A Systematic Review of Palliative Intent Medical Interventions for Patients with Advanced Heart Failure: A Best Evidence Synthesis Approach

Background: Heart failure (HF) remains a leading cause of morbidity and mortality. Current guidelines recommend improved palliative care delivery, in parallel with active treatment, in those with advanced HF. We investigated all reported interventions with palliative intent in advanced HF. Methods: Given the overall heterogeneity of studies, lack of randomised controlled trials (RCTs) and inconsistent outcome measures, a best evidence synthesis (BES) framework was applied to survey the current state of literature, adhering to the PRISMA Statement (2010). A computerised search was performed using Medline, CINAHL, Embase and Cochrane library, using a specifically designed strategy, for relevant articles describing non-surgical palliative interventions for advanced adult HF, excluding case reports; two independent reviewers graded methodological quality and relevance. Results: Of 6,259, seventeen studies were included, of which 15 demonstrated sufficient quality, according to BES scoring. Of these, the majority examined an outpatient population: 2 were RCTs, 11 were observational, one a case series and another a systematic review. Two studies reported the inefficacy of oxygen therapy. Seven pharmacological studies evaluated three main strategies, of which low dose oral opiates were more clearly effective than infusional inotropes or diuretics. Six reports evaluated various system of care interventions, all of which appeared effective. Measured endpoints were highly variable and no studies systematically addressed early referral. Conclusions: There is an overall paucity of high quality evidence in HF palliative care. Whilst RCTs and greater consensus regarding endpoints appear necessary, current evidence most clearly supports low dose opioids and an integrated system of care.