Cardiac Disease / Heart Disease / Cardiovascular

Congestive heart failure (CHF) means the heart is failing to pump blood properly and can’t meet the requirements of the body. Different heart diseases or disorders can cause this condition.

The degree of heart failure is often described using a system developed by the New York Heart Association. It has four classes, which define the degree of failure according to its effect on a person’s life. The higher the class number the worse the CHF, and the underlying heart disease. As someone’s disease worsens he or she will progress through these classes:

• Class 1 – No limitation in physical activity. Ordinary physical activity produces no symptoms.
• Class 2 – Slight limitation in physical activity. No symptoms at rest. Symptoms possible with ordinary physical activity.
• Class 3 – More severe limitations in physical activity. Usually comfortable at rest. Symptoms with unusual physical activity.
• Class 4 – Inability to carry on any physical activity without producing symptoms. Symptoms possible at rest.

It’s hard to predict how CHF will progress. It depends on the underlying disease. Some cardiac diseases produce more symptoms and more rapid decline than others. The following symptoms, however, are a good indicator of severity of the condition and often become worse as the disease progresses:

• fatigue;
• dyspnea – shortness of breath;
• edema – swelling in the limbs and other places in the body;
• increased heart rate;
• nighttime urination;
• chest pain;
• skin changes – cool and sometimes greyish skin.

Several tests are available to determine the degree of heart damage, and assess a person’s physical condition and capacities. Medications and other therapies can control symptoms. When the symptoms become severe, they can be treated in hospital. As someone’s CHF becomes worse, the person usually is admitted to hospital more often and for longer periods at a time.

Dyspnea is a common symptom in end-stage heart failure, and, in addition to optimizing cardiac medications, opioids can be very effective in reducing the sensation of air hunger. However, there is often some reluctance to prescribe opioids in patients with respiratory compromise, and there is some conflicting information about the safety of opioids in acutely decompensated heart failure.

In general, the most effective approach to relieving dyspnea in heart failure is to improve volume status and cardiac output; that is, to specifically treat the heart failure. However, in end-stage cardiac disease, dyspnea often persists in spite of maximal treatment of the heart failure.

In the management of dyspnea in heart failure, Goodlin stated that “dyspnea and fatigue seem to diminish with normalization in volume status. Opioids are the only specific intervention that has been tested in treatment of dyspnea. Other measures such as oxygen and nitrates may be worth a trial for dyspneic patients. Exercise may reduce dyspnea and fatigue.”[1]

In the very specific circumstances of acutely decompensated heart failure, some concerns have recently arisen about the safety of morphine. One study showed that patients receiving morphine in such circumstances have worse outcomes.[2] It is not clear whether this reflects the fact that morphine was used in more seriously ill patients, or if there are other factors at play. One theory is that patients in acutely decompensated heart failure require high sympathetic tone, and opioids may help dyspnea by interrupting excess sympathetic outflow.[3] If morphine is used in an acute-on-chronic decompensation of heart failure, it should be with conservative initial doses and gentle titration.

However, it is important to be aware that the above study did not refer to patients at end of life, but rather to patients with an acute decompensation of chronic heart failure. Opioids have an important role in symptom management at the end of life for patients with advanced heart disease, and should be used in such circumstances. The imperative to address comfort in a patient dying of cardiac failure should be the overriding goal in such situations, rather than being hindered by concerns arising from a single retrospective study that was not focused on end-of-life care.

Reviews of the literature suggest that dyspnea as the target symptom should not influence whether morphine, hydromorphone or fentanyl is used. While the body of evidence for opioids in dyspnea is largest for morphine, there is evidence for hydromorphone and fentanyl. The selection of opioid is determined by considerations such as renal function, available routes of administration, previous history of adverse effects, existing opioid tolerance, and so forth.

References

1. Goodlin SJ. Palliative care for end-stage heart failure. Curr Heart Fail Rep. 2005;2:155-160.

2. Peacock WF, Hollander JE, Diercks DB, Lopatin M, Fonarow G, Emerman CL. Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Emerg Med J. 2008;25:205-209.

3. Johnson MJ, Oxberry SG. The management of dyspnea in chronic heart failure. Curr Opin Support Palliat Care. 2010;4:63-68.

Other references

Clemens KE, Klaschik E. Effect of hydromorphone on ventilation in palliative care patients with dyspnea. Support Care Cancer. 2008;16:93-99.

Mahler DA, Selecky PA, Harrod CG, et al. American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease. Chest. 2010; 137: 674-691.

Sitte T, Bausewein C. Intranasal fentanyl for episodic breathlessness. J Pain Symptom Manage. 2008;36:e3-e6.