their prognosis as a foundation for treatment planning and shared decision-making. Of 26 patients approached for this qualitative research study, 24 agreed to participate and 17 wished to see their individualized survival estimates. Nine of the 17 did not feel it increased their anxiety to see their projected life expectancy and 15 of the 17 felt it was useful to review their results with a provider. It is both reassuring and in keeping with prior literature to know the majority of patients didn’t feel increased anxiety after seeing their results. However, nearly 40% of patients either felt that viewing their results was not useful or did not want to view the results in the first place. This begs the question—what makes a risk model valuable, from the patient’s perspective? Narayan and colleagues offer several important insights into patients’ perceptions of receiving risk estimates to inform healthcare decisions. First, the majority of patients expressed not only a desire to receive such estimates, but also a desire to receive them repeatedly over time as a “useful benchmark for how things are going”. Meeting this need requires a tectonic shift in the current practice of medicine, in which the infrastructure for generating and discussing prognosis needs to become more standardized. While electronic medical records could conceivably be programmed to regularly execute and update risk estimates, most currently do not do so. Moreover, it is not clear what models are most valid and useful. We would propose that guidelines committees move beyond the generic articulation of the importance of sharing patients’ prognoses with them to emphasizing the need both to identify the best and most valid models to use and to create the capacity of EMRs to integrate these into clinical documentation and patient portals. Second, patients in the study did not feel that the model results were personalized to them, despite the fact that the SHFM explicitly integrates a number of patient-specific factors to personalize survival estimates. Though the SHFM performs well at the population level, its ability to predict individual one-year survival has been previously questioned. This shortcoming notwithstanding, the failure of patients to understand that these estimates were, in fact, specific to them, highlights the need to better explain to patients what a risk model represents. Furthermore, the SHFM does not integrate important factors such as patients’ psychosocial and socio-economic status; this highlights the need to continually test, update and improve clinically-implemented risk models as new advancements in knowledge are achieved through research. Our group has created a number of risk models that do include more patient-specific health, psychosocial, socio-economic and stress variables, but many of these predictors are not routinely collected in registries and trials. They would need to be, in future studies, for patients to believe From the Saint Luke’s Mid America Heart Institute/UMKC, Kansas City, Missouri. Manuscript received February 10, 2017; revised manuscript accepted February 10, 2017. Reprint requests: John A. Spertus, MD, MPH, Saint Luke’s Mid America Heart Institute, 4401 Wornall Rd., Kansas City, MO 64111. Tel: +816 932 5613; Fax: +816 932 5179. E-mail: spertusj@umkc.edu See page ■■ for disclosure information. 1071-9164/

Frequency of Poor Outcome (Death or Poor Quality of Life) After Left Ventricular Assist Device for Destination TherapyClinical Perspective

see front matter

Frequency of Poor Outcome (Death or Poor Quality of Life) After Left Ventricular Assist Device for Destination TherapyClinical Perspective: Results From the INTERMACS Registry

Background—A left ventricular assist device (LVAD) improves survival and quality of life for many, but not all, patients with end-stage heart failure who are ineligible for transplantation. We sought to evaluate the frequency of poor outcomes using a novel composite measure that integrates quality of life with mortality. Methods and Results—Within the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) national registry, poor outcome was defined as death or an average Kansas City Cardiomyopathy Questionnaire <45 during the year after LVAD (persistently limiting heart failure symptoms and poor quality of life). Among 1638 patients with LVAD, 29.7% had a poor outcome, with death in 22.4% and persistently poor quality of life in 7.3%. Patients who had a poor outcome were more likely to have higher body mass indices (29.3 versus 28.2 kg/m2; P=0.007), lower hemoglobin levels (11.1 versus 11.4 g/dL; P=0.005), previous cardiac surgery (47.8% versus 39.8%; P=0.004), history of cancer (13.8% versus 9.7%; P=0.025), severe diabetes mellitus (15.6% versus 11.5%; P=0.038), and poorer quality of life preimplant (Kansas City Cardiomyopathy Questionnaire scores: 29.8 versus 35.3; P<0.001). Conclusions—Nearly one third of patients die or have a persistently poor quality of life during the year after LVAD. We identified several factors associated with a poor outcome, which may inform discussions before LVAD implantation to enable more realistic expectations of recovery.