Correspondence
Chronic Heart Failure and the Quality of Life
N Engl J Med 1999; 340:1511-1512May 13, 1999
- Article
To the Editor:
Stevenson, in her editorial in response to the article by Cohn et al. (Dec. 17 issue),1,2 writes tellingly regarding the problems of and prospects for patients with advanced congestive heart failure who are foundering despite the best pharmaceutical and systematized care and who are not candidates for transplantation or mechanical circulatory assistance.
It is perhaps not surprising that advanced heart failure has been termed “heart cancer” because of the inexorable and uncomfortable course patients follow, with their condition refractory to conventional and experimental therapy. The analogy to advanced cancer may also provide guidance on how we might best approach this growing number of patients. Oncologists have long recognized that certain forms of treatment provide palliation without reasonable hope of recovery. Such palliation, often administered within the context of a hospice program, provides relief of suffering, comfort, and the facilitation of whatever self-determination is feasible given the patient's condition, all in the patient's venue of choice, usually home.
The adoption of a “palliation” track in clinical or compassionate-use studies of heart failure would do much to provide optimal care to a small but growing number of patients whose conditions have become refractory to the best available care. Patients for whom no other conventional therapies are available are quite willing to accept a greater risk of death in exchange for the promise of an improved quality of life, particularly if they can be freed from the revolving door of recurrent hospitalization and the sinusoidal polarities of compensation and decompensation at ever more frequent intervals and if they prefer the prospect of sudden death to the insidious or not-so-insidious decline that robs them of self-determination.
Well-conceived studies or registries that allow for palliative therapies with oral vesnarinone or milrinone, with or without beta-blockers or rhythm-management devices, would do much to help our patients, perhaps teach us much about this particular phase of the disease and stage of life, and allow us to better fulfill our roles as comforters when a cure is no longer possible.
2 ReferencesMarc R. Pritzker, M.D.
Minneapolis Heart Institute Foundation, Minneapolis, MN 554071
Stevenson LW . Inotropic therapy for heart failure. N Engl J Med 1998;339:1848-1850
Full Text | Web of Science | Medline2
Cohn JN ,Goldstein SO ,Greenberg BH , et al. A dose-dependent increase in mortality with vesnarinone among patients with severe heart failure. N Engl J Med 1998;339:1810-1816
Full Text | Web of Science | Medline
To the Editor:
A cure for illness is the ultimate goal of both patients and physicians, but it is rarely achieved in the case of most cardiovascular diseases. Cardiovascular specialists accept therapies that prolong survival and improve the quality of life and reject therapies that shorten survival and adversely affect the quality of life. Confusion arises when a therapy achieves one of these objectives but not the other. Since we measure our success by the number of lives saved, we accept therapies that prolong life even if they are associated with adverse effects on the quality of life, provided that such effects are mild and transient. Similarly, we recommend therapies that improve the quality of life even if they are associated with a risk of death, provided the risk is relatively small and symptomatic improvement is clinically significant and long-lasting. For example, we accept a small surgical mortality rate to perform revascularization in a patient with three-vessel coronary artery disease who has angina and normal left ventricular function. What should we do when a therapy carries a clinically significant risk of death and yet provides a statistically significant improvement in the quality of life?
Cohn et al. presented an interesting argument about the use of vesnarinone in patients with severe congestive heart failure. They suggested that physicians might consider a trade-off between increased mortality and improvement in the quality of life. In the accompanying editorial, Stevenson discussed some helpful arguments from patients and physicians about the importance of the quality of life when it involves a disease with severe and disabling symptoms. No one denies the importance of the quality of life in this situation. However, I have doubts about the clinical significance of the improvement in the quality of life associated with vesnarinone. Although the improvement was statistically significant, I wonder whether patients appreciated the difference; even if they did, it did not last long. I also wonder how many of these patients had improvement in their congestive heart failure to class II or class I?
In order for an improvement in the quality of life to be worth an increase in mortality, it has to be clinically significant in addition to being statistically significant and should be long-lasting. I doubt that a two-point difference in the degree of improvement in the quality of life is a fair trade for an increase of four points in mortality. Nonetheless, the answer is neither easy nor simple. Sometimes, we may feel so desperate that we need an answer from the dead. If they could tell us that they felt really good and did not mind death before its time, making the choice in favor of the quality-of-life improvements might be worth it. Otherwise, I am certainly not ready for that trade.
Imad A. Alhaddad, M.D.
Bronx Lebanon Hospital Center, Bronx, NY 10457Author/Editor Response
Dr. Cohn replies:
To the Editor: The comments from Pritzker and Alhaddad represent the dialogue we hoped to initiate with our article. As we have previously noted and as cited in our paper, sick patients are willing to trade an increased risk of death for an improvement in the quality of their daily living. Indeed, after the data on vesnarinone were released and the increased mortality rate was explained to the patients in the study, many opted to continue the therapy because of the perception that their symptoms had improved.
The mean benefit of vesnarinone in terms of the quality of life is not particularly large or statistically sustained, so this drug may not be the ideal agent with which to launch a discussion of the therapeutic dilemma. Nonetheless, with this and other drugs, individual responses may be dramatic. Part of this heterogeneity undoubtedly relates to the multiple and varied mechanisms contributing to the symptoms and progression of disease in the patients we recruit for large-scale trials. Although it is impossible to base therapeutic recommendations on such largely anecdotal experiences, we must constantly remind ourselves that we practice medicine on single patients and we seek an individual response that may not match the mean effect of an intervention in a large trial. The challenge to the physician is to combine the data from these trials with other therapeutic and patient-related insights to form a rational approach to managing the care of a single person.
Jay N. Cohn, M.D.
University of Minnesota Medical School, Minneapolis, MN 55455- Citing Articles (1)
Citing Articles
1
Shigetake Sasayama. (2004) Optimising Outcomes in End-Stage Heart Failure Differences in Therapeutic Responses between Diverse Ethnic Groups. Drug Safety 27:Supplement 1, 19-24
CrossRef
