Friday, August 15, 2008
The Journal of Heart and Lung Transplantation has a fascinating article looking at treatment preferences in CHF patients. It involved a convenience sample of ~90 patients with CHF (either class II or IV) at a single Canadian center, who were given hypothetical scenarios about treatment options (essentially best medical management, longer life, lingering death; vs. oral inotropes, 4 months of improved symptoms, sudden death; vs. LVAD, improved symptoms and survival, lots of care burdens, lingering death). The basis of this seems to be several trials of oral inotropes which were stopped earlier because of increased mortality in the patients receiving oral inotropes. Despite the increased mortality, patients receiving the inotropes apparently had improved health related quality of life over those receiving best medical care, so the researchers here asked themselves, "Well, is that a reason to stop these trials - maybe some patients would prefer improved symptoms even if it meant decreased survival?" Thus, the current study.
The major findings can be summarized as 1) many patients were happy to take shortened survival if it meant improved symptoms and a non-lingering death and 2) treatment preferences didn't seem to correlate with current CHF severity, symptom severity, or health-related quality of life. While it goes without saying that the scenarios presented to patients were somewhat artificial, the important point here is that there were a substantial number of patients for whom longevity was not the preeminent concern.
This is of course not a surprise, but this paper is written directly at a cardiac research and clinical community and argues research in this population which assume survival benefit as the preeminent treatment outcome is short-sighted, and encourages further scrutiny of oral inotropes as palliative therapy for those patients with quality of life-predominant treatment goals. (Are there any agents currently available? None of the ones they mentioned are commercially available as far as I know. I remember encountering oral inotropes as a resident in research trials but don't know of anything available off the top of my head....)
The other intriguing thing here of course is that preferences didn't seem to be related to current health status or symptoms (the authors had hypothesized that those with the current worse symptoms would be more inclined to receive life-shortening but symptom alleviating treatments). The study wasn't specifically powered to find such a relationship as far as I can tell, however if it exists it is probably not a very powerful interaction. Values may be the more powerful predictor of treatment preferences here.