Symptom Control in Heart Failure. Dr Claire L Hookey

Transcription

1 Symptom Control in Heart Failure Dr Claire L Hookey

2 Heart Failure symptoms Class III/IV CHF, mean 67.1 years, mean EF 22.3% Most prevalent symptoms:- lack of energy (66%) dry mouth (62%) shortness of breath (56%) drowsiness (52%) Pain (33%) High symptom-related distress Quality of life moderately compromised, particularly psychological well-being Blinderman CD et al Symptom distress and quality of life in patients with advanced congestive heart failure. J Pain Symptom Management Jun;35(6):

3 Heart Failure symptoms HF and cancer patients have similar nos. physical symptoms (9.1 vs. 8.6, p = 0.79), depression scores (3.9 vs. 3.2, p = 0.53), and spiritual well-being (35.9 vs. 39.0, p = 0.31) Symptom burden, depression symptoms, and spiritual well-being were similar among HF patients and cancer patients (no difference with EF < or > 30) Advanced HF patients had greater no. physical symptoms higher depression scores and lower spiritual well-being than patients with advanced cancer Bekelman DB et al Symptom burden, depression & spiritual well-being: a comparison of heart failure & advanced cancer patients.. J Gen Intern Med, 2009 May;24(5):592-8.

4 Assessment is key! Thorough history Holistic assessment Appropriate examination?investigations

5 Breathlessness Reversible factors? Persistent pleural effusion Chest infection Anxiety Ascites General measures Breathing exercises Relaxation Pacing Fan

6 Specific management of breathlessness Opioids Benzodiazepines Oxygen

7 Opioids Cochrane review One of 18 studies in heart failure (12 patients) Small and probably clinically significant effect of oral and parenteral opioids Jennings et al Opioids for the palliation of breathlessness in advanced disease 2011

8 Opioids Randomised placebo controlled cross over study 10 patients 5mg morphine qds Median breathlessness score fell by 23mm with morphine Minimal side effects No difference in BP, PR, RR 4 continued morphine 1 year later with continued benefit Johnson MJ et al, Morphine for the relief of breathlessness in patients with chronic heart failure a pilot study Eur J Heart failure 2002;4:753-6

9 Benzodiazepines Cochrane review Advanced cancer and COPD, not heart failure Slight but non-significant trend towards benefit Simon et al Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults 2011

10 Oxygen Cochrane review 35/144 participants heart failure No consistent benefit of oxygen over air Russell 1999 no physiological/functional benefit of O2 in symptom-limited exercise testing Haque % O2 for 20 minutes-negative effect Cranston et al. Oxygen therapy for dyspnoea in adults 2009

11 Oxygen Consecutive cohort study 5,862 patients 1098 prescribed home oxygen 15 heart failure Breathlessness scores did not change appreciably in the 2 weeks after O2 prescribed Currow, Agar. Does palliative home oxygen improve dyspnoea? Palliative Medicine 2009;23:

12 Summary of management of breathlessness Treat treatable General measures?oxygen if hypoxic Treat panic and anxiety (incl lorazepam) Oral opioid: morphine 2.5-5mg up to QDS Johnson M, Management of end stage cardiac failure, Postgraduate Medical Journal, 2007; 83 pp

13 Fatigue Reversible factors? Hypokalaemia from diuretics Over-diuresis Beta-blockers Poor sleep (orthopnoea, PND?) Anaemia 75% patients iron-deficient: Fe Rx po/?iv 20% anaemia of chronic disease: EPO? Depression Exercise deconditioning Johnson M, Management of end stage cardiac failure, Postgraduate Medical Journal, 2007; 83 pp C&W Heart Failure Newsletter, 2010, P Banerjee

14 Pain Cardiac Angina (transdermal nitrate if can t take po) Non-cardiac Musculoskeletal Dyspepsia Gout Peripheral vascular disease Oedematous legs Tense ascites Johnson M, Management of end stage cardiac failure, Postgraduate Medical Journal, 2007; 83 pp

15 Non-cardiac pain WHO analgesic ladder Oral morphine 1 st line strong opioid, but care in renal impairment Avoid NSAIDs Fluid retaining Reduce response to diuretics Tricyclic antidepressants relatively contraindicated

16 Cardiac pain Opioids for refractory angina Small prospective study 12 patients Successful titration of morphine/oxycodone MR 2 unable to tolerate sedation and nausea Decrease frequency of angina / total pain burden Improvement in depression score and exercise capacity, social functioning Douglas et al 2004

17 Cardiac pain Other approaches TENS Spinal cord stimulation

18 Anorexia/Cachexia Reversible factors? Oral thrush, untreated nausea, ill-fitting dentures General Measures Frequent small meals, avoidance of cooking smells Address conflict in family Eat for enjoyment, little and often requires honest discussion re stage of disease

19 Nausea Causes : Drugs (aspirin, spironolactone, digoxin toxicity) Gut wall or liver congestion, renal failure, constipation Prokinetic anti-emetic Metoclopramide (Domperidone) Low dose haloperidol Avoid cyclizine (anticholinergic arrhythmias) Careful choice of laxative Fluid restriction - not fybogel Lactulose Johnson M, Management of end stage cardiac failure, Postgraduate Medical Journal, 2007; 83 pp

20 Dry mouth Causes: Drugs (diuretics, analgesics, antiemetics) Treat oral thrush Sugar-free gum stimulates saliva Mucin-based saliva substitutes

21 Skin care Regular emollients For itch Aqueous cream with menthol?mirtazepine (case studies)?gabapentin?ondansetron Johnson M, Management of end stage cardiac failure, Postgraduate Medical Journal, 2007; 83 pp

22 Depression Prevalence in heart failure 24-42% (Guck et al) Often undiagnosed and untreated Associated with rpt admissions and worse prog Treatment with SSRIs helpful and safe (Alvarez et al) Also antiplatelet action?helpful Avoid tricyclics (arrythmias) and venlafaxine Trazodone and mirtazepine safe Psychological treatments and exercise programmes