Identifying Acute Coronary Syndrome Patients Approaching End-of-Life

Abstract

BackgroundAcute coronary syndrome (ACS) is common in patients approaching the end-of-life (EoL), but these patients rarely receive palliative care. We compared the utility of a palliative care prognostic tool (Gold Standards Framework (GSF)) and the Global Registry of Acute Coronary Events (GRACE) score, to help identify patients approaching EoL.Methods and Findings172 unselected consecutive patients with confirmed ACS admitted over an eight-week period were assessed using prognostic tools and followed up for 12 months. GSF criteria identified 40 (23%) patients suitable for EoL care while GRACE identified 32 (19%) patients with ≥10% risk of death within 6 months. Patients meeting GSF criteria were older (p = 0.006), had more comorbidities (1.6±0.7 vs. 1.2±0.9, p = 0.007), more frequent hospitalisations before (p = 0.001) and after (0.0001) their index admission, and were more likely to die during follow-up (GSF+ 20% vs GSF- 7%, p = 0.03). GRACE score was predictive of 12-month mortality (C-statistic 0.75) and this was improved by the addition of previous hospital admissions and previous history of stroke (C-statistic 0.88).ConclusionsThis study has highlighted a potentially large number of ACS patients eligible for EoL care. GSF or GRACE could be used in the hospital setting to help identify these patients. GSF identifies ACS patients with more comorbidity and at increased risk of hospital readmission.

THE STORM (acute coronary Syndrome in paTients end Of life and Risk assesMent) study

“…Fenning et al 10 were the first to analyse the impact of EoL among patients with ACS admitted to the cardiology department using GSF. In their study, 23% of patients had a positive score and 20% of these patients died at 1 year of follow-up.…”

“…According to GSF criteria,10 (figure 1) patients were labelled as positive GSF status when they met at least one general criterion and two heart disease criteria.…”

“…The ‘Gold Standards Framework Prognostic Indicator Guide’ (GSF), originally developed for patients with cancer, recently demonstrated a good accuracy in determining risk stratification in unselected patients presenting with ACS; although it was a single centre experience and did not evaluate the difference between cardiovascular and non-cardiovascular adverse events at follow-up 10 11. WHOQOL-BREF12 represents another widely exploited score analysing physical, psycho-social, emotional and environmental issues, and has not yet been validated in ACS (see online supplementary appendix for details).…”

Future care planning: a first step to palliative care for all patients with advanced heart disease

“…A number of studies have evaluated ways of identifying patients with cardiac diseases who may be suitable for palliative care24 25 with an ongoing debate as to whether the needs of the patient or prognosis should trigger identification. Patients with a limited prognosis who are socially and medically well supported may need limited input from a specialist palliative care team and an approach focusing on proactive planning for the future may be ideally suited to this type of patient.…”

“…In both instances, prognosis is important but recognising the uncertainty of a patient's prognosis may be just as important and in itself should trigger discussions about planning for the future. Prognosis can be estimated or assessed using heart disease specific26–29 or generic30 31 clinical prognostic tools while other tools are sometimes used to assess the need for specialist palliative care 24 25 32. Natriuretic peptides may have a role in the identification of patients in need of a palliative approach to care.…”