Palliative Care in End-Stage Ischaemic Heart Disease: A Comprehensive Clinical Review

 Palliative Care in End-Stage Ischaemic Heart Disease: A Comprehensive Clinical Review

Authors: Dr. Shekhar Ingle and Team, Doctor’s Forum for All 🏥

Disclaimer: This article is for educational and clinical reference purposes only. It does not replace individualized clinical judgment, local protocols, or specialist consultation. Medication doses should be verified with current formularies and adjusted to patient-specific factors.

Abstract

End-stage ischaemic heart disease (IHD) represents the final common pathway of coronary artery disease, characterized by refractory angina, progressive heart failure, recurrent myocardial infarctions, malignant arrhythmias, and significant functional decline. Patients with end-stage IHD experience a high symptom burden including chest pain, dyspnoea, fatigue, depression, and existential distress. Palliative care should be integrated early alongside conventional cardiology management to optimise quality of life, support informed decision-making, and ensure goal-concordant care. This article provides a comprehensive, clinically verified review of palliative care principles and symptom management in end-stage ischaemic heart disease.

1. Introduction

Ischaemic heart disease remains the leading cause of death worldwide, accounting for approximately 9 million deaths annually [1]. While advances in revascularisation, pharmacotherapy, and device therapy have improved survival, many patients progress to an advanced stage characterized by:

· Refractory angina despite optimal medical therapy and revascularisation

· Severe left ventricular dysfunction (ejection fraction <30%)

· Recurrent hospitalisations for acute coronary syndromes or heart failure

· Malignant ventricular arrhythmias

· Significant functional limitation (NYHA Class III–IV)

· Frailty, cachexia, and multi-organ dysfunction

The illness trajectory of end-stage IHD is often unpredictable, with sudden death from arrhythmia or acute infarction possible at any time, punctuated by periods of relative stability [2]. This unpredictability necessitates early advance care planning and integration of palliative care alongside disease-directed therapy.

2. Disease Trajectory and Triggers for Palliative Care Referral

Palliative care referral should be considered when:

· Refractory angina (Canadian Cardiovascular Society Class III–IV) despite optimal anti-anginal therapy and revascularisation where appropriate.

· Severe left ventricular dysfunction with recurrent heart failure hospitalisations (>2 per year).

· Recurrent myocardial infarctions despite revascularisation.

· Malignant arrhythmias with recurrent ICD shocks.

· Progressive decline in renal function, cognitive impairment, or frailty.

· Inotrope dependence or consideration of mechanical circulatory support/transplant.

· Patient not a candidate for further revascularisation.

· Patient or family request for symptom management or goals-of-care discussion.

· Limited life expectancy (e.g., 6–12 months) as estimated by prognostic models (e.g., GRACE score, Seattle Heart Failure Model, SYNTAX Score II) [3,4].

3. General Principles of Palliative Care in End-Stage IHD

1. Concurrent care: Palliative care should be provided alongside ongoing cardiology management, including anti-anginal therapy, antiplatelet agents, statins, beta-blockers, and device therapy where appropriate.

2. Interdisciplinary team: Cardiologist, palliative care physician, cardiac nurse, pharmacist, physiotherapist, dietitian, psychologist, social worker, and chaplain.

3. Holistic assessment: Regular evaluation of physical, psychological, social, and spiritual needs.

4. Symptom-driven approach: Prioritise patient-reported outcomes and quality of life, not only cardiac parameters.

5. Communication and advance care planning: Discuss prognosis, goals, and preferences early, including ICD deactivation and place of death.

6. Medication review: Simplify polypharmacy; discontinue medications that do not provide immediate symptom benefit in the terminal phase [5].

4. Symptom Assessment and Management

4.1 Refractory Angina

Refractory angina is defined as chronic angina-type chest pain that persists despite optimal medical therapy and revascularisation, where further intervention is not feasible or has failed. It affects 5–15% of patients with coronary artery disease and profoundly impairs quality of life [6].

Management:

· Optimise anti-anginal therapy:

  · Beta-blockers (first-line): bisoprolol, carvedilol, or metoprolol; titrate to heart rate 55–60 beats/minute.

  · Calcium channel blockers: amlodipine or diltiazem; verapamil only if LV function preserved.

  · Long-acting nitrates: isosorbide mononitrate; ensure nitrate-free interval to prevent tolerance.

  · Ivabradine: reduces heart rate without affecting blood pressure.

  · Ranolazine: improves angina in refractory cases; contraindicated in severe hepatic impairment.

  · Nicorandil: potassium channel opener; may reduce angina frequency.

  · Trimetazidine: metabolic modulator; useful as add-on therapy.

· Opioids:

  · Morphine is effective for acute severe angina and for chronic refractory angina [7].

  · For chronic use: sustained-release morphine (e.g., 10–20 mg twice daily) or transdermal fentanyl.

  · Titrate cautiously; monitor for constipation, sedation, and respiratory depression.

  · Opioid rotation may be needed for tolerance or side effects.

· Non-pharmacological approaches:

  · Enhanced external counterpulsation (EECP): improves angina and quality of life in refractory cases [8].

  · Transcutaneous electrical nerve stimulation (TENS): may provide short-term relief.

  · Spinal cord stimulation: reduces angina frequency and improves exercise tolerance in selected patients [9].

  · Cognitive behavioural therapy and relaxation techniques.

· Interventional options (palliative intent):

  · Percutaneous coronary intervention (PCI) for symptom relief in selected patients with suitable anatomy.

  · Laser myocardial revascularisation: limited evidence; rarely used.

  · Coronary sinus reducer device: emerging therapy for refractory angina [10].

· End-of-life angina:

  · Continuous subcutaneous morphine infusion via syringe driver.

  · Sublingual or buccal opioids for breakthrough pain.

  · Consider sedation with midazolam if pain is severe and distressing.

4.2 Dyspnoea

Dyspnoea in end-stage IHD results from left ventricular dysfunction, pulmonary congestion, mitral regurgitation, or associated lung disease.

Management:

· Optimise heart failure therapy: Diuretics, ACE inhibitors/ARNIs, beta-blockers, and mineralocorticoid receptor antagonists as tolerated.

· Oxygen: Only if hypoxaemia (SpO₂ ≤ 90%). Routine oxygen for non-hypoxaemic patients is not recommended [11].

· Opioids: Low-dose oral or subcutaneous morphine (e.g., 2.5–5 mg every 4 hours as needed) is effective for refractory dyspnoea [12].

· Benzodiazepines: May be used for associated anxiety or panic; not first-line for isolated dyspnoea.

· Non-pharmacological: Fan therapy, cool air, positioning, pursed-lip breathing, and energy conservation.

· Acute pulmonary oedema: IV diuretics, nitrates, and non-invasive ventilation in hospital. In terminal phase, opioids and sedatives for comfort.

4.3 Pain

Chest pain from ischaemia is the hallmark symptom, but patients may also experience pain from musculoskeletal problems, peripheral vascular disease, or neuropathic sources.

Management:

· Ischaemic chest pain:

  · Short-acting nitrates (sublingual glyceryl trinitrate) for breakthrough angina.

  · Long-acting nitrates for prophylaxis.

  · Opioids for moderate-to-severe pain not responding to nitrates.

  · Beta-blockers reduce myocardial oxygen demand.

· Non-cardiac pain:

  · WHO analgesic ladder: paracetamol first-line; NSAIDs should be avoided due to cardiovascular and renal risks.

  · Weak opioids (tramadol, codeine) for moderate pain.

  · Strong opioids (morphine, oxycodone, fentanyl) for severe pain.

· Neuropathic pain:

  · Gabapentin or pregabalin.

  · Amitriptyline or duloxetine (caution with cardiac arrhythmias).

· Non-pharmacological: Physiotherapy, TENS, heat/cold, and psychological support.

4.4 Fatigue and Weakness

Fatigue is common due to low cardiac output, anaemia, deconditioning, depression, and medication side effects.

Management:

· Treat reversible causes: Anaemia (iron replacement if deficient), thyroid dysfunction, depression, and medication side effects (e.g., excessive beta-blockade).

· Exercise: Supervised cardiac rehabilitation or graded physical activity improves functional capacity and reduces fatigue [13].

· Energy conservation: Prioritise activities, use assistive devices, and plan rest periods.

· Psychological support: Cognitive behavioural therapy and counselling.

· Corticosteroids: Short-term dexamethasone (4–8 mg daily) may improve energy and appetite in terminal phase, but evidence is limited.

4.5 Depression and Anxiety

Depression occurs in 20–40% of patients with coronary artery disease and is associated with worse outcomes.

Management:

· Screening: Use PHQ-9 or HADS regularly.

· Pharmacotherapy: SSRIs (sertraline, citalopram, escitalopram) are first-line and generally safe in cardiac patients.

· Avoid tricyclic antidepressants due to cardiotoxicity and arrhythmia risk.

· Psychotherapy: Cognitive behavioural therapy, supportive counselling, and mindfulness.

· Anxiety: Short-term benzodiazepines for acute anxiety; consider buspirone or SSRIs for chronic anxiety.

4.6 Nausea, Anorexia, and Cachexia

Cardiac cachexia (involuntary weight loss >5% in 12 months) is associated with poor prognosis.

Management:

· Nausea: Treat reversible causes (digoxin toxicity, constipation, uraemia). Use metoclopramide (if no prolonged QT), ondansetron, or haloperidol.

· Anorexia: Small frequent meals, oral nutritional supplements, and appetite stimulants. Megestrol acetate may improve appetite but increases thromboembolic risk; use cautiously.

· Corticosteroids: Dexamethasone 4–8 mg daily can improve appetite and wellbeing in advanced disease.

· Hydration: Encourage oral fluids if not fluid-restricted; in terminal phase, avoid excessive IV fluids.

4.7 Constipation

Common due to reduced mobility, low fibre intake, dehydration, and medications (opioids, diuretics, iron).

Management:

· Prophylaxis with opioids: Prescribe laxatives (e.g., macrogol, senna) routinely.

· Titrate laxatives to achieve regular soft stools.

· Avoid bulk-forming agents if fluid restriction or mechanical obstruction.

· Treat faecal impaction with suppositories or enemas if needed.

4.8 Sleep Disturbance

Chest pain, orthopnoea, paroxysmal nocturnal dyspnoea, nocturia, and depression disrupt sleep.

Management:

· Treat underlying causes: Optimize angina control, diuretics and timing, pain control, and manage depression.

· Sleep hygiene: Regular schedule, avoid caffeine and alcohol.

· Non-benzodiazepine hypnotics: Short-term zolpidem or melatonin may be used; avoid long-term benzodiazepines.

4.9 Cognitive Impairment

Cognitive decline is common in advanced IHD due to cerebral hypoperfusion, stroke, or vascular dementia.

Management:

· Screen for delirium and dementia.

· Treat delirium: Identify and correct causes (infection, hypoxia, medications, urinary retention). Haloperidol or risperidone may be used for agitation.

· Support family with decision-making and provide a calm environment.

5. Device Deactivation and Advanced Therapies

5.1 Implantable Cardioverter-Defibrillators (ICDs)

Patients with end-stage IHD often have ICDs for prevention of sudden cardiac death. However, ICD shocks can be painful and distressing, especially in the terminal phase.

· Discuss deactivation early after device implantation and revisit at each clinical deterioration.

· Deactivation does not hasten death; it prevents painful shocks and allows natural death.

· Procedure: Arrange with cardiology/device clinic. External magnet can temporarily disable ICD in emergency; definitive deactivation should be planned.

· Pacemaker deactivation is more complex and ethically nuanced; usually continued as it does not cause discomfort, but may be turned off after discussion if the patient is dying.

5.2 Mechanical Circulatory Support (LVAD)

Patients with left ventricular assist devices (LVADs) require complex palliative care. End-of-life planning should include LVAD deactivation when appropriate.

5.3 Inotropes

Continuous inotropic support (dobutamine, milrinone) may be used as palliative therapy to improve symptoms and quality of life in selected patients with end-stage IHD and cardiogenic shock, despite limited survival benefit.

5.4 Revascularisation

In patients with end-stage IHD, further revascularisation (PCI or CABG) may be considered for symptom relief, but the risks may outweigh benefits. Palliative care discussions should include realistic expectations about outcomes.

6. Advance Care Planning and Communication

· Early discussion: Initiate advance care planning when the patient is stable, not during a crisis.

· Prognosis: Use validated tools (GRACE score, Seattle Heart Failure Model) but acknowledge uncertainty. Phrases like "I am worried that your heart is getting weaker despite our best treatments" can open conversations.

· Explore goals: "What is most important to you now?" "What are your hopes and worries for the future?"

· Document preferences: Preferred place of care and death, resuscitation status, and views on ventilation, dialysis, and device deactivation.

· Legal aspects: Appoint healthcare proxy or lasting power of attorney.

· Review regularly: Update preferences with clinical changes.

7. End-of-Life Care in End-Stage IHD

Recognising the terminal phase can be challenging. Features suggesting imminent death include:

· Progressive decline despite maximal therapy.

· Repeated hospital admissions.

· Worsening renal and hepatic function.

· Cachexia and severe fatigue.

· Refractory angina or dyspnoea at rest.

· Patient expresses desire for comfort-focused care.

Symptom control in the last days of life:

· Chest pain: Continuous subcutaneous morphine or diamorphine via syringe driver. Sublingual nitrates may still be used for breakthrough if helpful.

· Dyspnoea: Morphine 2.5–5 mg subcutaneously every 4 hours as needed, or continuous subcutaneous infusion if frequent doses required.

· Pain: Same as chest pain; adjust opioids based on prior use.

· Respiratory secretions: Glycopyrronium 0.2–0.4 mg subcutaneously every 6 hours as needed.

· Agitation/terminal restlessness: Midazolam 2.5–5 mg subcutaneously every 2–4 hours as needed, or continuous infusion.

· Nausea/vomiting: Haloperidol 0.5–1.5 mg subcutaneously every 8 hours as needed.

· Stop non-essential medications: Discontinue routine cardiovascular medications that do not provide immediate symptom benefit (e.g., statins, aspirin, ACE inhibitors) to reduce treatment burden [5].

· Fluid management: Avoid intravenous fluids unless for comfort. Diuretics may be continued if they relieve dyspnoea or oedema.

Care of the family: Provide emotional support, information, and bereavement follow-up.

8. Integration of Palliative Care in IHD Services

· Primary palliative care: Cardiology teams trained in basic symptom management, communication, and advance care planning.

· Specialist palliative care: Referral for complex symptoms, existential distress, or end-of-life care.

· Shared care models: Combined cardiology–palliative care clinics improve quality of life and reduce readmissions [14].

· Community support: Cardiac nurses, hospice at home, and telehealth monitoring.

9. Conclusion

End-stage ischaemic heart disease is a life-limiting condition with a high symptom burden and unpredictable course. Palliative care should be integrated early, alongside optimal medical and device therapy, to improve quality of life, support families, and ensure goal-concordant care. Clinicians must be skilled in managing refractory angina, dyspnoea, fatigue, depression, and other symptoms, while proactively addressing advance care planning and device deactivation. A multidisciplinary, patient-centred approach is essential.

References

1. GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017. Lancet. 2018;392(10159):1736-1788. doi:10.1016/S0140-6736(18)32203-7

2. Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. BMJ. 2005;330(7498):1007-1011. doi:10.1136/bmj.330.7498.1007

3. Eagle KA, Lim MJ, Dabbous OH, et al. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. JAMA. 2004;291(22):2727-2733. doi:10.1001/jama.291.22.2727

4. Pocock SJ, Ariti CA, McMurray JJ, et al. Predicting survival in heart failure: a risk score based on 39 372 patients from 30 studies. Eur Heart J. 2013;34(19):1404-1413. doi:10.1093/eurheartj/ehs337

5. Kutner JS, Blatchford PJ, Taylor DH Jr, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med. 2015;175(5):691-700. doi:10.1001/jamainternmed.2015.0289

6. Mannheimer C, Camici P, Chester MR, et al. The problem of chronic refractory angina. Eur Heart J. 2002;23(5):355-370. doi:10.1053/euhj.2001.2706

7. Moubarak G, Ernande L, Godin M, et al. Opioid therapy for refractory angina: a review. Ann Cardiol Angeiol (Paris). 2010;59(6):357-364. doi:10.1016/j.ancard.2010.08.001

8. Arora RR, Chou TM, Jain D, et al. The multicenter study of enhanced external counterpulsation (MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes. J Am Coll Cardiol. 1999;33(7):1833-1840. doi:10.1016/s0735-1097(99)00140-0

9. Mannheimer C, Eliasson T, Augustinsson LE, et al. Electrical stimulation versus coronary artery bypass surgery in severe angina pectoris: the ESBY study. Circulation. 1998;97(12):1157-1163. doi:10.1161/01.cir.97.12.1157

10. Verheye S, Jolicoeur EM, Behan MW, et al. Efficacy of a device to narrow the coronary sinus in refractory angina. N Engl J Med. 2015;372(6):519-527. doi:10.1056/NEJMoa1402556

11. Abernethy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet. 2010;376(9743):784-793. doi:10.1016/S0140-6736(10)61115-4

12. Jennings AL, Davies AN, Higgins JP, et al. A systematic review of the use of opioids in the management of dyspnoea. Thorax. 2002;57(11):939-944. doi:10.1136/thorax.57.11.939

13. O'Connor CM, Whellan DJ, Lee KL, et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301(14):1439-1450. doi:10.1001/jama.2009.454

14. Rogers JG, Patel CB, Mentz RJ, et al. Palliative care in heart failure: the PAL-HF randomized, controlled clinical trial. J Am Coll Cardiol. 2017;70(3):331-341. doi:10.1016/j.jacc.2017.05.030