Wellness
Palliative care beneficial to manage symptoms, improve quality of life for people with CVD
Implementing patient-centered palliative care therapies, including prescribing, adjusting or discontinuing medications as needed, may help control symptoms and improve quality of life for people with heart disease, according to a new scientific statement from the American Heart Association.
Decisions about initiating, adjusting or discontinuing cardiovascular and other medicines should be patient-centered and include input from multiple specialties including cardiology experts in close collaboration with primary care professionals.
Evidence shows that adding palliative care interventions to standard cardiovascular care improves outcomes for patients with heart disease. However, the latest research indicates palliative care is underutilised, especially among people from underrepresented racial and ethnic groups who are affected by unfavourable social determinants of health and health inequities.
The American Heart Association’s statement, published in the Association’s journal, Circulation: Cardiovascular Quality and Outcomes, reviews current evidence on the benefits and risks of cardiovascular and essential palliative medications.
The statement provides guidance for health care professionals to incorporate palliative methods as part of holistic medication management at all stages of a patient’s health conditions, emphasizing the importance of shared decision-making and goal-oriented care.
Palliative care is specialised medical care that aims to relieve symptoms and enhance quality of life for people experiencing health-related issues due to serious illnesses. This approach may benefit patients with cardiovascular disease, including coronary heart disease, valvular heart disease, pulmonary arterial hypertension and heart failure. These conditions significantly reduce quality of life, require ongoing treatment, are usually progressive and are associated with high mortality rates. The progression of many conditions, from chronic to advanced and end-stage, may be unpredictable and marked by worsening symptoms that result in recurrent hospitalisation.
Palliative care complements standard cardiovascular care by reducing physical symptoms, managing emotional distress and assisting patients in making decisions that coincide with their goals of care. A palliative approach can be integrated into the medication management of patients at any stage of heart disease, from chronic, stable heart disease to advanced and end-stage cardiovascular disease. And, importantly, palliative care supports a more goal-oriented, patient-centered approach to treatment.
Previous studies have found that adding palliative care interventions to evidence-based care improved patients’ quality of life, functional status, depression, anxiety and spiritual well-being and reduced the risk of hospital readmission for patients with advanced heart disease compared to clinical care alone. Despite these benefits, fewer than 20% of people with end-stage heart disease receive palliative care.
In addition, despite significant progress in cardiovascular care, disparities in care and outcomes related to race, ethnicity, gender and social determinants of health persist. People with heart failure who are referred to palliative care are predominantly white, have higher socioeconomic status and are more likely to receive care at academic medical centers. Patients from underrepresented racial and ethnic groups are less likely to receive palliative care, which contributes to poorer outcomes and increased risk of early mortality.
“It is critical for patients to be fully informed about their diagnosis and how medication management may change throughout the disease progression so they have ample time to set and share their goals,” said Chair of the statement writing group Katherine E. Di Palo, Pharm.D., M.B.A., M.S., FAHA, senior director of Transitional Care Excellence at Montefiore Medical Center and assistant professor of medicine at Albert Einstein College of Medicine in New York City.
“These goals often include reducing symptoms such as shortness of breath, fatigue, and pain as well as improving sleep, mood and appetite.”
To achieve these goals, cardiovascular medications that provide symptom relief, such as diuretics to manage fluid retention in heart failure, should be prioritised in patients with advanced heart disease.
Adding palliative medicines to evidence-based cardiovascular therapies can be complementary to manage symptoms and optimise quality of life. Examples of common palliative medicines include antidepressants, opioids for pain relief and difficulty breathing, and anti-nausea medications.
“Given the complexities of medication management in people with heart disease, a team-based approach is urged. Collaboration between multidisciplinary clinicians across primary care, cardiology and palliative care is needed to deliver effective, person-centered care,” said Di Palo.
Because the health status of patients can change rapidly, it is crucial to have ongoing discussions to ensure that treatment plans align with the patient’s preferences and priorities. Clinicians should routinely evaluate — and clearly communicate — to patients and their families about the potential risks, benefits and expected time to benefit of each medication.
Deprescribing and de-escalating medications are also essential components of palliative medication management for people with heart disease. Deprescribing involves tapering, withdrawing or discontinuing a medication to improve outcomes. De-escalating medications focuses on reducing the dose or switching to another medication based on the patient’s response to the medicine.
“Deprescribing that targets medications with limited benefit or increased risk of adverse events can be done safely with patient permission,” Di Palo said.
The statement provides several examples where deprescribing medications may be appropriate to consider, such as when the time to benefit from the medication may be longer than the patient’s life-expectancy.
Anti-clotting medications (also known as anticoagulants) may be prescribed to reduce the risk of blood clots. However, some of these medicines may increase the risk of bleeding, especially in older patients over the age of 75 who are at increased risk of falls.
Discontinuing non-steroidal anti-inflammatories (NSAIDs) may also be considered in patients with end-stage heart disease due to increased risk of bleeding and fluid retention. Although beta-blockers are commonly prescribed for high blood pressure and heart failure, they may contribute to fatigue and functional decline in end-stage heart disease. A slow-tapering schedule can help to reduce the risk of rebound high blood pressure or withdrawal when large doses are abruptly stopped.
Other reasons to consider deprescribing medications include polypharmacy, defined as taking five medications or more daily. This increases the risk of adverse reactions or side effects, not taking medications as prescribed, hospital readmission and mortality. Excessive out-of-pocket medication costs may also prompt the need to deprescribe certain medications.
Future research is needed to determine the best ways to provide timely and targeted access to palliative medication management, particularly for patients with advanced heart disease from under-represented racial and ethnic groups who are less likely to receive palliative care or may face barriers to care.
Gut-friendly foods such as kimchi and kombucha may carry hidden risks for heart health when eaten in excess, the British Heart Foundation (BHF) has warned.
The charity said foods marketed as prebiotic, probiotic or otherwise good for the gut can support the microbiome, but some may also be high in salt or sugar, which can raise the risk of cardiovascular disease.
Products highlighted by the British Heart Foundation included kimchi, kombucha, fruit yoghurts, smoothies and sauerkraut. It said there is no harm in including them as part of a healthy diet, but advised people to check labels for added salt and sugar and eat them in moderation.
Tracy Parker, the charity’s nutrition lead, said: “We encourage everyone to choose foods that can keep their gut microbiome healthy. The benefits are clear, and we are continuing to improve our understanding of how a gut-friendly diet may help our hearts.
“A lot of these products can contain high levels of salt or sugar though, so it is important to be aware of the potential drawbacks.
“By ensuring you check package labels for added salt and sugars, and eat each in moderation, you can make sure the risks do not outweigh the benefits for your heart health.”
Fermented foods such as kimchi and sauerkraut are rich in probiotics, the healthy bacteria produced during fermentation that can help support a diverse and healthy gut microbiome.
However, both are traditionally made using a lot of salt, which can raise blood pressure if eaten frequently or in large quantities. High blood pressure is known to increase the risk of heart attack and stroke.
Kombucha, a fermented tea, also contains probiotics and can be a healthier alternative to fizzy drinks, but many commercial and shop-bought versions contain added sugar.
Eating too much sugar can lead to weight gain, which can increase the risk of heart attack, stroke and other cardiovascular disease.
Fruit yoghurts can contain probiotic live bacteria cultures, but may also be high in sugar and have fewer live cultures than plain versions.
The charity said plain yoghurt with live and active cultures on the label can be a lower-sugar option, with whole fruit added at home for sweetness.
Smoothies made with whole fruits provide prebiotic fibre, which feeds beneficial gut bacteria and supports digestive health.
They can also provide vitamins and antioxidants, especially when made with a variety of plant-based ingredients.
But blending breaks down the structure of fruit, releasing free sugars that behave like added sugars in the body and can cause faster rises in blood sugar levels.
Regularly consuming too much sugar can lead to weight gain, which can increase the risk of developing type 2 diabetes, heart disease and kidney disease.
The charity said only one 150ml serving of any smoothie counts towards five-a-day, and suggested adding nuts or seeds for extra protein and fibre to help keep blood sugar levels more stable.
The BHF also noted that some shop-bought sauerkraut is pasteurised, which removes most of the live bacteria.
It advised checking the label, eating small portions and choosing unpasteurised products for those seeking the probiotic benefits.
The charity said beneficial gut bacteria produce short-chain fatty acids during digestion, which are linked to reduced inflammation, better metabolism and better heart and circulatory health.
These good bacteria also help digest polyphenols, natural plant chemicals thought to have antioxidant properties and which may help lower blood pressure.
By contrast, harmful gut bacteria, which thrive on diets high in fat and red meat, produce chemicals that can cause problems in the heart and blood vessels by increasing inflammation and altering how cholesterol is processed in the body.
Beneficial bacteria thrive on varied diets high in prebiotics, non-digestible fibres found in foods such as wholegrains, oats, beans, lentils, bananas and onions.
People with diabetes may have undiagnosed heart failure that could be detected by a simple screening blood test, research suggests.
The TARTAN-HF trial found that one in four patients with diabetes who had at least one other risk factor for heart failure had undiagnosed heart failure detected through screening with a blood test and ultrasound scanning of the heart.
Experts said the findings show the extent of unrecognised heart failure in people with diabetes, and how the condition can be detected using a widely available blood test called NT-proBNP, which measures how much strain the heart is under.
They suggest a heart failure screening programme for diabetics could improve diagnosis rates, lead to earlier treatment and potentially reduce the risk of hospitalisation and death.
The study, involving 700 patients, was led by the University of Glasgow in collaboration with AstraZeneca, Roche Diagnostics, Us2.ai, NHS Greater Glasgow and Clyde and NHS Lanarkshire.
Dr Kieran Docherty, clinical senior lecturer at the University of Glasgow’s School of Cardiovascular and Metabolic Health, said: “Our results from the landmark TARTAN-HF trial identified heart failure in a large proportion of people living with diabetes, emphasising the need for a heart failure screening strategy in this group of patients.
“We know that many of the symptoms and signs of heart failure are non-specific, and may go unrecognised as potentially being due to heart failure for a long time.
“The strategy used in our trial is simple and easy to implement in clinical practice, and will aid in the early identification of heart failure in people with diabetes, and facilitate the initiation of medications that we know improve outcomes in patients with heart failure.”
The study, which began more than three years ago, involved more than 700 people with diabetes from the two health board areas who had at least one other risk factor for heart failure.
They were randomly assigned either to receive heart failure screening or to continue with their usual care.
Researchers found screening uncovered a large number of previously unrecognised cases of heart failure. Around one in four, or 24.9 per cent, of those screened were found to have the condition within six months, compared with 1 per cent in the group continuing their usual care.
The study, involving patients with type 1 and type 2 diabetes, found almost all of the participants found to have heart failure had preserved ejection fraction, which can be difficult to detect without dedicated testing.
The findings of the TARTAN-HF trial were presented at the American College of Cardiology conference taking place from 28 to 30 March in New Orleans in the US.
Dr Edward Piper, medical director at AstraZeneca UK, said: “Delayed diagnosis and treatment of heart failure in people with type 2 diabetes contributes to poor long-term outcomes. TARTAN-HF demonstrates that targeted, risk-based screening can identify previously undiagnosed heart failure in approximately one in four high-risk patients with diabetes, enabling earlier intervention with guideline-directed therapy.”
Dr Christian Simon, head of global medical affairs at Roche Diagnostics, said: “We are proud to have supported the landmark TARTAN-HF trial. These findings demonstrate the transformative power of early, accessible diagnostics like the NT-proBNP blood test.
“By identifying unrecognised heart failure in people with diabetes, we enable clinicians to initiate appropriate treatments sooner, ultimately improving patient outcomes and lives.”
The UK has launched a £6.3m men’s health fund to back local projects aimed at helping men and boys live longer, healthier lives.
The Men’s Health Community Fund is a partnership between the Department of Health and Social Care, Movember and People’s Health Trust.
The government is contributing £3m, while the two charities are more than doubling that to take the total to £6.3m.
Grants will support community projects reaching underserved men and boys aged 16 and over, particularly in the most disadvantaged areas and at key points in their lives such as becoming a father, losing a job or retiring.
Projects could include support for new fathers, activities for men facing loneliness and social isolation, services to help young men engage with the health system, and support for men in work, out of work and moving into retirement.
The programme will bring together voluntary, community and social enterprise organisations to test new ways of reaching men who are least likely to use traditional health services.
An evaluation funded through the National Institute for Health and Care Research will assess what works and help inform future policy and delivery.
Health and social care secretary Wes Streeting said: “Too many men across the country are living shorter, less healthy lives, particularly those in our most disadvantaged communities.
“This new partnership will help men get the support they need in the places they feel most comfortable, their communities, among people they trust.
“By working with expert charities and local organisations, we can reach the men who are too often missed by traditional services and help them take better care of their mental and physical health.”
“It is a key step in delivering our first ever Men’s Health Strategy and driving forward our ambition to halve the gap in healthy life expectancy between the richest and poorest areas.”
The Men’s Health Strategy sets out plans to tackle the physical and mental health challenges men and boys face.
Men can be less likely to seek help and more likely to suffer in silence, while higher rates of smoking, drinking, gambling and drug use are damaging men’s health and affecting families, workplaces and communities.
The government is also investing £3.6m over the next three years in suicide prevention projects for middle-aged men in local communities across areas of England where men are most at risk, many of which are also among the most deprived. Suicide is one of the biggest killers of men under 50, and three-quarters of all suicides are men.
The projects will aim to break down barriers middle-aged men face in seeking support, including stigma around asking for help and a lack of awareness of what is available and how to access it.
They will be co-designed with experts and men with lived experience of mental health crises and suicidal thoughts.
Gut-friendly foods may damage heart, charity warns
Diabetes patients face increased risk of undiagnosed heart failure
UK government announces £6.3m fund to boost men’s health
Brain health collaboratory launches in Gulf South
