Elsevier

Journal of Cardiac Failure

Volume 28, Issue 2, February 2022, Pages 334-338
Journal of Cardiac Failure

Brief Report
Polypharmacy in Palliative Care for Advanced Heart Failure: The PAL-HF Experience

https://doi.org/10.1016/j.cardfail.2021.08.021Get rights and content

Highlights

  • Palliative care interventions designed for advanced, complex chronic illness aim to improve symptoms and quality of life, in part through medication management.

  • Few palliative care interventions report the effect of the intervention on patterns of polypharmacy, or the relationship of those patterns with quality of life.

  • In the Palliative Care in HF trial, polypharmacy was universal at enrollment, and the number of medications prescribed increased in both the intervention and standard care groups over time.

  • Although medications increased in both arms, patient-reported quality of life improved among those in the intervention arm compared with the control arm.

  • Appropriate polypharmacy may be an important contributor to quality of life for patients with heart failure receiving palliative care.

Abstract

Background

Palliative care (PC) in advanced heart failure (HF) aims to improve symptoms and quality of life (QOL), in part through medication management. The impact of PC on polypharmacy (>5 medications) remains unknown.

Methods and Results

We explored patterns of polypharmacy in the Palliative Care in HF (PAL-HF) randomized controlled trial of standard care vs interdisciplinary PC in advanced HF (N = 150). We describe differences in medication counts between arms at 2, 6, 12, and 24 weeks for HF (12 classes) and PC (6 classes) medications. General linear mixed models were used to evaluate associations between treatment arm and polypharmacy over time. The median age of the patients was 72 years (interquartile range 62–80 years), 47% were female, and 41% were Black. Overall, 48% had ischemic etiology, and 55% had an ejection fraction of 40% or less. Polypharmacy was present at baseline in 100% of patients. HF and PC medication counts increased in both arms, with no significant differences in counts by drug class at any time point between arms.

Conclusions

In a trial of patients with advanced HF considered eligible for PC, polypharmacy was universal at baseline and increased during follow-up with no effect of the palliative intervention on medication counts relative to standard care.

Section snippets

Methods

The PAL-HF trial is a previously reported randomized controlled trial designed to test the efficacy of a multidisciplinary PC intervention on QOL in patients with advanced HF.6 The study protocol was approved by the institutional review board, and all participants gave informed consent. Patients admitted to a single center with a primary diagnosis of acute decompensated HF with advanced disease were randomized to standard care (n = 75) vs standard care and an interdisciplinary PC intervention (n

Results

The median age of the patients was 72 (interquartile range 62–80) years, 47% were female, and 41% were Black. Overall, 48% had an ischemic etiology, and 55% had an ejection fraction 40% or less.

At 2 weeks after hospital discharge, the mean count for HF medications in the intervention arm was 6.7 ± 5.2 vs 6.5 ± 5.0 in the control arm (P = .84), and the mean count for PC medications was 3.6 ± 3.4 vs 3.0 ± 2.9 (P = .25), respectively. At 6 months, the mean count for HF medications in the

Discussion

In the PAL-HF trial, polypharmacy as defined by the World Health Organization was universal, and the number of prescribed medications actually increased over time. Importantly, this result occurred in the context of improved patient-reported QOL among those in the intervention arm.6

Historically, PC studies have found that achieving the key goals of PC, such as ameliorating symptoms, decreasing the frequency of symptom exacerbations, and improving comfort, often necessitates a burgeoning number

Limitations

Several caveats should be considered in interpreting the results presented in this report. First, the sample size was relatively small, and patients were enrolled at a single academic center. Second, the duration of follow-up was short, and longer term follow-up of the patterns of medication use in these patients remains undefined. Third, we do not know how much selection for PAL-HF enrollment affected the patterns of medication use relative to comparably ill advanced HF patients not considered

Conclusions

Polypharmacy was universal at enrollment into the PAL-HF trial and the number of medications prescribed increased in both the PAL-HF intervention and standard care groups over time. Optimizing medications for symptom management regardless of medication count, known as appropriate polypharmacy, may be an important component in interventions to improve QOL for patients with advanced HF.

Patient Significance

  • Palliative care aims to improve symptoms and quality of life for people with serious illness, including advanced heart failure.

  • Palliative care helps patients manage symptoms in part through medications, which may increase the total number of medications prescribed.

  • This study showed that, despite increasing medications, the palliative care intervention improved symptoms and quality of life in people participating in the intervention, which may be beneficial for patients with advanced heart

Lay Summary

Palliative care aims to improve symptoms and quality of life for people with serious illness. In advanced heart failure, palliative care helps patients to manage their symptoms in part through medications, which may increase the total number of medications prescribed. This is known as polypharmacy (>5 medications). The effects of polypharmacy on patient outcomes in advanced heart failure are unknown. This study showed that the number of medications prescribed in the PAL-HF trial increased in

Funding

The PAL-HF study was funded by the National Institute of Nursing Research (NINR: R01NR013428) from the National Institutes of Health under randomized controlled trial no. NCT01589601.

Author Contributions

All authors have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.

Disclosures

Bradi Granger receives research support from the American Heart Association, Novartis, and the Alpha Phi Foundation; Brystana G. Kaufman receives research support from AstraZeneca. Robert J. Mentz receives research support from the National Institutes of Health (U10HL110312 and R01AG045551-01A1), Amgen, AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Gilead, Medtronic, Novartis, Otsuka, and ResMed; honoraria from HeartWare, Janssen, Luitpold Pharmaceuticals, Novartis, ResMed, and

Data Availability Statement

Owing to the sensitive nature of the questions asked in this study, survey respondents were assured raw data would remain confidential and would not be shared. De-identified data are available with permission in the National Institutes of Health (NIH) data sharing repository.

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