Search

Heart failure (HF) treatment is based on pharmacological therapy, interventional and surgical procedures and cardiac devices implantation. Implantable devices are primarily used to prevent sudden death as with the implantable cardioverter-defibrillator (ICD), to treat left ventricular dysfunction and complete left bundle branch block through cardiac resynchronisation therapy (CRT), eventually also associated with ICD (CRT-D), and to treat bradyarrhythmias with the cardiac pacemaker (PM).

Patients with the advanced stage of disease admitted to the cardiac intensive care unit (CICU) present different symptoms that affect the quality of life and sometimes survival. Dyspnea, pain, thirst, mood disorders (especially delirium), nausea, and constipation are the main symptoms. These are discussed in detail throughout the chapter.

Palliative care is indicated in patients with heart failure since the early phases of the disease, as suggested by international guidelines. However, patients are referred to palliative care very late. Many barriers could explain the gap between the guidelines’ indications and clinical practice. The term palliative is perceived as a stigma by doctors, patients, and family members because it is charged with negative meanings, a poor prognosis, and no hope for improvement. Many authors prefer the term supportive care, which could facilitate a discussion between doctors, patients, and caregivers. There is substantial variation and overlap in the meanings assigned to these two terms in the literature. Prognosis, as the main indication to palliative care, delays its implementation. It is necessary to modify this paradigm, moving from prognosis to patients’ needs. The lack of access to palliative care programs is often due to a lack of palliative care specialists and this shortage will be greater in the near future. In this study, a new model is proposed to integrate early over the course of the disease the palliative care (PC) specialist in the heart failure team, allowing to overcome the barriers and to achieve truly simultaneous care in the treatment of heart failure (HF) patients.

Purpose of review The number of patients who die in the hospital in the Western world is high, and 20-30% of them are admitted to an ICU in the last month of life, including those in cardiac ICUs (CICUs) where invasive procedures are performed and mortality is high. Palliative consultation is provided in only a few cases. The ethical and decisional aspects associated with the advanced stages of illness are very rarely discussed. Recent findings The epidemiological and clinical landscape of CICUs has changed in the last decade; the incidence of acute coronary syndromes has decreased, whereas noncardiovascular diseases, comorbidities, the patients' age and clinical and therapeutic complexity have increased. The use of advanced and invasive treatments, such as mechanical ventilation, mechanical circulatory support and renal replacement therapies, has increased. This evolution increases the possibility of developing a life-threatening clinical event. Summary This review aimed to analyze the main epidemiological, clinical, ethical and training aspects that can facilitate the introduction of supportive/palliative care programs in the CICU to improve symptom management during the advanced/terminal stages of illness, and address such issues as advance care planning, withdrawing/withholding life-sustaining treatments, deactivation of implantable defibrillators and palliative sedation.

In the last few years, important changes have occurred in the clinical and epidemiological characteristics of patients that were admitted to cardiac intensive care units (CICU). Care has shifted from acute coronary syndrome patients towards elderly patients, with a high prevalence of non-ischemic cardiovascular diseases and a high burden of non-cardiovascular comorbid conditions: both increase the susceptibility of patients to developing life-threatening critical conditions. These conditions are associated with a significant symptom burden and mortality rate and an increased length of stay. In this context, palliative care programs, including withholding/withdrawing life support treatments or the deactivation of implanted cardiac devices, are frequently needed, according to the specific guidelines of scientific societies. However, the implementation of these recommendations in clinical practice is still inconsistent. In this review, we analyze the reasons for this gap and the main cultural changes that are required to improve the care of patients with advanced illness.

Takotsubo cardiomyopathy typically presents in menopausal women following episodes of intense physical or mental stress. To our knowledge, the literature contains only two documented cases of Takotsubo cardiomyopathy arising following a suicide attempt, neither of which involved pharmaceutical poisoning. Here, however, we document the case of a young male patient with borderline personality disorder and a clinical and angiographic presentation compatible with Takotsubo cardiomyopathy arising following a suicide attempt by voluntary drug intoxication (risperidone, barbiturates, and benzodiazepine). The potential pathophysiological mechanisms behind this unusual clinical picture are discussed.

The electrocardiogram (ECG) is a specific but relatively insensitive tool for diagnosing acute cor pulmonale, which is almost always caused by pulmonary embolism. Acute overload of the right ventricle is manifested by a typical triad of ECG features referred to as the S1Q3T3 complex or McGinn and White triad. It includes the presence of S waves in lead I and Q waves with T-wave inversion in lead III (Fig. 14.1). Acute cor pulmonale can also be associated with right axis deviation, transient right bundle-branch block (RBBB), and T-wave inversion in the right precordial leads (Fig. 14.2). It has been suggested that inverted T waves in lead V2 or V3 are a common ECG sign of massive pulmonary embolism. In another study on pulmonary embolism, the pseudoinfarction pattern (QR in V1) and T-wave inversion in lead V2 were strongly correlated with the presence of right ventricular dysfunction and independent predictors of an unfavorable clinical outcome.

Reductions in blood flow (and consequently the oxygen supply) to the myocardium can cause transient or permanent damage (ischemia and necrosis, respectively). Atherosclerosis of the coronary arteries is the most common cause. In most cases, the ischemia initially involves the subendocardial layers of the myocardium, which are characterized by a higher metabolic rate and oxygen consumption than the subepicardial layers since they more exposed to extravascular compressive forces (systolic tension, ventricular filling pressure). Only later does the damage extends to the full thickness of the myocardium (Fig. 11.1).

Acute pericarditis is associated with inflammation of the subepicardial layers of the myocardium, which are in contact with the pericardium. The electrocardiogram (ECG) can be useful in the diagnosis of this disorder, revealing diffuse ST-segment and T-wave changes that evolve in a characteristic manner and are phase-specific.

Arrhythmias are cardiac rhythm abnormalities, that is, rhythms differing from the normal sinus rhythm, which is characterized by heart rates ranging from 60 to 100 beats per minute (bpm). When the rate falls below 60 bpm, the patient is said to have a bradyarrhythmia, whereas rates above 100 bpm are referred to as tachyarrhythmias. Electrocardiographic analysis of an arrhythmia is not limited, however, to heart rate (increased versus decreased): it also includes the rhythm (which can be regular or irregular), the origin (supraventricular versus ventricular), and the morphology of the QRS complex (narrow versus wide) (Table 4.1).

This group of arrhythmias includes several specific syndromes, the most important of which are

A number of cardioactive drugs can cause changes in the electrocardiogram (ECG), the antiarrhythmic agents in particular. The most important effects produced by these drugs are bradyarrhythmias, which have been discussed in detail in Chap. 5. In this chapter, we will examine some of the specific effects of individual drugs, with special emphasis on their proarrhythmic effects.

In its most common form, the Wolff-Parkinson-White (WPW) syndrome is caused by the presence of an embryonic remnant consisting of an accessory atrioventricular pathway. When the pathway bypasses the AV node and connects the atria directly to the ventricles, it is referred to as the bundle of Kent. Less frequently, the anomalous connection is between the AV node or bundle of His and the ventricles, and it is referred to as the bundle of Mahaim. The bundle of Kent is by far the more common variant. In this case, the excitation wavefront travels simultaneously through the usual pathway (the AV node, which normally slows conduction) and much more rapidly through the accessory pathway, thereby activating the ventricles earlier than usual. As a result, the P-R interval is shortened, and the initial part of the ventricular complex is slurred or notched. This distortion is referred to as a delta wave, and it is pathognomonic for the WPW syndrome. The QRS complex in this case is actually a fusion of the complexes resulting from the two pathways of ventricular activation (Figs. 7.1 and 7.2).