Advanced Cardiac Disease

Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
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Physicians
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CME Provider Information

VITAS® Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through:
VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board
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are provided CE credit for their Social Workers through VITAS Healthcare Corporation, provider #1222, is approved as a provider for social
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participating in these courses will receive 1 clinical continuing education clock hour. {Counselors/MFT/IMFT are not eligible in Ohio}.
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Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and
provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education
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completing this course receive 1.0 continuing education credits.
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No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.
CE Provider Information

To leverage evidence-based data and case studies to understand
hospice eligibility and benefits for patients with advanced cardiac
disease (ACD) who have a prognosis of ≤ 6 months.
Goal

By the end of this presentation, you should be able to:
• Recognize the burden associated with heart failure
• Identify patients with advanced heart failure who are
eligible for hospice through evidence-based research
• Understand palliative interventions for patients with
advanced cardiac disease
• Understand the role of advanced technologies in
end-of-life care
Objectives

41.3%
17.2%
9.9%
11.7%
2.8%
17.3%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
Coronary Heart Disease
Stroke
Heart Failure
High Blood Pressure
Diseases of the Arteries
Other
Percent of Total CVD Deaths
• Heart disease is the #1 cause of
death in the US in 2021, followed
by cancer and COVID-191
• 30-day post-discharge mortality for
Medicare beneficiaries with heart
failure is 8.7%. Heart failure patients
also experience more post-discharge
visits to the ED2
• About 697,000 people in the United
States died from heart disease in
2020—that’s 1 in every 5 deaths.3,4
1Xu, et al. (2022). Mortality in the United States, 2021. NCHS Data Brief No. 456. Available at:
https://www.cdc.gov/nchs/products/databriefs/db456.htm#:~:text=Heart%20disease%2C%20cancer%2C%20and%20COVID,100%2C000%20live%20births%20in%202021.
2
Khera, et al. (2020). Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States. British Medical Journal, 368:6831.
3Centers for Disease Control and Prevention, National Center for Health Statistics. (2022) About Multiple Cause of Death, 1999–2020. CDC WONDER Online Database website. Atlanta, GA: Centers for Disease Control and Prevention.
4Tsao, et al. (2022) Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association. Circulation. 145(8):e153–e639.
5
American Heart Association. (2022). 2022 Heart Disease and Stroke Statistics Update Fact Sheet At-a-Glance. Available at: https://www.heart.org/-/media/PHD-Files-2/Science-News/2/2022-Heart-and-Stroke-Stat-Update/2022-
Stat-Update-At-a-Glance.pdf
Percentage Breakdown of US Deaths Attributable
to Cardiovascular Disease, 20195
Heart Disease in the US

0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
38
40
42
44
46
48
50
2015 2017 2019 2021 2023 2025 2027 2029 2031 2033 2035
Percent
of
US
Population
Projected Prevalence of Stated Disease (2015-2035)
CHD CHF Stroke
Any CVD
Heart Disease Prevalence
American Heart Association. (2017). Cardiovascular disease: A costly burden for America projections through 2035.

Heart Disease as Primary Hospice Diagnosis
• In 2020, circulatory/heart disease (excluding stroke)
was the second most common principal diagnosis
for patients enrolled in hospice, with over
160,000 Medicare decedents receiving care
• The median lifetime length of hospice care
received by this population was 33 days
• The most common hospice diagnoses were
Alzheimer’s/dementia, and Parkinson’s
Heart Disease and Hospice
1
NHPCO. (2021). Facts and Figures: Hospice Care in America.

The Burden of Heart Disease on the US Health System
Adapted from American Heart Association. (2017). Cardiovascular disease: A costly burden for America projections through 2035.
Current 2035
Total Direct
(Medical) Costs
$318
billion
$749
billion
Total Indirect
Costs
$237
billion
$368
billion
Projections – CVD Direct and
Indirect Costs Through 2035
$0
$50
$100
$150
$200
$250
2015 2035
Billions
of
Dollars
Projected CVD Direct and Indirect Costs Through 2035 by Condition
Direct. Indirect
CHD CHF Stroke Other

• 80% with HF are hospitalized
in the last 6 months of life
• Hospital readmission is
21.4% within 30 days
• Almost 50% of patients die
within 5 years of HF diagnosis
Heart Failure Hospital Utilization in the
Last Year of Life
1
Benjamin, et al. (2019) “Heart disease and stroke statistics—2019 update: a report from the American Heart Association.” Circulation 139.10 (2019): e56-e528.
2Alghanem et al. (2020) Narrowing performance gap between rural and urban hospitals for acute myocardial infarction care. Am J Emerg Med. 38(1):89-94.
• The number of hospitalizations and days hospitalized prior to death are displayed
for 486 decedents with at least a full year of follow-up from heart failure diagnosis
until death
0
50
100
150
200
250
300
350
331-365 301-330 271-300 241-270 211-240 181-210 151-180 121-150 91-120 61-90 31-60 0-30
Number
of
Hospitalizations
Hospitalizations Days in Hospital
• Healthcare utilization increases as patients near the end of life
• Hospitalizations are most common among home patients and
those with multiple comorbidity, such as PVD, DM, COPD

Most common symptoms of heart failure2
Shortness of breath, pain, feeling drowsy/tired,
worry, irritability, feeling sad, being nervous
The Burden of Heart Failure on Patients – Symptoms
1
Bekelman, et al. (2009). Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients. Journal of General Internal Medicine, 24(5), 592-598.
2Riley, et al. (2017). Palliative Care in heart failure: facts and numbers. ESC Heart Failure, 4:81-87.
3Alpert, et al. (2017). Symptom burden in heart failure: assessment, impact on outcomes, and management. Heart Fail Rev, 22:25-39.
Outcome1 Heart Failure
Low EF
Heart Failure
Normal EF
Advanced Cancer
Number of Physical Symptoms 9.4 8.7 8.7
Depression Score 3.6 4.3 3.2
Spiritual Well-Being 35.2 36.3 39.1
Common (and easily missed) symptoms3
pain, dyspnea, depression, nausea,
constipation, anorexia, fatigue

• Approximately 41.8 million
Americans have provided
unpaid care to an adult age
> 50 in the last 12 months
• Those in high-intensity
caregiving situations more
often report high physical
strain (29%) and higher
emotional stress (49%)
The Burden of Heart Failure on the Family
National Alliance for Caregiving and AARP (2020). Caregiving in the US 2020.
As a result of providing care to your [relation], have you ever experienced
any of these financial Things?
2020 Base: Caregivers of Recipient Age 18+ (n=1,392)
Note: Respondents may select more than one response; results add to greater than 100 percent
Top Financial Impacts as a Result of Caregiving
15%
19%
22%
23%
28%
34%
45%
Borrowed money from family or friends
Left your bills unpaid/paid them late
Use up your personal short-term saving
Took on more debt
Stopped saving
2+ financial impacts
Any of these
% Yes

The Burden of Heart Failure on the Family (cont.)
Kitko, et al. on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and
Outcomes Research; Council on Clinical Cardiology; and Council on Lifestyle and Cardiometabolic Health. (2020). Family Caregiving for
Individuals with Heart Failure. Circulation. 2020;141:e864–e878. DOI: 10.1161/CIR.0000000000000768
Multidimensional Burden
• Increased responsibilities
and tasks
• Social isolation
• Financial strain
• Loss of former identity
• Decreased quality of life
Physical Health
• Neglected management
of own health
• Fatigue
• Sleep disruption
• Increased mortality
Psychological Health
• Anxiety
• Depression
• Hypervigilance
• PTSD symptoms
• Coping
Rewards
• Accomplishment
• Satisfaction
• Meaning
Known Relationship-Level Outcomes
• Communication challenges
• Concealment of symptoms/feelings
• Conflict or resentment
• Effects on relationship quality
(strengthened or stressed)
• Changes in sexual
relationship (couples)
Known Caregiver Influence
on Patient Outcomes
• Increased quality of life
• Adherence
• Increased physical function
• Emotional well-being
• Decreased healthcare utilization

Clinical Course of Heart Failure
Mclluennan, et al. (2016). Palliative care in patients with heart failure. British Medical Journal, 6:352.
Transition to Advanced Heart Failure
• Oral therapies
• A time for many major decisions
• Consider MCS and/or
transplantation (if eligible)
• Consider inversion of care plan
to one dominated by a palliative
approach, which may involve
formal hospice
Clinical course
Traditional care: including
disease-modifying therapies
Palliative care: including
symptom management

Class Functional Capacity
I
No limitation of physical activity. Ordinary physical activity does not
cause undue fatigue, palpitation, or dyspnea (shortness of breath).
II
Slight limitation of physical activity. Comfortable at rest. Ordinary
physical activity results in fatigue, palpitation, or dyspnea
(shortness of breath).
III
Marked limitation of physical activity. Comfortable at rest. Less
than ordinary activity causes fatigue, palpitation, or dyspnea.
IV
Unable to carry on any physical activity without discomfort.
Symptoms of heart failure at rest. If any physical activity is
undertaken, discomfort increases.
NYHA Classification of Heart Failure
American Heart Association. (2020). Classes of Heart Failure. Retrieved from: https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/classes-of-heart-failure

Stages of Heart Failure
Heidenreich, et al. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
Journal of the American College of Cardiology 79.17 (2022): e263-e421.
Stage A
At-Risk for Heart Failure
Stage B
Pre-Heart Failure
Stage C
Symptoms Heart Failure
Stage D
Advanced Heart Failure
Patients at risk for HF but
without current or previous
symptoms/signs of HF
and without structural/
functional heart disease or
abnormal biomarkers
Patients with hypertension,
CVD, diabetes, obesity,
exposure to cardiotoxic
agents, genetic variant
for cardiomyopathy, or
family history of
cardiomyopathy
Patients without current
or previous symptoms/
signs of HF but evidence
of 1 of the following:
Structural heart disease
Evidence of increased
filling pressure
Risk factors and
• increased natriuretic
peptide levels or
• persistently elevated
cardiac troponin in
the absence of
competing diagnosis
Patients with current
or previous
symptoms/signs
of HF
Marked HF symptoms that
interfere with daily life and
with recurrent hospitalizations
despite attempts to
optimize GDMT

HF Outcomes by Type
1Gotsman, et al. (2012). Heart failure and preserved left ventricular function: long term clinical outcome. PLoS One, 7(7), e41022.
2Shah, (2017) et al. Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology. 70.20: 2476-2486.
18.7
15.1
11.9
9.1
6.8
5
3.6
2.9
2.3
1.7
1.2
0.8
3.3
2.8 2.6
1.8
1.3 1
4
3.4
2.6
2.2
1.5
0.9
0
2
4
6
8
10
12
14
16
18
20
Median
Survival
in
Years
Median Survival Stratified by Age
Life Expectancy in US HFrEF Patients HFbEF Patients HFpEF Patients

Isolation in Heart Disease
Lee, et al. (2021). Social Isolation and All-Cause and Heart Disease Mortality Among Working-Age Adults in the United States: “The 1998–2014 NHIS–NDI Record Linkage Study.” Health Equity. 5.1; 750-761.
Cumulative Mortality Incidence Function for US Adults Aged 18–64

HF Functional Status and Survival
Creber, et al. (2019). Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart failure. ESC Heart Failure, 6(2), 371-378.
PPS
Score
Ambulation
Activity and
Evidence
of Disease
Self-Care Intake
Conscious
Level
60 Reduced
Unable to do
hobby/housework
Significant disease
Occasional
assistance
necessary
Normal
or
reduced
Full
or
confusion
50
Mainly
sit/lie
Unable to do
any housework
Extensive disease
Considerable
assistance
required
40
Mainly
in bed
Unable to do
most activities
Extensive disease
Mainly
assistance Full or
drowsy
+/-
confusion
30
Totally
bedbound
Unable to do
any activities
Extensive disease
Requires
total care
• Patients with a PPS score of ≤ 50 are generally hospice-eligible; some patients with a higher PPS may also be eligible

Hospice Eligibility Guidelines for ACD
NYHA Class III as manifested
by any of the following symptoms
during less-than-normal activity:
NYHA Class IV as
manifested by any of the
following symptoms:
• Fatigue
• Dyspnea and/or other symptoms at
rest or minimal exertion
• Palpitations
• Inability to carry out physical activity
without dyspnea and/or other symptoms
• Angina or dyspnea
• If physical activity is undertaken,
symptoms worsen
• Plus significant comorbidities
• Patient is optimally treated for heart
disease or maximally treated and
not pursuing surgical options

• Significant/supporting comorbidities:
– Hypertension
– Diabetes
– Coronary artery disease
– Prior myocardial infarction
– Valvular heart disease
Hospice Eligibility Guidelines for ACD (cont.)
• Indicators of poor prognosis:
– Renal dysfunction
– Cachexia
– Valvular regurgitation
– Ventricular arrhythmias
– Low left ventricular ejection
fractions (LVEF)
– Elevated B-type natriuretic
peptides (BNP)
– Low serum sodium
– Marked left ventricular dilatation
– Syncope and near-syncope

• Hospice admission guidelines
are independent of labs and EF
• The question to ask oneself:
“Would I be surprised if the
patient were to die in the
next year? 6 months?”
• Key indicators for a hospice referral:
– Decrease in function
– Increase in patient
symptoms and distress
– Frequent/increased utilization
of medical care, especially
hospitalization and ED visits
• Start the conversation
Hospice Eligibility Guidelines for ACD (cont.)

• 76-year-old female compliant with cardiologist and PCP follow-ups. PMH: NYHA
Class III/IV HFpEF, LV EF 48%, AFIB, hypertension, COPD, dementia
Case of AM
– Weight loss >5% over past
month, diffuse muscle wasting
– Current medications: diuretics,
ACE inhibitor, oxygen, nebulizers
– BP 92/64, HR 108 bpm, RR 22,
pulse ox 93% 2L NC, afebrile
– In the last 6 months, AM has had
increased visits to office due to
intensifying HF symptom
burden and recent fall.
– Symptoms of SOB, fatigue, and
palpitations worsen despite a
recent visit to the cardiologist and
optimal medical management

• AM’s symptoms worsen after
cardiology appointment and she
is admitted to the hospital with
Class IV heart failure
• She improves and is d/c home
with home health (HH) and physical
therapy (PT) for unsteady gait s/p fall
• AM is unable to tolerate PT due
to dyspnea and fatigue
• During PT visit the following week,
she develops chest pain and
SOB, sent to the hospital
• She is admitted to the ICU for
HF exacerbation and requires
ventilator and pressors
• After 10 days, she undergoes
trach and PEG and is transferred
to long-term acute care (LTAC)
still on ventilator
• After 3 weeks, she develops
sepsis due to UTI, transferred
to the hospital, then returns
to LTAC still intubated
• After 2 more weeks, daughter
opts for comfort care and AM
undergoes compassionate
withdrawal of ventilator
support and dies in the LTAC
AM Pathway 1 – No Hospice

Hospitalized older adults
discharged to LTAC:
• 8.3-month median survival
• Patients ≥ 85: 4-month
median survival
– Spent 97.7% of remaining
days as an inpatient
• Patients with respiratory Dx
– 5.3-month median survival,
spent 88.8% of remaining
days as an inpatient
LTAC for the Older Adult
Makam, et al. (2019). The Clinical Course after Long-Term Acute Care Hospital Admission among Older Medicare Beneficiaries. JAGS, 67(11). https://doi.org/10.1111/jgs.16106

• In a study of 14,072 hospitalized older adults discharged to LTAC:
– Median survival 8.3 months,
57% deceased at 1 year
– 47.1% achieved recovery,
with plateau at 9 months
– Median time of remaining life
spent in an inpatient facility
was > 65%
– More than one-third died
in an inpatient setting
Makam, et al. (2019). The Clinical Course after Long-Term Acute Care Hospital Admission among Older Medicare Beneficiaries.
JAGS, 67(11). https://doi.org/10.1111/jgs.16106
– Only 16% enrolled in hospice,
with median 10 hospice days
– Prognosis worse for patients
≥ 85 and those admitted with
primary respiratory diagnosis
– Older adults discharged from
hospital to LTAC don’t get to
go home.
Long-term Acute Care (LTAC) for the Older Adult

• Determine goals of care –
what is important?
• Manage symptoms holistically
– Psychosocial interventions
– Nonpharmacologic interventions
– Medications
• Avoid suffering and prolongation
of dying
• Achieve a sense of control
• Relieve burdens
• Strengthen relationship with
loved ones
The Role of Hospice in ACD

Pharmacologic Interventions for Heart Failure
Class Name Indication Adverse Effects Comments
Aldosterone Blocker Spironolactone NYHA III or IV
• Hyperkalemia
• Renal dysfunction
Monitor hyperkalemia
ACEi
Enalapril
Lisinopril
Ramipril
HF Stage B-D
• Hyperkalemia
• Hypotension Angioedema
• Cough First line for HFrEF
Beta-Blockers
Carvedilol
Metoprolol
• Fatigue
• Hypotension
• Depressed mood
ARBs
Losartan
Valsartan
Candesartan
• Hyperkalemia
• Hypotension
Substitution for ACE
inhibitors, not with ACEI
ARNi
Entresto
(Sacubitril-Valsartan)
NYHA II or III
• Hyperkalemia
• Dizziness, Fatigue
Not to be used
with ACEI
Diuretics
Furosemide
Metolazone
Thiazides
Volume overload
• Frequent urination
• Increase thirst
IV or Sub Q admin
Soluble Guanylate Cyclase
Stimulator
Vericiguat
Symptomatic
HF after 1st line
• Hypotension
• Anemia
Second line for HFrEF
Cardiac Glycosides Digoxin
Arrhythmias; symptomatic
HF after 1st line
• Cardiac arrhythmias
• Vision changes (green)
• Dizziness, Nausea
• Delirium
Second line for HFrEF
Narrow treatment window
Many contraindications

• Other Cardiac Medications:
• Entresto – angiotensin receptor
neprilysin inhibitor (ARNi)
• Corlanor/Ivabradine
• Soluble guanylate cyclase
(sGC) stimulators
• Farxiga//dapagliflozin
• Pulmonary hypertension medications
Pharmacologic Interventions for Heart Failure (cont.)

• AM is admitted for hospital
for HF exacerbation
(NHYA Class IV)
• AM improves (NYHA Class
III) and is d/c home with follow
up with cardiologist and
PCP 3 days later
• AM continues to have
SOB, congestion
• Instead of returning to the hospital,
daughter gets an urgent telehealth
visit with the cardiologist, who
advises another change
in her HF regimen and reaches
out to the primary care physician
• They have a GOC discussion
with AM and her daughter, and
AM is referred to VITAS
for hospice care at home
• She is admitted that same
day to hospice
Case of AM – Pathway 2 Hospice and
Timely Prognostication

• No hospital
• Minimal tests
• Improve shortness of breath
• Continue to live at home
• Live as long as possible
Elements Important to Goals-of-Care Conversation,
Shared Decision-Making
Allen, et al. (2012). Decision making in advanced heart failure: a scientific statement
from the American Heart Association. Circulation, 125(15), 1928-1952.
Survival
Costs/Burden
Direct medical costs
indirect costs
lost opportunities
caregiver burden
Outcomes
Relevant to
Individual
Patient Quality of Life
Symptoms
Physical function
Mental
Emotional
Social

• Is AM hospice-eligible? Yes. Why?
– NYHA Class III or IV with
dyspnea on minimal exertion
– AFIB, COPD, O2
dependent and Dementia
– Hypotensive and unable
to tolerate optimized
medical therapy for HF
– Functional decline, progressive
fatigue with tachycardia at
rest, recent fall, and not
improving with PT
– Recurrent heart failure
exacerbations despite
frequent follow up with
cardiologist and PCP, and
ongoing titration of cardiac
medication regimen
– Increased health care
utilization for HF
including hospitalizations
Case of AM – Pathway 2 Hospice and
Timely Prognostication

Association of Hospice Admission With Rehospitalization
Kheirbek, et al. (2015). Discharge hospice referral and lower 30-day all-cause readmission in Medicare beneficiaries hospitalized for heart failure.
Circulation: Heart Failure, 8(4), 733-740.
• 41% of the heart failure patients
who died within 6 months of hospital
discharge and did not receive
hospice services had at least one
rehospitalization within 30 days
prior to death
• Only 5% of heart failure patients
who died within 6 months and
were admitted to hospice were
rehospitalized within 30 days
• Findings suggest that only 10%
of 1,790 patients who died within
6 months after hospital discharge
received hospice referral
Patients Who Received Hospice Had Significantly
Lower 30-Day All-Cause Readmission Rates

Comprehensive Services
VITAS Palliative Care Home Health
Eligibility Requirements
Prognosis required: ≤ 6 months if
the illness runs its usual course
Prognosis varies by program,
usually life-defining illness
Prognosis not required
Skilled need not required Skilled need not required Skilled need required
Plan of Care Quality of life and defined goals Quality of life and defined goals Restorative care
Length of Care Unlimited Variable Limited, with requirements
Homebound Not required Not required Required, with exceptions
Targeted Disease-Specific
Program
✓ Variable Variable
Medications Included ✓ X X
Equipment Included ✓ X X
After-Hours Staff Availability ✓ X X
RT/PT/OT/Speech ✓ X ✓
Nurse Visit Frequency Unlimited Variable Limited, based on diagnosis
Palliative Care Physician Support ✓ Variable X
Levels of Care 4 1 1
Bereavement Support ✓ X X

• Unpredictable trajectory
• Patient overestimates survival
• Physicians overestimate survival
• Frequent exacerbations
• Hospitalized HF patient lacks DNR status
• Patient misunderstands hospice
• Physicians misunderstand hospice
• Prognostication proves challenging
• “Treatments are discontinued in hospice”
Discomfort
around EOL
issues
Communication
breakdown
Misinformation
Patients’ and Clinicians’ Barriers to Hospice

• During her 3 ½ months of well-
managed care by VITAS, AM has
two episodes of symptom exacerbation
with increased dyspnea, decreased
level of consciousness, and poor
oral intake
• Each time, AM is placed on Intensive
Comfort Care®
for symptom
management in the comfort of her
home with her daughter at bedside
• SQ Lasix is provided
for congestion
• Cardiac medications,
O2, and opioids titrated
for SOB and comfort
• VITAS physician, RT,
SW, and chaplain visit AM
• After a total of 111 days of
care at home, AM dies
comfortably with her daughter
by her side with VITAS
staff in attendance
Case of AM Pathway 2 Hospice and Timely Prognostication

Advanced, aggressive interventions may
be appropriate to palliate symptoms of
ACD in hospice.
These may include:
• Parenteral diuretics
• IV inotropes
• Pacemaker or cardiac
resynchronization therapy (CRT)
• Ventricular assist device (VAD)
Defibrillator – not palliative
Advanced Cardiac Interventions in Hospice

• Diuretics can be administered
IV or SQ
• SQ diuretics can eliminate
the need for an IV for
patients at home
• Similar outcomes between
SQ and IV
– Similar diuresis
– No difference
in rehospitalizations
• Dosing can be continuous
or intermittent infusion
• Limited data in severely
obese and end-stage
kidney disease
• Local side effects can occur:
tingling, burning, swelling
Advanced Interventions – Parenteral Diuretics
Afari, et al. (2019). Subcutaneous furosemide for the treatment of heart failure: a state-of-the art review. Heart Failure Reviews, 24(3), 309-313.

Advanced Interventions – Inotropes
Ginwalla, et al. (2018). Current Status of Inotropes in Heart Failure. Heart Failure Clinics,14;601-616.
• IV inotropes may be used for palliation of
symptoms in select patients with advanced
HF on optimal medical management and who
are not candidates for MCS or transplant
– Improve NYHA Class – Functional Capacity
– No association with mortality
– No association with hospital readmission
– May increase risk of ICD shock

Considerations for hospice:
• Hospice may provide inotropes
to palliate symptoms with
ongoing assessment
• Cardiologist should be involved
• Requires more permanent
central venous access
• Fixed dose, no active up-titration
• Patient/family agreeable to hospice
plan of care: no cardiac monitor
• Typically admitted to hospice
on continuous care
Advanced Interventions – Inotropes (cont.)

Advanced Interventions – Inotropes (cont.)
Ginwalla et al. (2016). Home inotropes and other palliative care. Heart Failure Clinics, 12(3), 437-448.
Name
Mechanism
of Action
Primary
Effects
Maintenance
Dose
Benefits
Risks/
Adverse
Effects
Significant
Adverse
Reaction
Indications for
Discontinuation
Dobutamine
Stimulates
Beta-1 and
Beta-2 receptors
Inotropic and
chronotropic
2-20
mcg/kg/min
Slows heart rate
and strengthens
cardiac
contractility
Reduces
sinoatrial
firing rate
Reduces atrial
fibrillation and
ventricular flutter
Increases
ejection fraction
Decreases
pulmonary
congestion
Tachycardia
Dizziness
Nausea and
vomiting
Anorexia
Blurred
vision
Interacts
with many
meds and
most
OTC drugs
•PVC’s
•Palpitations
•Headache
•Nausea
Side effects
outweigh benefits
Patient request
(requires goals of care
discussion)
Refractory to inotrope/
Tolerance
Develop HF symptoms
Milrinone
Phosphodiesterase
III Inhibitor
Inotropic,
arterial and
venous
dilation
0.375-0.75
mcg/kg/min
•Arrhythmias
•Hypotension
•Angina
•Hypokalemia

Type Indication Benefits Burdens Comments/Reasoning
Pacemakers/
CRTs
Both:
• Symptomatic bradycardia
• 2○
or 3○
heart block
CRT only:
• NYHA Class III and IV
• Certain Class II patients
Improves:
• Symptoms of heart disease
• Quality of life
• Cardiac function
All:
•Battery lifespan
•Infection (rare)
•Malfunction (rare)
•Poorer outcomes1:
–Typically placed in patients who
are > 90 y/o, renal failure, active
malignancy, connective tissue
disorder, dementia
cerebrovascular disease,
AICD only:
•Risk of traumatic death
Life expectancy of years
Rare to discontinue–may
result in acute HF
exacerbation
Not palliative
Recommend to deactivate
when patient has
advanced illness
Defibrillators/
AICDs
High risk of life-threatening
arrhythmias
Delivers shock
to convert to normal rhythm
Fewer hospitalizations
VADs
(LVAD, RVAD,
BiVAD)
Advancing HF despite
maximal medical therapy–
Bridge to transplant/
decision/recovery or
destination therapy
Improves:
• HF symptoms
• Quality of life
Complications:
• Stroke
• Infection
• Sepsis/pneumonia
• Serious bleeds
• Pump malfunction (rare)
External battery must always
be connected
LVAD does not improve
1-yr survival but does show
significant symptom benefit
over OMM after 1 yr
Improved survival with
continuous flow2
:
• 78% at 1 yr
• 45% at 4 yrs
Mechanical Interventions
1Harrington, et al. (2019). Cardiac Pacemakers at End-of-Life. Palliative Care Network of Wisconsin.
2Balla, et al. (2019). Prognosis after pacemaker implantation in extreme elderly. European Journal of Internal Medicine, 65:37-34.

Trajectories After LVAD Implantation
DeFilippis, et al. (2019). Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions.
Journal of the American Geriatrics Society, 67(11), 2410–2419. https://doi.org/10.1111/jgs.16105
1
Preimplantation advanced
care planning
Inpatient support, symptom
management
Review of progress and goals
of care, symptom management
Triggered revisiting of goals
of care
Bereavement support
1
2
3
4
5

• Caring for a patient with a VAD is
fundamentally no different than
caring for a patient without a VAD
• Hospice team trained in VAD-
specific symptom management,
differences in physical exam,
technical concerns
• Hospice and cardiology teams
collaborate closely
• Address any patient and
family concerns
VADs and Hospice

• Although the majority of VAD patients
die with their VAD still functioning,
elective discontinuation is a
treatment option, decision made
with treatment teams
• Clinical indications for VAD deactivation
– Complications of the VAD or
VAD failure
– Poor quality of life despite VAD
– Advanced comorbid conditions
• Can occur at home or inpatient unit
– Clinical and psychosocial team
involvement with patient and family
– Survival after deactivation ranges
from minutes to days (average
survival 20 minutes)
VAD Deactivation
Brush, et al. (2010). End-of-life decision making and implementation in recipients of a destination left ventricular assist device.
The Journal of Heart and Lung Transplantation, 29(12), 1337-1341.

In Summary
• Heart Failure causes significant burden
on patients and their caregivers
• Patients with HF are generally eligible
for hospice when they are mainly in
bed or chair and have symptoms
with less-than-normal activity
• Hospice can prevent and alleviate
symptoms, including the use of
advanced interventions, for
patients with HF

Afari, et al. (2019). Subcutaneous furosemide for the treatment of heart failure: a state-of-the art review. Heart failure reviews,
24(3), 309-313.
Alghanem et al. (2020) Narrowing performance gap between rural and urban hospitals for acute myocardial infarction care.
Am J Emerg Med. 38(1), 89-94.
Allen, L. A., et al. (2012). Decision making in advanced heart failure: a scientific statement from the American Heart Association.
Circulation, 125(15), 1928-1952.
Alpert, A., et al. (2017). Symptom burden in heart failure: assessment, impact on outcomes, and management. Heart Fail
Rev, 22:25-39.
American Heart Association. (2017). Cardiovascular disease: A costly burden for America projections through 2035.
American Heart Association. (2020). Classes of Heart Failure. Retrieved from: https://www.heart.org/en/health-topics/
heart-failure/what-is-heart- failure/classes-of-heart-failure
American Heart Association. (2022). 2022 Heart Disease and Stroke Statistics Update Fact Sheet At-a-Glance. Available at:
https://www.heart.org/-/media/PHD-Files-2/Science-News/2/2022-Heart-and-Stroke-Stat-Update/2022-Stat-Update-At-a-Glance.pdf
Balla, C., et al. (2019). Prognosis after pacemaker implantation in extreme elderly. European Journal of Internal Medicine, 65: 37- 43.
References

Bekelman, D., et al. (2009). Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced
cancer patients. Journal of General Internal Medicine, 24(5), 592-598.
Benjamin E., et al. (2019). Heart disease and stroke statistics: 2019 update. Circulation, 139(10):e56–528.
Brush, et al. (2010). End-of-life decision making and implementation in recipients of a destination left ventricular assist device.
The Journal of Heart and Lung Transplantation, 29(12), 1337-1341.
Centers for Disease Control and Prevention, National Center for Health Statistics. (2022) About Multiple Cause of Death,
1999–2020. CDC WONDER Online Database website. Atlanta, GA: Centers for Disease Control and Prevention.
Creber, et al. (2019). Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart failure.
ESC Heart Failure, 6(2), 371-378.
Criteria Committee, New York Heart Association Inc. Diseases of the Heart and Blood Vessels. (1964). Nomenclature and
Criteria for diagnosis, 6th edition. Little, Brown and Co.
DeFilippis, et al. (2019). Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions.
Journal of the American Geriatrics Society, 67(11), 2410–2419. https://doi.org/10.1111/jgs.16105
Ginwalla, et al. (2016). Home inotropes and other palliative care. Heart Failure Clinics, 12(3), 437-448.
References

Gotsman, et al. (2012). Heart failure and preserved left ventricular function: long term clinical outcome. PLoS One, 7(7), e41022.
Harrington, et al. (2019). Cardiac Pacemakers at End-of-Life. Palliative Care Network of Wisconsin.
Heidenreich, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of
Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of
Cardiology 79.17 (2022): e263-e421.
Kheirbek, et al. (2015). Discharge hospice referral and lower 30-day all-cause readmission in Medicare beneficiaries hospitalized
for heart failure. Circulation: Heart Failure, 8(4), 733-740.
Khera, et al. (2018). Association of HRRP with mortality during acute hospitalization. JAMA Network Open, 1(5), e182777-e182777.
Khera, R., et al. (2020). Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective
cohort study of Medicare beneficiaries in the United States. British Medical Journal, 368:|6831
Kitko, et al. on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and
Outcomes Research; Council on Clinical Cardiology; and Council on Lifestyle and Cardiometabolic Health. (2020). Family Caregiving
for Individuals with Heart Failure. Circulation. 2020;141: e864–e878. DOI: 10.1161/CIR.0000000000000768
References

Lee, et al. (2021). Social Isolation and All-Cause and Heart Disease Mortality Among Working-Age Adults in the United States:
The 1998–2014 NHIS–NDI Record Linkage Study." Health Equity. 5.1; 750-761.
Makam, et al. (2019). The Clinical Course after Long-Term Acute Care Hospital Admission among Older Medicare Beneficiaries.
JAGS, 67(11). https://doi.org/10.1111/jgs.16106
Mclluennan, et al. (2016). Palliative care in patients with heart failure. British Medical Journal, 6:352. National Alliance for
Caregiving and AARP. Caregiving in the US 2020.
NHPCO. (2021). Facts and Figures: Hospice Care in America.
Riley, et al. (2017). Palliative Care in heart failure: facts and numbers. ESC Heart Failure; 4:81-87.
Tsao, et al. (2022) Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association.
Circulation. 145(8):e153–e639.
Xu, et al. (2022). Mortality in the United States, 2021. NCHS Data Brief No. 456. Available at: https://www.cdc.gov/nchs/
products/databriefs/db456.htm#:~:text=Heart%20disease%2C%20cancer%2C%20and%20COVID, 100%2C000%
20live%20births%20in%202021.
References

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