This section is meant to assist in the determination of prognosis for patients with end-stage heart disease. It is important to remember that with skillful palliation including judicious use of diuretics and vasodilators, particularly angiotensin-converting enzyme (ACE) inhibitors, some patients may survive for long periods with extremely severe symptoms. These drugs definitely promote patient comfort, but they also prolong life. On the other hand, some patients with advanced coronary disease may die suddenly and unexpectedly from acute ventricular arrhythmias.
The likelihood of early mortality is increased in patients who show all of the following characteristics:
I. Symptoms of recurrent congestive heart failure (CHF) at rest.
. These patients are classified as New York Heart Association (NYHA) Class IV.
. Ejection fraction of 20% or less is helpful supplemental objective evidence, but should not be required if not already available.
II. Patients should already be optimally treated with diuretics and vasodilators, preferably angiotensin-converting enzyme (ACE) inhibitors.
. The patient experiences persistent symptoms of congestive heart failure despite attempts at maximal medical management with diuretics and vasodilators.
. "Optimally treated" means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.
. Although newer beta blockers with vasodilator activity, e.g., carvedilol, have recently been shown to decrease morbidity and mortality in chronic CHF, they are not included in the definition of "optimal treatment" at this time.
III. In patients with refractory, optimally treated CHF as defined above, each of the following factors has been shown to decrease survival further, and thus may help in educating medical personnel as to the appropriateness of hospice for cardiac patients.
. Symptomatic supraventricular or ventricular arrhythmias that are resistant to anti-arrhythmic therapy
. History of cardiac arrest and resuscitation in any setting
. History of unexplained syncope
. Cardiogenic brain embolism, i.e., embolic CVA of cardiac origin
. Concomitant HIV disease
Adapted from U.S. Department of Health and Human Services. Assistant Secretary for Planning and Evaluation. Important questions for hospice in the next century. Internet. Accessed on April 29, 2010.