Acute Coronary Syndrome in an Older Adult with Recent or Ongoing Cancer Treatment: A Palliative Care Viewpoint
The clinical care of patients with cardiovascular disease (CVD) is infrequently simple and complexity often rises exponentially as patients get older. For many patients, CVD does not exist in isolation, and they frequently have multiple comorbidities that can attenuate the benefits and magnify the risk of treatments and procedures. Patients with comorbidities experience greater decision conflict and do not experience the same benefits from procedures as patients without comorbidities.1
Both clinical cases present challenges to the patients and clinicians. They are ostensibly similar yet fundamentally different.
In case 1, a 78-year-old woman presents with unstable angina and at baseline she has angina that limits her significantly as to function. Complicating the situation is the fact that she has a history of lung cancer, which is currently in remission. The question here is whether the team should proceed with a cardiac catheterization.
In this case, cardiac catheterization might well be considered a palliative intervention, for it is meant specifically to help relieve the patient's debilitating symptoms. This would be particularly true if the patient is already being prescribed maximally tolerated anti-anginal medications.
We are not told anything about the patient's goals of care, values or wishes pertaining to resuscitation but, presumably, she would prefer to be free of angina. While there might be a notion that a palliative therapy and an invasive procedure may be mutually exclusive, this case represents a thoughtful deployment of a procedure to help improve a patient's quality of life. Any potential mortality benefit is secondary but, presumably, would not represent an unwanted prolongation of life. This might particularly be applicable for a procedure that has gotten safer over time such as percutaneous coronary intervention (PCI). It is important in this case to proceed with a radial approach to minimize complications. Nonetheless, complications can happen during procedures, and resuscitation status discussions should be had with the patient prior to the procedure. The situation may change if the patient has triple vessel disease involving the left main and is diabetic with a low ejection fraction. Depending on her values and wishes, coronary artery bypass grafting may constitute a higher risk intervention with significant post-operative discomfort that does not fit into her goals of care. Multivessel PCI, despite recent trial data, may adequately address the issue of symptom relief, even though it represents a "second best" option, at least in terms of repeat revascularization.
In case 2, a 79-year-old male presents with minimal chest pain and is found to have a troponin elevation and therefore a non-ST elevation myocardial infarction (NSTEMI). The patient has metastatic bladder cancer and is actively being treated with pembrolizumab. In this case, the team correctly consulted with oncology to find out that the patient has a very limited survival due to his cancer.
In this case, the correct decision may be to forego cardiac catheterization. The patient had minimal to no chest pain and therefore PCI would be unlikely to have benefited him from a purely palliative and symptomatic point of view. Furthermore, given his limited survival due to the metastatic bladder cancer, he was also unlikely to experience the other benefits in "hard outcomes" that an invasive approach could traditionally yield. Mortality benefits are likely moot, and it makes little sense to subject him to the very low but potential risk of morbidity related to the procedure. Treatments with antiplatelet agents may increase the propensity of patients to have hematuria and other bleeding complications. The only potential benefit would be in avoiding a similar representation. While it is true that, for most people, frequent hospital visits for non-lethal cardiac events are not compatible with a good quality of life, it is likely that medical therapy for NSTEMI (minus medications that cause bleeding, light-headedness or fatigue) should go a long way toward avoiding this outcome. If they prove insufficient, it would be reasonable to reconsider the non-invasive approach. A decision to implant a coronary stent cannot be rescinded.
Importantly, there are multiple other causes of troponin elevation, including effects from chemotherapy, and these should be investigated prior to diagnosing a coronary event. Although it involves a fair amount of nephrotoxic contrast administration, this may represent an indication for a "triple rule out" computed tomography (CT) angiogram, and/or a cardiac magnetic resonance imaging (MRI) to assess for myocarditis. Establishing an explanation for the troponin elevation may help with prognostication, even if it does not lead to a therapeutic intervention, and would certainly direct medical therapies (antiplatelet agents).
These cases present real-word scenarios challenging the traditional role of coronary interventions in the care of patients with acute coronary syndromes. Procedures do not necessarily have to be at odds with palliative care, provided they help patients achieve their goals.
- Warraich HJ, Allen LA, Blue LJ, et al. Comorbidities and the decision to undergo or forego destination therapy left ventricular assist device implantation: an analysis from the DECIDE-LVAD study. Am Heart J 2019;213:91-96.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardio-Oncology, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and SIHD, Interventions and ACS
Keywords: Acute Coronary Syndrome, Percutaneous Coronary Intervention, Angina Pectoris, Coronary Artery Bypass, Heart Diseases, Patient Care Planning, Patient Care, Terminal Care, Geriatrics, Cardiotoxicity, Cardio-oncology
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