Modest Inroads Made for Palliative Care in Acute MI

Patrice Wendling

January 10, 2020

Although strides have been made in the utilization of palliative care in some settings, a new nationwide analysis shows only limited growth over the past 2 decades in patients with acute myocardial infarction (MI).

"In acute myocardial infarction, it's not something where people have really thought about it. I mean those words typically don't go together — palliative care and acute myocardial infarction," senior author Deepak Bhatt, MD, MPH, Brigham and Women's Hospital Heart and Vascular Center, Boston, told theheart.org | Medscape Cardiology.

"Obviously for most patients coming in with an acute myocardial infarction, aggressive therapy will be appropriate, but it's important to keep in mind the option of palliative care if things don't go well or it is deemed futile care right at the outset," he said. "So our purpose was really to try to call attention to this with some data."

Despite advances in treatment in the contemporary era, rates of in-hospital mortality have remained at about 5% with acute MI and 30% to 40% in those with cardiogenic shock.

The investigators, led by Islam Elgendy, MD, also with the Brigham, identified 9,443,587 hospitalizations with a primary diagnosis of acute MI in the National Inpatient Sample database from 2002 to 2016.

The overall incidence of palliative care was low, only 1.3%, with rates among patients with high-risk features of 6.5% for cardiogenic shock, 5.4% for mechanical complications, and 4.9% for cardiac arrest, the authors reported January 7 in the Journal of the American College of Cardiology.

Still, palliative care encounters increased over the study period (0.2% in 2002 to 3.0% in 2016). Gains were mainly among patients who died in hospital, where rates jumped from just 1.5% to 31.6% (P for trend <.001 for both).

Penetration also increased among the high-risk patients, particularly those with cardiogenic shock (0.6% to 14%; P for trend < .001). At the same time, in-hospital mortality declined in those with cardiogenic shock and in the overall cohort. However, higher in-hospital mortality in palliative care recipients than in nonrecipients (53.7% vs 5.2%; P < .001) suggests it is mostly used in the critically ill, the authors note.

A Shift in Thinking

Previous work indicates barriers to integrating palliative care, such as lack of knowledge and skills among treating physicians, a view that intensive care and palliative care are sequential and mutually exclusive, and unrealistic expectations of patients, family, and physicians regarding treatment.

"Having a physician with expertise in dealing with these issues is really added value," Bhatt said. "I think there may not be great familiarity with what palliative care physicians do, and just sort of a belief that they're just coming to make the patient DNR and not realize they've got a broad skill set of things they do that include making patients more comfortable, but not necessarily de-escalating care."

Multivariable analysis identified several patient- and hospital-related factors associated with palliative care encounters, including older age; heart, renal, or liver failure; and cardiogenic shock. Other patient factors were treatment with an intra-aortic balloon pump or percutaneous ventricular assist device, and not undergoing percutaneous coronary intervention.

Palliative care encounters were also more common in the western region of the United States and at large, urban teaching hospitals.

"The next step is to track what happens over time and beyond that, to actually get palliative care physicians more involved and get their input on how their services could be expanded," Bhatt said.

Telemedicine or other modalities could play a role at small, rural hospitals with limited access to 24/7 palliative care services, but a "bit of a shift in thinking" may also be required among interventionalists, typically focused on procedural care and making sick patients better, he said.

One thing that may help is a generational change, as physicians in training for cardiology have greater exposure to palliative care and try to marry those interests.

"Among fellows we are interviewing now, there is usually one or two who is interested in this area, really sick cardiac patients and end-of-life care," Bhatt said. "That was, I would say, unheard of 10 or 20 years ago. I'd never met a fellow who had interest in both palliative care and cardiology and now there's a few every year."

Having professional societies take more of a stance and the new specialty of cardio-oncology may also stimulate uptake of palliative care.

"A big thing going on in cardiology is, of course, cardio-oncology, where we are learning all sorts of things from oncologists, and that sort of bridge-building between cardiologists and oncologists is one thing we could tap into more," Bhatt said. "Other than just dealing with drugs that treat cancer and cause heart disease — those things we're sort of focused on now — we could bring in their expertise in how best to liaise with palliative care."

Bhatt reports numerous relationships with device makers, pharmaceutical companies, and publications, including receiving honoraria from WebMD, publisher of theheart.org | Medscape Cardiology. Full details and coauthor disclosures are listed in the paper.

J Am Coll Cardiol. 2020;1:113-117. Abstract

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