Symptom Management in End Stage Heart Disease

Many individuals on hospice for heart disease will require new medications to treat symptoms associated with end stage disease. Symptoms and possible treatment options can include a wide variety of medications ranging from the use of diuretics to opioids.

Symptom Management

• Swelling (edema) – Swelling is common in end stage heart disease especially when the heart has difficulty pumping blood throughout the body. A diuretic such as furosemide (Lasix®) may treat swelling in the legs and feet and other areas of the body. Diuretics can also improve shortness of breath that occurs from swelling in the upper abdomen or lung areas. Patients may often develop resistance to loop diuretic therapy. Changing to a different loop diuretic (furosemide to bumetanide), and increasing to twice daily dosing in the am and early afternoon may help to overcome the resistance. Metolazone is often added to enhance diuresis with loop diuretics.  Avoid the use of NSAIDs and corticosteroids which may worsen edema.  If a corticosteroid is needed, dexamethasone may cause less edema.
• Shortness of breath (dyspnea) – Persons with end stage heart disease may experience shortness of breath during episodes of chest pain, during CHF exacerbations, while walking or exercising, or even just at rest. An opioid pain medication such as morphine or an anti-anxiety medication such as lorazepam (Ativan®) can help a person feel less short of breath as well as calm anxiety and assist with deeper, slower breaths. Morphine should be considered for patients who have failed maximum therapy with diuretic and have become volume overloaded and report dyspnea. Use of bronchodilators such as albuterol have minimal effect in managing dyspnea associated with heart failure.
• Chest pain – Chest pain is common in end stage heart disease and may be mild or severe. Contact the hospice nurse or nursing facility staff immediately if experiencing chest pain. Nitroglycerin tablets that are placed under the tongue can help relieve chest pain. Morphine may also be helpful for the pain that is no longer responsive to nitroglycerin.
• Anxiety – Anxiety is common in heart disease and is often associated with chest pain or shortness of breath. Anti-anxiety medications such as lorazepam (Ativan®) or alprazolam (Xanax®) may be used as needed for episodes of anxiety or may also be scheduled to use a few times per day to keep anxiety and other symptoms under control. The hospice team might also recommend an antidepressant that has an indication for treating anxiety.
• Pain – Up to 41% of heart failure patients experience moderate to severe pain in the last 3 days of life. The use of opioids such as morphine have the added benefit of helping with chest pain and dyspnea. Non-opioids such as acetaminophen, tramadol, methadone, and NSAIDs do not improve symptoms of dyspnea.

Discontinuing medications

Discontinuing medications should be done on an individual patient basis with consideration given to patient specific concerns, symptoms, and functional status. Many of the medications used for heart disease may not be necessary near the end of life. The hospice nurse or physician may also recommend discontinuing medications due to swallowing difficulty, bothersome side effects such as hypotension (low blood pressure) or bradycardia (slow heart rate), drug interactions, or lack of benefit for symptom management (medications for high cholesterol).

• Medications which lower blood pressure (anti-hypertensives) may be discontinued. Low blood pressure can cause tiredness, lack of energy, and increase the risk of falls. These side effects can be reduced by stopping the medications.
• Medications which prevent blood clotting (anti-coagulant or anti-platelet drugs) may be discontinued for safety reasons. Dietary changes and reduced intake can increase the risk of bleeding with warfarin (Coumadin®). As persons decline and have trouble walking, they may fall or injure themselves and the anticoagulants can cause excessive bleeding from injuries.
• Medications for arrhythmias or cholesterol may be discontinued without harm since they usually do not provide added symptom management benefit near the end of life.

References:

Caring for Someone with End Stage Heart Disease Page 1 ©2017, Optum druginformation@hospiscript.com

PMcCrate B, Kimbrel J, Grauer P. 2015 Palliative Care Consultant 4^th Ed Montgomery, AL. Hospiscript