Many patients with heart failure would prefer to be on chronic
medical therapy, which is likely to prolong survival at the cost of
some quality of life, while others would rather be on a treatment
that makes them feel better but perhaps die sooner, such as oral
inotropic agents--that much is well known. But the path a patient
would choose appears unrelated to LV ejection fraction, NYHA
functional class, quality-of-life scores, or other measures of
symptom status and overall health, according to a small study of
adults with heart failure published online July 28, 2008 in the
Journal of Heart & Lung Transplantation [1], with Jane MacIver
(Toronto General Hospital, ON) as the first author.

"There is no easy way to determine who falls into which group,"
observe the authors. "Talking to patients about their treatment
options, before they are in the terminal stages of heart failure, is
still the best way to understand treatment preferences."

Their analysis included 91 patients with heart failure of either
NYHA class 2 or 4 who were interviewed on management preferences and
completed the Minnesota Living with Heart Failure Questionnaire and
other subjective tests.

The 43 patients in NYHA class 4 had significantly poorer quality-of-
life and dyspnea scores and poorer health overall compared with the
48 in NYHA class 2, to be sure, but the latter group with less
severe disease and the sicker patients didn't differ much in how
often they preferred quality over quantity of life or the reverse.

"One thing we had thought going into the study was that patients who
had suffered extensively from advanced heart failure might feel
differently than those who had never had severe heart failure. But
in fact, that wasn't the case," primary author Dr Heather J Ross
(Toronto General Hospital) told heartwire.

"The reality we've learned, by and large as doctors, is that we're
probably not the best at assuming what they will or won't want," she
said. "I think actually us showing that the patients are making
these decisions early in the course of their illness is an important
thing that the study found."

As part of the interview process, the patients were informed about
the "outcome, treatment burden, and mode of death" for three
treatment options: standard medical therapy, oral inotropic therapy,
and implantation with a left ventricular assist device (LVAD). They
also expressed preferences in hypothetical treatment situations that
accounted for what each option offered with respect to symptom
relief vs survival.

Asked to choose between two of the treatment options, on average the
patients preferred oral inotropes over optimal standard medical
therapy (p<0.01), "indicating a strong preference for the symptom
relief afforded by inotropes" over the better survival promise of
standard meds; optimal medical therapy over an LVAD (p<0.01); and
inotropic drugs over an LVAD (p<0.05).

More patients ranked inotropic therapy as their first choice among
the three options (42%) than an LVAD (32%) or optimal medical
therapy (26%).

The findings support the idea, familiar in the heart-failure
community, that oral inotropic drugs should be available for
palliative care to patients who aren't candidates for heart
transplantation or destination LVAD therapy and want to sacrifice
some survival time in order to feel better, Ross and her colleagues
write.

"In patients who understand, recognize, and are competent enough to
appreciate that distinction, given how horrible death from advanced
heart failure can be," Ross said, "I think [oral inotropic agents]
should be a potential treatment option in the palliative care
setting."

MacIver J, Rao V, Delgado DH, et al. Choices: a study of preferences
for end-of-life treatments in patients with advanced heart failure.
J Heart Lung Transpl 2008; DOI:10.1016/j.healun.2008.06.002 .
Available at: http://www.jhltonline.org.