Commentary Title: Patient-centered Symptom Management and Cardiovascular Treatment

Di Palo and colleagues underscore the crucial role of integrating a palliative approach to medication management for people who live cardiovascular disease. This scientific statement provides much needed information on how both cardiovascular and palliative medications can be used to improve symptoms and quality of life. Contrary to common belief, guideline-directed medical therapy and palliative pharmacotherapy are not mutually exclusive; many cardiovascular drugs not only treat underlying diseases but also alleviate symptoms. The authors offer practical guidance on integrating palliative pharmacotherapy throughout the care continuum for patients with cardiovascular disease. The statement also emphasizes the importance of eliciting patients' preferences and medical care goals, and subsequently providing pharmacotherapy to honor these preferences and goals. This statement has complementary usefulness to all who care for people living with serious cardiovascular disease, including primary care, geriatrics, palliative care, and cardiology.

Beyond shortness of breath and edema: assessing and managing diverse physical and psychological symptoms

Patients with cardiovascular conditions often experience a range of symptoms that may be overlooked without regular assessment. Symptoms such as depression, anxiety, pain, sleep disturbance, and gastrointestinal symptoms are prevalent and distressing in this population but are less commonly assessed.^1–5 This is a challenge in part because much cardiovascular pharmacotherapy is based on disease indications (e.g., ejection fraction or disease etiology) and less commonly specific symptoms. Incorporating symptom-based pharmacotherapy guidance such as the authors did in this statement is a start. However, addressing symptoms and quality of life often requires multiple modalities, such as combinations of medications, behavior change, counseling to address coping, physical or occupational therapy, etc.⁶

The importance of patient-centered decision making in prescribing and deprescribing

Ultimately, patient goals and their personal definition of quality of life should drive treatment decisions. It is the responsibility of all clinicians, especially those who have frequent interactions with patients and families, to elucidate these goals. Given the limited availability of specialty palliative care, cardiovascular and primary care clinicians must lead the charge in patient-centered decision-making across all aspects of care. ^7–9 Clinicians can draw upon the helpful tables this statement that depict which cardiovascular medications reduce symptoms by illness, and which palliative medications can help with symptoms that persist despite cardiovascular pharmacotherapy.

We would like to highlight the deprescribing guidance in this statement. There remains limited knowledge on the risks and adverse effects of cardiovascular medications in older adults, especially those with multimorbidity or advanced illness. There is growing yet still limited evidence on how benefits of many cardiovascular medications may change in these populations.^10,11 We congratulate the authors on including deprescribing guidance. However, more understanding is needed of the relative benefits versus risks and adverse effects in people with cardiovascular disease who may be approaching their finals months to short years to fully inform patient-centered decision making.

Key takeaways and next steps

This scientific statement offers several key takeaways. First, identifying patient goals around symptoms, function, and quantity vs. quality of life should be central when making treatment decisions at any stage of the disease. Second, depending on goals and a patient's stage of illness, deprescribing should be considered. Tools such as the Beer's criteria¹² and guidance in this statement can assist in identifying potentially inappropriate medications and aid in deprescribing. Third, routine screening for diverse physical and psychological symptoms is vital in the care of individuals with cardiovascular disease.¹ Following assessment, clinicians can consider both pharmacological and non-pharmacological treatments to alleviate symptom burden.

Further research and guidance are needed to develop best practices for integrating patient-centered decision-making across the cardiovascular disease care continuum and furthering the evidence base for palliative pharmacotherapy. For instance, how can we routinely assess multi-domain symptoms and determine which clinicians will address these symptoms? Who will take the lead in conducting timely goals of care conversations for patients with multiple health care professionals, and how can these preferences and goals be effectively communicated across clinicians and specialties? What is the safety, relative benefit, and adverse effect and risk profiles of palliative, symptom-based medications? What patient-facing materials, such as decision aids, would be most useful for palliative pharmacotherapy or deprescribing?

Conclusion

As we provide pharmacologic treatment to patients with cardiovascular disease, understanding goals of care and engaging in shared decision-making should be our foundation and guiding light. Ultimately, pharmacological treatment decisions should be guided by these goals and effectively communicated across the care teams.