AHA offers guidance on palliative pharmacotherapy for cardiovascular disease

A scientific statement from the American Heart Association (AHA) calls for use of guideline-directed and evidence-based palliative therapies in end-stage heart failure, pulmonary arterial hypertension, coronary heart disease, and other cardiac conditions.

Patients with cardiovascular disease (CVD) can benefit from palliative pharmacotherapy, but it is underused in this population, according to a recent scientific statement from the American Heart Association.

The statement, which is intended for clinicians caring for patients with CVD, provides practical suggestions for incorporating palliative medication management and notes that palliative care reduces physical symptoms, manages emotional and spiritual distress, provides sufficient support for caregivers, and helps patients make decisions that align with their goals of care. It was published July 1 by Circulation: Cardiovascular Quality and Outcomes.

"Because adults with multiple chronic conditions are often on intricate and onerous drug regimens that may change frequently as a result of clinical instability, a multidisciplinary team approach is required to maneuver each patient's evolving circumstances and personal goals of care," the authors wrote.

Deprescribing and de-escalating are a key part of palliative medication management, the statement noted. Clinicians may consider cardiovascular drugs too essential to deprescribe, but these medications can have less value in patients with limited life spans, it said. The authors stressed that polypharmacy can be warranted if medications are evidence-based, align with goals of care, and have benefits that outweigh risks.

"It is also important to acknowledge that for some patients deprescribing could be perceived as a signal of 'giving up,' which may aggravate emotional distress. In such cases, ensuring drug safety is prudent to enable appropriate polypharmacy," the authors wrote. "This can be achieved through rational prescribing and includes selecting the most appropriate treatment based on diagnosis, prognosis, and goals, with careful monitoring for effects."

The statement provided detailed advice on managing medications for heart failure, transthyretin cardiac amyloidosis and hypertrophic cardiomyopathy, coronary heart disease, arrhythmias, and pulmonary arterial hypertension. It also provided an overview of common palliative drugs for CVD and their potential uses, including topical analgesics, nonopioid analgesics, and opioids for musculoskeletal and inflammatory pain; tricyclic antidepressants for neuropathic pain; selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, atypical antidepressants, and stimulants for depression and anxiety; atypical antidepressants, melatonin-receptor antagonists, and hypnotics for insomnia; antitussives, benzodiazepines, and opioids for dyspnea and cough; steroids and stimulants for fatigue; laxatives and antiemetics for nausea, vomiting, and constipation; and steroids, synthetic cannabinoids, and progestins for appetite stimulation.

"Clear communication from health care professionals to patients and families with regard to expected benefits and potential risks is requisite to prescribe common palliative drugs," the statement stressed. It also highlighted the importance of team-based care and specialty-aligned palliative care (SAPC), noting that the latter is underused despite guideline recommendations and that recruiting and training clinicians from underrepresented backgrounds will be critical to increasing access going forward.

"Palliative pharmacotherapy encompassing cardiovascular drugs and essential palliative medicines can be implemented across the clinical course of CVD to improve quality of life and decrease burden. Early warning signs of decompensation such as refractory symptoms and increased health care use should prompt clinicians to intensify palliative pharmacotherapy among individuals with [end-stage] CVD and refer to SAPC teams," the statement concluded. "The cardinal principles of goals of care and shared decision-making are foundational for a patient-centered approach to palliative prescribing and deprescribing."