Toronto, ON - 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."

We had thought . . . 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.

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.

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.

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."