Palliative medicine for patients with advanced heart failure: New evidence

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Solís García del Pozo, C. Olmeda Brull, J.J. de Arriba Méndez, M. Corbí Pascual" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Solís García del Pozo" "email" => array:1 [ 0 => "julianeloysolis@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Olmeda Brull" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J.J." "apellidos" => "de Arriba Méndez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Corbí Pascual" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital General de Villarrobledo, Villarrobledo, Albacete, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Medicina Paliativa, Complejo Hospitalario y Universitario de Albacete, Albacete, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cardiología, Complejo Hospitalario y Universitario de Albacete, Albacete, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Medicina paliativa en pacientes con insuficiencia cardiaca avanzada: Nuevas evidencias" ] ] "textoCompleto" => "BackgroundHeart failure is one of the most important clinical syndromes due to its high incidence rate, prevalence, morbidity and mortality. The condition entails considerable healthcare resource expenditures and hospitalization costs, which will probably increase considerably in the coming years. In internal medicine departments, heart failure is represented in more than 12% of hospital discharges.<a class="elsevierStyleCrossRef" href="#bib0215">1</a> Patients hospitalized for heart failure in internal medicine departments have special characteristics, such as high physical dependency and a high percentage of women with preserved left ventricular ejection fraction.<a class="elsevierStyleCrossRefs" href="#bib0220">2,3</a> In individuals older than 75years, the prevalence of heart failure is >15%.<a class="elsevierStyleCrossRef" href="#bib0230">4</a> This clinical importance is also reflected in terms of research and the number of medical publications, demonstrated by the 9283 articles returned by a search for “advanced heart failure” in PubMed (November 2017), 7776 of which (84%) have been published since 2000. The articles dedicated to palliative care in heart failure from the same date, although obviously fewer, also reflect its growing importance, with 1316 articles returned by PubMed with this search. Of these, 1128 (86%) have been published since 2000.An example that illustrates the growing importance of studying palliative care in heart failure is the recent publication of clinical trials that have demonstrated that a multidisciplinary palliative intervention provides benefits for patients with advanced heart failure in terms of quality of life, spiritual wellbeing and reduced depression and anxiety. This perspective currently connects with the humanization trends in health care, which are gaining importance in the Spanish healthcare system. As happens with other chronic nononcologic diseases, however, the difficulty in establishing a prognosis for patients with heart failure causes physicians to overestimate these patients’ survival. This overestimation contributes to a perceived lack of care in planning palliative treatment for these patients.<a class="elsevierStyleCrossRef" href="#bib0235">5</a>The objective of this review is therefore to describe the new evidence in the form of clinical trials conducted during the past 5 years on the usefulness of palliative care for patients with advanced heart failure and its effect in controlling symptoms and improving the living conditions of these patients.What is meant by advanced heart failure?Heart failure is a first-order healthcare problem. In recent years, there has been an increase in the number of hospitalizations for heart failure in Spain.<a class="elsevierStyleCrossRef" href="#bib0240">6</a> The American College of Cardiology and the American Heart Association classify patients with heart failure into 4 groups (A, B, C and D). Group C presents heart failure symptoms such as dyspnea and exercise intolerance, and group D presents refractory heart failure or symptoms at rest despite optimal treatment. This classification can be supplemented with the New York Heart Association (NYHA) classification, which categorizes patients from I to IV according to their functional capacity. Class III patients have significant limitations and symptoms even with mild activity. Class IV patients present severe limitations and symptoms even at rest.There is no clear consensus of how to define patients with advanced or terminal heart failure. It seems clear that stage D patients or those with an NYHA classification of IV could be encapsulated in this advanced or terminal heart failure group. Nevertheless, we must consider other factors such as frequent hospitalizations, inability to perform daily life activities and the need for intravenous drug support.<a class="elsevierStyleCrossRef" href="#bib0245">7</a> Following Crespo Leiro and Paniagua Martín, we can differentiate between advanced and terminal heart failure.<a class="elsevierStyleCrossRef" href="#bib0250">8</a> Advanced or refractory heart failure can be defined as the persistence of symptoms that limit daily life (NYHA functional class III or IV, stage D of the ACC/AHA) despite a previous optimal treatment. Lacking a contraindication, these patients would be candidates for alternative therapies such as heart transplantation, surgical ventricular restoration, mechanical circulatory assistance and the intravenous administration of inotropic drugs.<a class="elsevierStyleCrossRef" href="#bib0250">8</a> In the last stage of advanced heart failure, we have terminal heart failure, in which patients respond poorly to all forms of treatment, with significantly impaired quality of life, frequent hospitalizations and a life expectancy of less than 6months.<a class="elsevierStyleCrossRef" href="#bib0250">8</a> Based on our current knowledge, palliative treatment should always be introduced gradually as the disease progresses and should be offered to all patients with heart failure who need palliative care, even when they are not in stage D.Moreover, the difficulty in establishing the prognosis for patients with heart failure causes physicians and patients to overestimate the survival and underestimate the risk of death by heart failure. As a result, patients do not participate to the desired extent in the decisions on palliative treatment that directly affect them. Despite the apparent simplicity of the stages and classifications mentioned earlier, recognizing that a patient is at stage D or has advanced heart failure is often highly complicated and unclear from the clinical standpoint. This uncertainty is likely determined by the differing progression of chronic medical diseases compared with oncologic diseases, in which practitioners are more accustomed to recognizing their final stages,<a class="elsevierStyleCrossRef" href="#bib0255">9</a> and by the heterogeneity in the progression of the end-of-life experience of patients with advanced organ disease such as heart failure.<a class="elsevierStyleCrossRef" href="#bib0260">10</a>Given the enormous difficulty in predicting the prognosis of patients with heart failure, a number of instruments have been developed to improve this issue. The recently developed models for improving the recognition and prognosis of chronic medical diseases include the PALIAR index implemented in Spain,<a class="elsevierStyleCrossRef" href="#bib0265">11</a> which covers a series of predictors for mortality in the 6 subsequent months. These predictors include an age of 85years or older, the presence of anorexia, the presence of pressure ulcers, a serum albumin level <2.5g/dL, an Eastern Cooperative Oncology Group (ECOG) score ≥3, and an NYHA functional class of IV or grade 4 on the modified dyspnea scale of the Medical Research Council (mMRC). Another of these instruments is the NECPAL-CCOMS-ICO 3.0, which employs general variables for chronic diseases regarding nutritional, functional, cognitive, dependence, psychosocial and resource use aspects, among others, and includes specific items for various chronic diseases, including items for heart failure.<a class="elsevierStyleCrossRef" href="#bib0270">12</a>Other specific instruments have been developed for patients with heart failure such as the Seattle Heart Failure Model (SHFM), the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) model and the Heart Failure Survival Score. SHFM includes 10 continuous variables (age, left ventricular ejection fraction, NYHA class, systolic blood pressure, weight-adjusted diuretic dosage, lymphocyte count, hemoglobin level, serum sodium level, total cholesterol level and uric acid level) and 10 categorical variables (sex, ischemic cardiomyopathy, QRS >120ms, use of β-blockers, use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, potassium-sparing diuretics, statins and allopurinol and carrier of implantable cardioverter defibrillator/cardiac resynchronization therapy). These variables are included in an equation that provides a risk assessment for our patients, which can be expressed as life expectancy at 1, 2 or 5years, although it provides a modest discriminative capacity. A calculator for this model can be downloaded from <a href="http://depts.washington.edu/shfm/?width=1366%26height=768">http://depts.washington.edu/shfm/?width=1366&height=768</a>.<a class="elsevierStyleCrossRef" href="#bib0275">13</a>However, these scales are difficult to implement and interpret due to the variability in the progression of heart failure among patients and according to cause and associated disease. A number of medical associations have therefore proposed a set of clinical indicators that help practitioners suspect that their patients are at an advanced stage of their disease. For example, the Heart Failure Society of America proposed a set of clinical indicators that include 2 or more hospitalizations for heart failure in a year, diuretic therapy refractoriness, persistent hyponatremia, progressive/persistent NYHA class III or IV, mortality risk at 1 year (e.g., 20–25%) determined by predictive models such as SHFM, inability to perform daily life activities, presence of cardiac cachexia and progressive organ dysfunction such as renal and hepatic failure. These indicators thereby establish the following definition for advanced heart failure (stage D): the presence of progressive or persistent signs and severe symptoms of heart failure despite optimal medical therapy, surgery and cardiac support devices. Advanced heart failure is generally accompanied by frequent hospitalizations, severely limited tolerance to exercise, and impaired quality of life and is associated with high morbidity and mortality. The medical associations clearly specify that the progressive deterioration must be caused primarily by the heart failure syndrome.<a class="elsevierStyleCrossRef" href="#bib0280">14</a>The US National Hospice Organization developed criteria for selecting patients who are candidates for admission to a hospice, with a survival of less than 6months. In addition to a set of general standards for all patients, the organization established criteria for patients with heart failure that included a functional class of IV despite optimal therapy, left ventricular ejection fraction <20%, and the presence of other factors such as a history of syncope, having required cardiopulmonary resuscitation, human immunodeficiency virus infection, embolism of cardiac origin and the presence of arrhythmias uncontrollable with medication. These criteria could be highly restrictive and might lack sensitivity, especially among the elderly.<a class="elsevierStyleCrossRef" href="#bib0285">15</a>Symptoms in advanced heart failureThe symptoms needing palliative care for patients with heart failure include common ones such as pain and dyspnea and in general do not differ from those known in other chronic diseases in advanced phases.<a class="elsevierStyleCrossRef" href="#bib0290">16</a> The Edmonton Symptom Assessment Scale (ESAS) is one of the instruments employed in clinical trials on palliative care for heart failure to assess symptoms. This instrument was developed in 1991,<a class="elsevierStyleCrossRef" href="#bib0295">17</a> and its original version examined 9 symptoms (pain, asthenia, anorexia, nausea, anxiety, depression, general wellbeing, drowsiness and respiratory distress), although subsequent versions have introduced variations. Each symptom is assessed on a scale from 0 (absence of symptom) to 10 (maximum symptom intensity). The scale has been widely used in palliative medicine.<a class="elsevierStyleCrossRef" href="#bib0300">18</a>Another aspect is the instruments for assessing the quality of life of patients with heart failure. In addition to generic instruments not specifically adapted to this type of patient, such as the EQ-5D, specific questionnaires have been developed, such as the Kansas City Cardiomyopathy Questionnaire (KCCQ),<a class="elsevierStyleCrossRef" href="#bib0305">19</a> which includes an assessment of the various physical, mental and social measures, an assessment of the change in symptoms and a measure of these patients’ self-care. There is a Spanish-validated version of this instrument.<a class="elsevierStyleCrossRef" href="#bib0310">20</a>Clinical trials conducted on palliative treatment in advanced heart failure in the past 5 yearsAlthough data have been published on the efficacy of palliative care for patients with heart failure,<a class="elsevierStyleCrossRef" href="#bib0315">21</a> several more recently conducted randomized trials have stressed the importance of palliative care in advanced heart failure (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Most of these trials refer to interventions conducted with the patient at home or after discharge. This type of intervention usually consists of a combination of telephone calls through nursing and home visits by the palliative team, as well as educational interventions for patients and relatives on symptom care and control.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>To find these trials, we searched PubMed using the terms “palliative care” and “heart failure”, limiting the search to the last 5years and using the filter for clinical trials. The search was performed in November 2017, and 32 references were found. We chose those studies that assessed the efficacy of a palliative intervention for patients with advanced heart failure, in terms of symptom control, quality of life and improved care and/or communication. We also reviewed the references listed in the trials in search of other studies. Among the search results, we found an article that described the methodology of a trial that was subsequently published in 2018.<a class="elsevierStyleCrossRefs" href="#bib0320">22,23</a> For another of the trials published in 2016, new supplementary results have been presented in 2018.<a class="elsevierStyleCrossRef" href="#bib0330">24</a> Both references have been included in this review.One of the main difficulties when selecting a trial is its heterogeneity, because some trials are conducted with hospitalized patients and others with discharged patients, and the interventions also differ among each other in various aspects. One of the other challenges in these trials is the appropriate identification of patients with terminal heart disease. Despite these difficulties, this review offers an overview of trials conducted on this topic in recent years.Brännstrom and Boman<a class="elsevierStyleCrossRefs" href="#bib0335">25,26</a> recruited 72 patients at NYHA functional stage III–IV who were randomized to undergo a PREFER intervention (person-centered and integrated palliative advanced home care and heart failure). The intervention established a collaboration between the team who treated the heart failure and those responsible for palliative care. A patient-focused palliative intervention was conducted at home, based on aspects that included the patient's self-image, social relationships, symptoms and autonomy. Compared with the patients in the control group, the patients who underwent this intervention improved in terms of quality of life measured with the EQ-5D questionnaire and had reduced readmissions, but there were no differences in the symptoms measured with ESAS. Based on this study's patients, Sahlen et al.<a class="elsevierStyleCrossRef" href="#bib0345">27</a> published a study in 2016 on cost effectiveness. The results showed a gain of 0.25 quality-adjusted life years, and the cost analysis showed a significant reduction in the intervention group, including a lower consumption of hospital resources.Sidebottom et al.<a class="elsevierStyleCrossRef" href="#bib0350">28</a> conducted a trial with hospitalized patients who received palliative care versus those who received conventional care. The trial initially included 116 patients in each group (232 in total). The follow-up showed greater improvement in months 1 and 3 in the intervention group, both in terms of quality of life (p<.001) and symptom burden measured by the ESAS.In 2015, Thoonsen et al.<a class="elsevierStyleCrossRef" href="#bib0355">29</a> conducted a trial aimed at improving general practitioners’ identification of patients with chronic obstructive pulmonary disease (COPD), heart failure and cancer who require palliative care. The identified patients were offered a session with a palliative care specialist to refine a structured care plan. There was no difference in the identification of patients among the physicians who underwent the training and those who did not. Despite this, the patients who were identified had more contact with their general practitioner, were less often hospitalized and more frequently died at home, which continues to show the value of developing new strategies for identifying these patients. In any case, the number of patients with heart failure identified as needing palliative care was very low.Among the trials conducted mainly with hospitalized patients with advanced decompensated heart failure, there is the study by Hopp et al.<a class="elsevierStyleCrossRef" href="#bib0360">30</a> published in 2016, which included African-American patients with advanced heart failure who were hospitalized for acute decompensation. The study compared the effect of a palliative care consultation versus conventional care. The primary endpoint was the proportion of patients who chose “comfort-focused” care (hospice and/or do-not-resuscitate orders). Some 9.3% of the 43 patients with this intervention chose comfort-focused care versus none of the 42 patients in the other group. These results were not statistically significant.In 2016, Ritchie et al.<a class="elsevierStyleCrossRef" href="#bib0365">31</a> conducted a study with patients with COPD or heart failure to improve the transition from hospital to home through the support of a nurse, follow-up and post-hospitalization telephone calls. In the COPD group, the intervention was associated with shorter hospital stays but did not improve the rate of readmission at 30days; this benefit was not demonstrated in the patient subgroup with heart failure. Nevertheless, this study included patients with heart failure discharged with a prognosis estimated at longer than 6months. The results might therefore not be applicable to patients with a poorer prognosis.In 2016, Denvir et al.<a class="elsevierStyleCrossRef" href="#bib0370">32</a> conducted a small trial with 50 patients hospitalized with heart failure or acute coronary syndrome with a mortality risk >20% at 12months. The patients were randomized to standard care alone or to standard care plus future care planning, i.e., an intervention directed at documenting and implementing end-of-life decisions. The patients were divided into 2 groups. Twenty-five patients were randomized to this intervention in the first 12weeks after discharge, followed by another 12weeks of standard care. The second group received standard care for the first 12weeks, followed by the intervention for the last 12weeks of the trial. The patients in the first group more frequently arrived at decisions on the various end-of-life aspects including issues on medical care, legal aspects and the patient's preferred location for their death. The authors found that this type of intervention did not increase the patients’ anxiety or stress and that it was well assessed by the patients, caregivers and family physicians. This trial did not show an improved quality of life, measured with the EQ-5D questionnaire.Doorenbos et al.<a class="elsevierStyleCrossRef" href="#bib0375">33</a> published a randomized study to determine the efficacy of a strategy to improve communication on care objectives, initially based on a telephone call performed before the medical visit by a nurse. This intervention succeeded in improving the number of conversations regarding these objectives and the quality of the communication at the end of life without increasing the patients’ anxiety or depression.Wong et al.<a class="elsevierStyleCrossRef" href="#bib0380">34</a> designed a study in Hong Kong that employed as an intervention a home palliative care plan after the hospital discharge. The trial participants were patients discharged from hospital and referred to the palliative care department. The intervention consisted of weekly home visits or telephone calls for the first 4 weeks and then monthly, conducted by a case manager nurse. There were 43 patients in the intervention group and 41 in the control group. The intervention group had a lower rate of readmission at 12weeks (p=.009) and clinical improvement in variables such as depression (p<.05) and dyspnea (p<.05) and a higher score on the ESAS (p<.05) at 4weeks. This improvement in symptoms was calculated using the classification for each patient in improvement/deterioration/no change based on previously published cutoffs<a class="elsevierStyleCrossRefs" href="#bib0385">35,36</a> for the minimum clinically significant difference. There were also differences in the quality of life measured with the McGill QOL questionnaire. These authors subsequently published a study on cost effectiveness in which they concluded that a home intervention such as the one described above is cost effective.<a class="elsevierStyleCrossRef" href="#bib0395">37</a> Subsequently in 2018, these authors published the results of their trial, emphasizing the quality of life, symptoms, satisfaction with the care and caregiver burden. The authors found significant differences at 12weeks, with improvement in the intervention group in terms of quality of life, satisfaction with the care and caregiver burden.<a class="elsevierStyleCrossRef" href="#bib0330">24</a>In 2017, Rogers et al.<a class="elsevierStyleCrossRef" href="#bib0400">38</a> published a clinical trial that compared 75 patients who underwent conventional treatment with another 75 who underwent conventional treatment and were prescribed a multidisciplinary intervention in palliative care in coordination with the cardiology team who treated the patient. Most of the participants were patients who had undergone a consultation with the palliative care team before the hospital discharge. After discharge, the patient was followed-up and managed by the palliative care team, maintaining the cardiac therapy. The latter group achieved improved scores on the quality-of-life questionnaires, Kansas City Cardiomyopathy Questionnaire (KCCQ) and Functional Assessment of Chronic Illness Therapy-Palliative Scale (FACIT-Pal) at 6months of the intervention (p=.03 and p=.035, respectively for the questionnaires). Improvement was also demonstrated using the Hospital Anxiety and Depression Survey (HADS), the HADS-depression scale (p=.020) and the HADS-anxiety scale (p=.048); improved spiritual wellbeing was also demonstrated (FACIT-Sp, p=.077). There were no differences between the groups for readmissions or mortality.The recently published Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) randomized trial<a class="elsevierStyleCrossRefs" href="#bib0320">22,23</a> went beyond the scope of palliative care by assessing the effect of an intervention based on treating the symptoms of patients with symptomatic heart failure, along with a psychosocial approach by a multidisciplinary team that included a nurse and a social worker, contact with the primary care physician, cardiologist and palliative medicine physician, comparing this approach to standard care. The study measured the efficacy at 6months for patients with heart failure and a poor state of health. The primary outcome measure was the Kansas City Cardiomyopathy Questionnaire-Short Form (KCCQ-12), along with other measures of depression, distress, patient satisfaction, quality of life, hospitalizations and mortality. The patients in the intervention group improved their KCCQ scores but not significantly compared with the control group. The patients in the intervention group improved in terms of depression and asthenia (p=.02). There were no significant changes in general anxiety, in other symptoms such as pain and respiratory distress, in the number of hospitalizations or in the mortality at 12months. This group had previously published a small pilot trial to determine the feasibility of the intervention.<a class="elsevierStyleCrossRef" href="#bib0405">39</a>In 2014, Higginson et al.<a class="elsevierStyleCrossRef" href="#bib0410">40</a> published a trial that offered a care service that integrated palliative care, medicine, physical therapy and occupational therapy to patients with dyspnea due to advanced disease. The study included patients with cancer, COPD, interstitial lung disease and heart failure. The patients improved their dyspnea, which lead the authors to support integrating palliative care for patients with dyspnea due to diseases other than cancer. Unfortunately, this trial only included 5 patients with heart failure (4 in the intervention group and 1 in the control group) and was therefore not included in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.In 2016, Malhotra et al.<a class="elsevierStyleCrossRef" href="#bib0415">41</a> published the design of a trial whose objective was to assess whether patients with advanced heart failure for whom advance care is planned have a greater probability of receiving this end-of-life care according to their preferences compared with those who receive standard care. The intervention assumes having a facilitator who performs this planning and who also provides emotional support for patients and families with the end-of-life decision-making process.ConclusionsThroughout this review, we have briefly discussed some of the aspects related to palliative care directed to patients with advanced heart failure. From what we have reviewed, it seems clear that starting palliative treatments for patients with heart failure does not preclude implementing other active cardiac procedures. In fact, the approach of relieving symptoms and addressing the comprehensive treatment of heart failure can already be started for patients who have not yet reached stage D of the disease and can be increased in intensity and importance as the heart disease progresses. This is the current vision in which palliative treatment and “active” treatment are 2 complementary aspects of patient management that should not be overlooked. It remains to be seen how the new (such as sacubitril-valsartan) and future treatments for heart failure will alter the clinical spectrum and disease evolution and thereby the best time for planning the start of palliative measures in patients with heart disease.The recent trials conducted with patients with advanced heart disease make it clear in any case that an appropriate palliative intervention for these patients improves their quality of life, prevents readmissions and is cost-effective. As we have seen in the study by Denvir et al.,<a class="elsevierStyleCrossRef" href="#bib0370">32</a> an appropriate intervention focused on including patients in the decision-making process for the end of their lives is important not only for making decisions on the medical care but also for arranging legal issues and determining the location where the patient prefers to be cared for and where they want to die. Moreover, the option of early planning for health care with the participation of all those involved and over the entire disease process improves the relationship with the patient, the care provided and the optimization of resources.<a class="elsevierStyleCrossRef" href="#bib0420">42</a>One of the problems in implementing this strategy lies in the fact that practitioners, patients and relatives do not perceive the actual severity and prognosis of this disease and overestimate the survival and treatment options in the disease progression. The main result of this overestimation is that the patient is often prevented from receiving the most appropriate treatment for their condition. Providing physicians with strategies to recognize patients who are candidates for palliative measures without neglecting the rest of the treatment of their heart failure might be the first steps in this direction.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1225429" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1139228" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1225428" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1139229" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "What is meant by advanced heart failure?" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Symptoms in advanced heart failure" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Clinical trials conducted on palliative treatment in advanced heart failure in the past 5 years" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-04-01" "fechaAceptado" => "2018-09-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1139228" "palabras" => array:3 [ 0 => "Heart failure" 1 => "Palliative care" 2 => "Clinical trials" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1139229" "palabras" => array:3 [ 0 => "Insuficiencia cardiaca" 1 => "Cuidados paliativos" 2 => "Ensayos clínicos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Although heart failure is one of the most common clinical syndromes in medicine and has a high mortality rate, few patients have access to adequate palliative care for their clinical situation. Several trials have recently been published on the usefulness of starting palliative treatment along with cardiac treatment for patients with advanced heart failure. In this review, we analyze the aspects of diagnosing and controlling the symptoms of patients with advanced heart failure and provide a collection of clinical trials that have analyzed the efficacy of a palliative intervention in this patient group. Physicians need to be equipped with strategies for recognizing the need for this type of intervention without it resulting in neglecting the active treatment of the patient's heart failure." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "A pesar de que la insuficiencia cardiaca es uno de los síndromes clínicos más frecuentes en medicina y de su elevada mortalidad, pocos son los pacientes que se benefician del acceso a unos cuidados paliativos adecuados a su situación clínica. Recientemente se han publicado varios ensayos para comprobar la utilidad de iniciar tratamiento paliativo junto con el tratamiento cardiológico en pacientes con insuficiencia cardiaca avanzada. En la presente revisión se analizan aspectos sobre el diagnóstico y el control de síntomas de pacientes con insuficiencia cardiaca avanzada, y se ofrece una recopilación de ensayos clínicos que analizan la eficacia de una intervención paliativa en este grupo de pacientes. Es preciso dotar al médico de estrategias para reconocer la necesidad de este tipo de intervenciones sin que ello implique descuidar el tratamiento activo de su insuficiencia cardiaca." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Solís García del Pozo J, Olmeda Brull C, de Arriba Méndez JJ, Corbí Pascual M. Medicina paliativa en pacientes con insuficiencia cardiaca avanzada: Nuevas evidencias. Rev Clin Esp. 2019;219:332–341." ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: ACP, advance care planning; EFFECT score, Enhanced Feedback for Effective Cardiac Treatment score; EQ-5D, quality-of-life questionnaire; ESAS, Edmonton Symptom Assessment Scale; FACIT-Pal, Functional Assessment of Chronic Illness Therapy-Palliative Care; GAD-7, Generalized Anxiety Disorder Questionnaire; GRACE, Global Registry of Acute Coronary Events; HADS, Hospital Anxiety and Depression Scale; KCCQ, Kansas City Cardiomyopathy Questionnaire; MLHFQ, Minnesota Living with Heart Failure Questionnaire; MQOL-HK, McGill Quality of Life Questionnaire – Hong Kong; PHQ-9, 9-item Patient Health Questionnaire; PPS, Palliative Performance Status; QOC questionnaire, Quality Of Communication questionnaire." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Year \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Duration \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Characteristics of the included patients \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intervention \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Result \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Brännstrom and Boman<a class="elsevierStyleCrossRefs" href="#bib0335">25,26</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72 (36:36) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic heart failure NYHA III–IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multidisciplinary approach between palliative medicine and heart failure specialists Individual-focused care, structured and at home \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">EQ-5D with improvement in the intervention group. ESAS and KCCQ with improvement in some items but with no significant differences as a whole. Fewer hospitalizations in the intervention group. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sidebottom et al.<a class="elsevierStyleCrossRef" href="#bib0350">28</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">232 (116:116) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3–6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adult patients hospitalized with a diagnosis of heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consultations with the palliative care team \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ESAS, PHQ-9, MLHFQ, ACP: improvement with the intervention. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thoonsen et al.<a class="elsevierStyleCrossRef" href="#bib0355">29</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">134 (57:77) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The intervention was performed on the general practitioners. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Training to identify patients with palliative care needs. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No differences in the low patient identification rate. The identified patients kept greater contact with their general practitioner, had fewer hospitalizations and were more likely to die at home than at the hospital. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hopp et al.<a class="elsevierStyleCrossRef" href="#bib0360">30</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85 (43:42) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients hospitalized with acute heart failure, with a 1-year mortality risk ≥33% and/or NYHA III–IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consultation with palliative care in the hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The selection of hospice care or do-not-resuscitate orders increased for those where palliative care was consulted but was not statistically significant. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wong et al.<a class="elsevierStyleCrossRef" href="#bib0380">34</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2016 (2018<a class="elsevierStyleCrossRef" href="#bib0330">24</a>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">84 (43:41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NYHA III-IV, life expectancy <1year, readmitted, presence of symptoms despite appropriate treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transitional care palliative - end-stage heart failure (TCP-ESHF) with home visits and telephone calls \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Improved readmission rate at 12 weeks for the intervention group. ESAS, MQOL-HK improved in the intervention group at 4 weeks. No significant differences in PPS between the groups. Improved QOL, satisfaction of care and caregiver burden (data published in 2018) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Denvir et al.<a class="elsevierStyleCrossRef" href="#bib0370">32</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 (25:25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with heart failure or acute coronary syndrome with a mortality rate ≥20% at 12months according to the GRACE or EFFECT scores. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Personalized interviews (initial and home), telephone support and discussion on future care planning. Crossover trial with 2 groups: Early intervention group after hospital discharge and another group with a late intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ESAS, EQ-5D, Kessler distress score, no differences between the groups in these questionnaires; however, the patients with an early intervention after the hospital discharge reached a larger number of end-of-life decisions. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ritchie et al.<a class="elsevierStyleCrossRef" href="#bib0365">31</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">478 (233:245) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with congestive heart failure or COPD who required hospitalization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">“E-Coach” intervention through telephone calls and contact with a trained nurse, if needed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No benefit was demonstrated in patients with heart failure in terms of rehospitalization or mortality \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Doorenbos et al.<a class="elsevierStyleCrossRef" href="#bib0375">33</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80 (41:39) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Upon finishing the intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with heart failure with reduced (≤40%) or preserved (<50%) ejection fraction. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Telephone intervention by nursing to subsequently start a discussion about care objectives at the next visit. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Improvement in the number of conversations regarding the care objectives and Quality of Communication (QOC questionnaire) about the end of life.No differences in PH-9, GAD-7, number of referrals to palliative care and completion of advance directives. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rogers et al.<a class="elsevierStyleCrossRef" href="#bib0400">38</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">150 (75:75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with advanced heart failure and a high risk of death at 6months (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Interdisciplinary intervention in palliative care along with the standard management of heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">KCCQ, FACIT-Pal, HADS: improved in the intervention group compared with the nonintervention group. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bekelman et al.<a class="elsevierStyleCrossRef" href="#bib0325">23</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2018 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">314 (157:157) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6–12 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with symptomatic heart failure and deteriorated state of health \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention by nursing along with psychosocial intervention by a social worker in contact with the primary care physician, cardiologist and palliative care physician. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">KCCQ no significant differences between the groups. PHQ-9 significant improvement in the intervention group. GAD-7 significant improvement in the intervention group at 3months but not at 6months.General Symptom Distress Scale, hospitalizations and mortality with no significant differences between groups. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2092918.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Studies included in the review." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:42 [ 0 => array:3 [ "identificador" => "bib0215" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "La insuficiencia cardiaca en los servicios de medicina interna (estudio SEMI-IC)" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "Grupo de trabajo de insuficiencia cardiaca de la Sociedad Española de Medicina Interna (SEMI)" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2002" "volumen" => "118" "paginaInicial" => "605" "paginaFinal" => "610" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0220" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Análisis de 2 años de actividad de Medicina Interna en los hospitales del Sistema Nacional de Salud" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. 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Palliative medicine for patients with advanced heart failure: New evidence

Medicina paliativa en pacientes con insuficiencia cardiaca avanzada: Nuevas evidencias

J. Solís García del Pozoa,

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julianeloysolis@gmail.com

Corresponding author.

, C. Olmeda Brulla, J.J. de Arriba Méndezb, M. Corbí Pascualc

a Servicio de Medicina Interna, Hospital General de Villarrobledo, Villarrobledo, Albacete, Spain

b Unidad de Medicina Paliativa, Complejo Hospitalario y Universitario de Albacete, Albacete, Spain

c Servicio de Cardiología, Complejo Hospitalario y Universitario de Albacete, Albacete, Spain

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            "apellidos" => "Corb&#237; Pascual"
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            "entidad" => "Servicio de Medicina Interna&#44; Hospital General de Villarrobledo&#44; Villarrobledo&#44; Albacete&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
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            "entidad" => "Unidad de Medicina Paliativa&#44; Complejo Hospitalario y Universitario de Albacete&#44; Albacete&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
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            "entidad" => "Servicio de Cardiolog&#237;a&#44; Complejo Hospitalario y Universitario de Albacete&#44; Albacete&#44; Spain"
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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Medicina paliativa en pacientes con insuficiencia cardiaca avanzada&#58; Nuevas evidencias"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure is one of the most important clinical syndromes due to its high incidence rate&#44; prevalence&#44; morbidity and mortality&#46; The condition entails considerable healthcare resource expenditures and hospitalization costs&#44; which will probably increase considerably in the coming years&#46; In internal medicine departments&#44; heart failure is represented in more than 12&#37; of hospital discharges&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">1</span></a> Patients hospitalized for heart failure in internal medicine departments have special characteristics&#44; such as high physical dependency and a high percentage of women with preserved left ventricular ejection fraction&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#44;3</span></a> In individuals older than 75<span class="elsevierStyleHsp" style=""></span>years&#44; the prevalence of heart failure is &#62;15&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">4</span></a> This clinical importance is also reflected in terms of research and the number of medical publications&#44; demonstrated by the 9283 articles returned by a search for &#8220;advanced heart failure&#8221; in PubMed &#40;November 2017&#41;&#44; 7776 of which &#40;84&#37;&#41; have been published since 2000&#46; The articles dedicated to palliative care in heart failure from the same date&#44; although obviously fewer&#44; also reflect its growing importance&#44; with 1316 articles returned by PubMed with this search&#46; Of these&#44; 1128 &#40;86&#37;&#41; have been published since 2000&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">An example that illustrates the growing importance of studying palliative care in heart failure is the recent publication of clinical trials that have demonstrated that a multidisciplinary palliative intervention provides benefits for patients with advanced heart failure in terms of quality of life&#44; spiritual wellbeing and reduced depression and anxiety&#46; This perspective currently connects with the humanization trends in health care&#44; which are gaining importance in the Spanish healthcare system&#46; As happens with other chronic nononcologic diseases&#44; however&#44; the difficulty in establishing a prognosis for patients with heart failure causes physicians to overestimate these patients&#8217; survival&#46; This overestimation contributes to a perceived lack of care in planning palliative treatment for these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The objective of this review is therefore to describe the new evidence in the form of clinical trials conducted during the past 5 years on the usefulness of palliative care for patients with advanced heart failure and its effect in controlling symptoms and improving the living conditions of these patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">What is meant by advanced heart failure&#63;</span><p id="par0020" class="elsevierStylePara elsevierViewall">Heart failure is a first-order healthcare problem&#46; In recent years&#44; there has been an increase in the number of hospitalizations for heart failure in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">6</span></a> The American College of Cardiology and the American Heart Association classify patients with heart failure into 4 groups &#40;A&#44; B&#44; C and D&#41;&#46; Group C presents heart failure symptoms such as dyspnea and exercise intolerance&#44; and group D presents refractory heart failure or symptoms at rest despite optimal treatment&#46; This classification can be supplemented with the New York Heart Association &#40;NYHA&#41; classification&#44; which categorizes patients from I to IV according to their functional capacity&#46; Class III patients have significant limitations and symptoms even with mild activity&#46; Class IV patients present severe limitations and symptoms even at rest&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">There is no clear consensus of how to define patients with advanced or terminal heart failure&#46; It seems clear that stage D patients or those with an NYHA classification of IV could be encapsulated in this advanced or terminal heart failure group&#46; Nevertheless&#44; we must consider other factors such as frequent hospitalizations&#44; inability to perform daily life activities and the need for intravenous drug support&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">7</span></a> Following Crespo Leiro and Paniagua Mart&#237;n&#44; we can differentiate between advanced and terminal heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a> Advanced or refractory heart failure can be defined as the persistence of symptoms that limit daily life &#40;NYHA functional class III or IV&#44; stage D of the ACC&#47;AHA&#41; despite a previous optimal treatment&#46; Lacking a contraindication&#44; these patients would be candidates for alternative therapies such as heart transplantation&#44; surgical ventricular restoration&#44; mechanical circulatory assistance and the intravenous administration of inotropic drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a> In the last stage of advanced heart failure&#44; we have terminal heart failure&#44; in which patients respond poorly to all forms of treatment&#44; with significantly impaired quality of life&#44; frequent hospitalizations and a life expectancy of less than 6<span class="elsevierStyleHsp" style=""></span>months&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a> Based on our current knowledge&#44; palliative treatment should always be introduced gradually as the disease progresses and should be offered to all patients with heart failure who need palliative care&#44; even when they are not in stage D&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Moreover&#44; the difficulty in establishing the prognosis for patients with heart failure causes physicians and patients to overestimate the survival and underestimate the risk of death by heart failure&#46; As a result&#44; patients do not participate to the desired extent in the decisions on palliative treatment that directly affect them&#46; Despite the apparent simplicity of the stages and classifications mentioned earlier&#44; recognizing that a patient is at stage D or has advanced heart failure is often highly complicated and unclear from the clinical standpoint&#46; This uncertainty is likely determined by the differing progression of chronic medical diseases compared with oncologic diseases&#44; in which practitioners are more accustomed to recognizing their final stages&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">9</span></a> and by the heterogeneity in the progression of the end-of-life experience of patients with advanced organ disease such as heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Given the enormous difficulty in predicting the prognosis of patients with heart failure&#44; a number of instruments have been developed to improve this issue&#46; The recently developed models for improving the recognition and prognosis of chronic medical diseases include the PALIAR index implemented in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">11</span></a> which covers a series of predictors for mortality in the 6 subsequent months&#46; These predictors include an age of 85<span class="elsevierStyleHsp" style=""></span>years or older&#44; the presence of anorexia&#44; the presence of pressure ulcers&#44; a serum albumin level &#60;2&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; an Eastern Cooperative Oncology Group &#40;ECOG&#41; score &#8805;3&#44; and an NYHA functional class of IV or grade 4 on the modified dyspnea scale of the Medical Research Council &#40;mMRC&#41;&#46; Another of these instruments is the NECPAL-CCOMS-ICO 3&#46;0&#44; which employs general variables for chronic diseases regarding nutritional&#44; functional&#44; cognitive&#44; dependence&#44; psychosocial and resource use aspects&#44; among others&#44; and includes specific items for various chronic diseases&#44; including items for heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Other specific instruments have been developed for patients with heart failure such as the Seattle Heart Failure Model &#40;SHFM&#41;&#44; the Enhanced Feedback for Effective Cardiac Treatment &#40;EFFECT&#41; model and the Heart Failure Survival Score&#46; SHFM includes 10 continuous variables &#40;age&#44; left ventricular ejection fraction&#44; NYHA class&#44; systolic blood pressure&#44; weight-adjusted diuretic dosage&#44; lymphocyte count&#44; hemoglobin level&#44; serum sodium level&#44; total cholesterol level and uric acid level&#41; and 10 categorical variables &#40;sex&#44; ischemic cardiomyopathy&#44; QRS &#62;120<span class="elsevierStyleHsp" style=""></span>ms&#44; use of &#946;-blockers&#44; use of angiotensin-converting enzyme inhibitors&#44; angiotensin receptor blockers&#44; potassium-sparing diuretics&#44; statins and allopurinol and carrier of implantable cardioverter defibrillator&#47;cardiac resynchronization therapy&#41;&#46; These variables are included in an equation that provides a risk assessment for our patients&#44; which can be expressed as life expectancy at 1&#44; 2 or 5<span class="elsevierStyleHsp" style=""></span>years&#44; although it provides a modest discriminative capacity&#46; A calculator for this model can be downloaded from <a href="http://depts.washington.edu/shfm/?width=1366%26height=768">http&#58;&#47;&#47;depts&#46;washington&#46;edu&#47;shfm&#47;&#63;width&#61;1366&#38;height&#61;768</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">13</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">However&#44; these scales are difficult to implement and interpret due to the variability in the progression of heart failure among patients and according to cause and associated disease&#46; A number of medical associations have therefore proposed a set of clinical indicators that help practitioners suspect that their patients are at an advanced stage of their disease&#46; For example&#44; the Heart Failure Society of America proposed a set of clinical indicators that include 2 or more hospitalizations for heart failure in a year&#44; diuretic therapy refractoriness&#44; persistent hyponatremia&#44; progressive&#47;persistent NYHA class III or IV&#44; mortality risk at 1 year &#40;e&#46;g&#46;&#44; 20&#8211;25&#37;&#41; determined by predictive models such as SHFM&#44; inability to perform daily life activities&#44; presence of cardiac cachexia and progressive organ dysfunction such as renal and hepatic failure&#46; These indicators thereby establish the following definition for advanced heart failure &#40;stage D&#41;&#58; the presence of progressive or persistent signs and severe symptoms of heart failure despite optimal medical therapy&#44; surgery and cardiac support devices&#46; Advanced heart failure is generally accompanied by frequent hospitalizations&#44; severely limited tolerance to exercise&#44; and impaired quality of life and is associated with high morbidity and mortality&#46; The medical associations clearly specify that the progressive deterioration must be caused primarily by the heart failure syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">14</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The US National Hospice Organization developed criteria for selecting patients who are candidates for admission to a hospice&#44; with a survival of less than 6<span class="elsevierStyleHsp" style=""></span>months&#46; In addition to a set of general standards for all patients&#44; the organization established criteria for patients with heart failure that included a functional class of IV despite optimal therapy&#44; left ventricular ejection fraction &#60;20&#37;&#44; and the presence of other factors such as a history of syncope&#44; having required cardiopulmonary resuscitation&#44; human immunodeficiency virus infection&#44; embolism of cardiac origin and the presence of arrhythmias uncontrollable with medication&#46; These criteria could be highly restrictive and might lack sensitivity&#44; especially among the elderly&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Symptoms in advanced heart failure</span><p id="par0055" class="elsevierStylePara elsevierViewall">The symptoms needing palliative care for patients with heart failure include common ones such as pain and dyspnea and in general do not differ from those known in other chronic diseases in advanced phases&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">16</span></a> The Edmonton Symptom Assessment Scale &#40;ESAS&#41; is one of the instruments employed in clinical trials on palliative care for heart failure to assess symptoms&#46; This instrument was developed in 1991&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">17</span></a> and its original version examined 9 symptoms &#40;pain&#44; asthenia&#44; anorexia&#44; nausea&#44; anxiety&#44; depression&#44; general wellbeing&#44; drowsiness and respiratory distress&#41;&#44; although subsequent versions have introduced variations&#46; Each symptom is assessed on a scale from 0 &#40;absence of symptom&#41; to 10 &#40;maximum symptom intensity&#41;&#46; The scale has been widely used in palliative medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Another aspect is the instruments for assessing the quality of life of patients with heart failure&#46; In addition to generic instruments not specifically adapted to this type of patient&#44; such as the EQ-5D&#44; specific questionnaires have been developed&#44; such as the Kansas City Cardiomyopathy Questionnaire &#40;KCCQ&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">19</span></a> which includes an assessment of the various physical&#44; mental and social measures&#44; an assessment of the change in symptoms and a measure of these patients&#8217; self-care&#46; There is a Spanish-validated version of this instrument&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical trials conducted on palliative treatment in advanced heart failure in the past 5 years</span><p id="par0065" class="elsevierStylePara elsevierViewall">Although data have been published on the efficacy of palliative care for patients with heart failure&#44;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">21</span></a> several more recently conducted randomized trials have stressed the importance of palliative care in advanced heart failure &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Most of these trials refer to interventions conducted with the patient at home or after discharge&#46; This type of intervention usually consists of a combination of telephone calls through nursing and home visits by the palliative team&#44; as well as educational interventions for patients and relatives on symptom care and control&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">To find these trials&#44; we searched PubMed using the terms &#8220;palliative care&#8221; and &#8220;heart failure&#8221;&#44; limiting the search to the last 5<span class="elsevierStyleHsp" style=""></span>years and using the filter for clinical trials&#46; The search was performed in November 2017&#44; and 32 references were found&#46; We chose those studies that assessed the efficacy of a palliative intervention for patients with advanced heart failure&#44; in terms of symptom control&#44; quality of life and improved care and&#47;or communication&#46; We also reviewed the references listed in the trials in search of other studies&#46; Among the search results&#44; we found an article that described the methodology of a trial that was subsequently published in 2018&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">22&#44;23</span></a> For another of the trials published in 2016&#44; new supplementary results have been presented in 2018&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a> Both references have been included in this review&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">One of the main difficulties when selecting a trial is its heterogeneity&#44; because some trials are conducted with hospitalized patients and others with discharged patients&#44; and the interventions also differ among each other in various aspects&#46; One of the other challenges in these trials is the appropriate identification of patients with terminal heart disease&#46; Despite these difficulties&#44; this review offers an overview of trials conducted on this topic in recent years&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Br&#228;nnstrom and Boman<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">25&#44;26</span></a> recruited 72 patients at NYHA functional stage III&#8211;IV who were randomized to undergo a PREFER intervention &#40;person-centered and integrated palliative advanced home care and heart failure&#41;&#46; The intervention established a collaboration between the team who treated the heart failure and those responsible for palliative care&#46; A patient-focused palliative intervention was conducted at home&#44; based on aspects that included the patient&#39;s self-image&#44; social relationships&#44; symptoms and autonomy&#46; Compared with the patients in the control group&#44; the patients who underwent this intervention improved in terms of quality of life measured with the EQ-5D questionnaire and had reduced readmissions&#44; but there were no differences in the symptoms measured with ESAS&#46; Based on this study&#39;s patients&#44; Sahlen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">27</span></a> published a study in 2016 on cost effectiveness&#46; The results showed a gain of 0&#46;25 quality-adjusted life years&#44; and the cost analysis showed a significant reduction in the intervention group&#44; including a lower consumption of hospital resources&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Sidebottom et al&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">28</span></a> conducted a trial with hospitalized patients who received palliative care versus those who received conventional care&#46; The trial initially included 116 patients in each group &#40;232 in total&#41;&#46; The follow-up showed greater improvement in months 1 and 3 in the intervention group&#44; both in terms of quality of life &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; and symptom burden measured by the ESAS&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In 2015&#44; Thoonsen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">29</span></a> conducted a trial aimed at improving general practitioners&#8217; identification of patients with chronic obstructive pulmonary disease &#40;COPD&#41;&#44; heart failure and cancer who require palliative care&#46; The identified patients were offered a session with a palliative care specialist to refine a structured care plan&#46; There was no difference in the identification of patients among the physicians who underwent the training and those who did not&#46; Despite this&#44; the patients who were identified had more contact with their general practitioner&#44; were less often hospitalized and more frequently died at home&#44; which continues to show the value of developing new strategies for identifying these patients&#46; In any case&#44; the number of patients with heart failure identified as needing palliative care was very low&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Among the trials conducted mainly with hospitalized patients with advanced decompensated heart failure&#44; there is the study by Hopp et al&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">30</span></a> published in 2016&#44; which included African-American patients with advanced heart failure who were hospitalized for acute decompensation&#46; The study compared the effect of a palliative care consultation versus conventional care&#46; The primary endpoint was the proportion of patients who chose &#8220;comfort-focused&#8221; care &#40;hospice and&#47;or do-not-resuscitate orders&#41;&#46; Some 9&#46;3&#37; of the 43 patients with this intervention chose comfort-focused care versus none of the 42 patients in the other group&#46; These results were not statistically significant&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In 2016&#44; Ritchie et al&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">31</span></a> conducted a study with patients with COPD or heart failure to improve the transition from hospital to home through the support of a nurse&#44; follow-up and post-hospitalization telephone calls&#46; In the COPD group&#44; the intervention was associated with shorter hospital stays but did not improve the rate of readmission at 30<span class="elsevierStyleHsp" style=""></span>days&#59; this benefit was not demonstrated in the patient subgroup with heart failure&#46; Nevertheless&#44; this study included patients with heart failure discharged with a prognosis estimated at longer than 6<span class="elsevierStyleHsp" style=""></span>months&#46; The results might therefore not be applicable to patients with a poorer prognosis&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In 2016&#44; Denvir et al&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">32</span></a> conducted a small trial with 50 patients hospitalized with heart failure or acute coronary syndrome with a mortality risk &#62;20&#37; at 12<span class="elsevierStyleHsp" style=""></span>months&#46; The patients were randomized to standard care alone or to standard care plus future care planning&#44; i&#46;e&#46;&#44; an intervention directed at documenting and implementing end-of-life decisions&#46; The patients were divided into 2 groups&#46; Twenty-five patients were randomized to this intervention in the first 12<span class="elsevierStyleHsp" style=""></span>weeks after discharge&#44; followed by another 12<span class="elsevierStyleHsp" style=""></span>weeks of standard care&#46; The second group received standard care for the first 12<span class="elsevierStyleHsp" style=""></span>weeks&#44; followed by the intervention for the last 12<span class="elsevierStyleHsp" style=""></span>weeks of the trial&#46; The patients in the first group more frequently arrived at decisions on the various end-of-life aspects including issues on medical care&#44; legal aspects and the patient&#39;s preferred location for their death&#46; The authors found that this type of intervention did not increase the patients&#8217; anxiety or stress and that it was well assessed by the patients&#44; caregivers and family physicians&#46; This trial did not show an improved quality of life&#44; measured with the EQ-5D questionnaire&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Doorenbos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">33</span></a> published a randomized study to determine the efficacy of a strategy to improve communication on care objectives&#44; initially based on a telephone call performed before the medical visit by a nurse&#46; This intervention succeeded in improving the number of conversations regarding these objectives and the quality of the communication at the end of life without increasing the patients&#8217; anxiety or depression&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Wong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">34</span></a> designed a study in Hong Kong that employed as an intervention a home palliative care plan after the hospital discharge&#46; The trial participants were patients discharged from hospital and referred to the palliative care department&#46; The intervention consisted of weekly home visits or telephone calls for the first 4 weeks and then monthly&#44; conducted by a case manager nurse&#46; There were 43 patients in the intervention group and 41 in the control group&#46; The intervention group had a lower rate of readmission at 12<span class="elsevierStyleHsp" style=""></span>weeks &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009&#41; and clinical improvement in variables such as depression &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; and dyspnea &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; and a higher score on the ESAS &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; at 4<span class="elsevierStyleHsp" style=""></span>weeks&#46; This improvement in symptoms was calculated using the classification for each patient in improvement&#47;deterioration&#47;no change based on previously published cutoffs<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">35&#44;36</span></a> for the minimum clinically significant difference&#46; There were also differences in the quality of life measured with the McGill QOL questionnaire&#46; These authors subsequently published a study on cost effectiveness in which they concluded that a home intervention such as the one described above is cost effective&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">37</span></a> Subsequently in 2018&#44; these authors published the results of their trial&#44; emphasizing the quality of life&#44; symptoms&#44; satisfaction with the care and caregiver burden&#46; The authors found significant differences at 12<span class="elsevierStyleHsp" style=""></span>weeks&#44; with improvement in the intervention group in terms of quality of life&#44; satisfaction with the care and caregiver burden&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In 2017&#44; Rogers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">38</span></a> published a clinical trial that compared 75 patients who underwent conventional treatment with another 75 who underwent conventional treatment and were prescribed a multidisciplinary intervention in palliative care in coordination with the cardiology team who treated the patient&#46; Most of the participants were patients who had undergone a consultation with the palliative care team before the hospital discharge&#46; After discharge&#44; the patient was followed-up and managed by the palliative care team&#44; maintaining the cardiac therapy&#46; The latter group achieved improved scores on the quality-of-life questionnaires&#44; Kansas City Cardiomyopathy Questionnaire &#40;KCCQ&#41; and Functional Assessment of Chronic Illness Therapy-Palliative Scale &#40;FACIT-Pal&#41; at 6<span class="elsevierStyleHsp" style=""></span>months of the intervention &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;03 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;035&#44; respectively for the questionnaires&#41;&#46; Improvement was also demonstrated using the Hospital Anxiety and Depression Survey &#40;HADS&#41;&#44; the HADS-depression scale &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;020&#41; and the HADS-anxiety scale &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;048&#41;&#59; improved spiritual wellbeing was also demonstrated &#40;FACIT-Sp&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;077&#41;&#46; There were no differences between the groups for readmissions or mortality&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The recently published Collaborative Care to Alleviate Symptoms and Adjust to Illness &#40;CASA&#41; randomized trial<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">22&#44;23</span></a> went beyond the scope of palliative care by assessing the effect of an intervention based on treating the symptoms of patients with symptomatic heart failure&#44; along with a psychosocial approach by a multidisciplinary team that included a nurse and a social worker&#44; contact with the primary care physician&#44; cardiologist and palliative medicine physician&#44; comparing this approach to standard care&#46; The study measured the efficacy at 6<span class="elsevierStyleHsp" style=""></span>months for patients with heart failure and a poor state of health&#46; The primary outcome measure was the Kansas City Cardiomyopathy Questionnaire-Short Form &#40;KCCQ-12&#41;&#44; along with other measures of depression&#44; distress&#44; patient satisfaction&#44; quality of life&#44; hospitalizations and mortality&#46; The patients in the intervention group improved their KCCQ scores but not significantly compared with the control group&#46; The patients in the intervention group improved in terms of depression and asthenia &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41;&#46; There were no significant changes in general anxiety&#44; in other symptoms such as pain and respiratory distress&#44; in the number of hospitalizations or in the mortality at 12<span class="elsevierStyleHsp" style=""></span>months&#46; This group had previously published a small pilot trial to determine the feasibility of the intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">39</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In 2014&#44; Higginson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">40</span></a> published a trial that offered a care service that integrated palliative care&#44; medicine&#44; physical therapy and occupational therapy to patients with dyspnea due to advanced disease&#46; The study included patients with cancer&#44; COPD&#44; interstitial lung disease and heart failure&#46; The patients improved their dyspnea&#44; which lead the authors to support integrating palliative care for patients with dyspnea due to diseases other than cancer&#46; Unfortunately&#44; this trial only included 5 patients with heart failure &#40;4 in the intervention group and 1 in the control group&#41; and was therefore not included in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In 2016&#44; Malhotra et al&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">41</span></a> published the design of a trial whose objective was to assess whether patients with advanced heart failure for whom advance care is planned have a greater probability of receiving this end-of-life care according to their preferences compared with those who receive standard care&#46; The intervention assumes having a facilitator who performs this planning and who also provides emotional support for patients and families with the end-of-life decision-making process&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">Throughout this review&#44; we have briefly discussed some of the aspects related to palliative care directed to patients with advanced heart failure&#46; From what we have reviewed&#44; it seems clear that starting palliative treatments for patients with heart failure does not preclude implementing other active cardiac procedures&#46; In fact&#44; the approach of relieving symptoms and addressing the comprehensive treatment of heart failure can already be started for patients who have not yet reached stage D of the disease and can be increased in intensity and importance as the heart disease progresses&#46; This is the current vision in which palliative treatment and &#8220;active&#8221; treatment are 2 complementary aspects of patient management that should not be overlooked&#46; It remains to be seen how the new &#40;such as sacubitril-valsartan&#41; and future treatments for heart failure will alter the clinical spectrum and disease evolution and thereby the best time for planning the start of palliative measures in patients with heart disease&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The recent trials conducted with patients with advanced heart disease make it clear in any case that an appropriate palliative intervention for these patients improves their quality of life&#44; prevents readmissions and is cost-effective&#46; As we have seen in the study by Denvir et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">32</span></a> an appropriate intervention focused on including patients in the decision-making process for the end of their lives is important not only for making decisions on the medical care but also for arranging legal issues and determining the location where the patient prefers to be cared for and where they want to die&#46; Moreover&#44; the option of early planning for health care with the participation of all those involved and over the entire disease process improves the relationship with the patient&#44; the care provided and the optimization of resources&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">42</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">One of the problems in implementing this strategy lies in the fact that practitioners&#44; patients and relatives do not perceive the actual severity and prognosis of this disease and overestimate the survival and treatment options in the disease progression&#46; The main result of this overestimation is that the patient is often prevented from receiving the most appropriate treatment for their condition&#46; Providing physicians with strategies to recognize patients who are candidates for palliative measures without neglecting the rest of the treatment of their heart failure might be the first steps in this direction&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:11 [
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          "identificador" => "xres1225429"
          "titulo" => "Abstract"
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              "identificador" => "abst0005"
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        1 => array:2 [
          "identificador" => "xpalclavsec1139228"
          "titulo" => "Keywords"
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        2 => array:3 [
          "identificador" => "xres1225428"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec1139229"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Background"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "What is meant by advanced heart failure&#63;"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Symptoms in advanced heart failure"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Clinical trials conducted on palliative treatment in advanced heart failure in the past 5 years"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conclusions"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Conflicts of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2018-04-01"
    "fechaAceptado" => "2018-09-04"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1139228"
          "palabras" => array:3 [
            0 => "Heart failure"
            1 => "Palliative care"
            2 => "Clinical trials"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1139229"
          "palabras" => array:3 [
            0 => "Insuficiencia cardiaca"
            1 => "Cuidados paliativos"
            2 => "Ensayos cl&#237;nicos"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Although heart failure is one of the most common clinical syndromes in medicine and has a high mortality rate&#44; few patients have access to adequate palliative care for their clinical situation&#46; Several trials have recently been published on the usefulness of starting palliative treatment along with cardiac treatment for patients with advanced heart failure&#46; In this review&#44; we analyze the aspects of diagnosing and controlling the symptoms of patients with advanced heart failure and provide a collection of clinical trials that have analyzed the efficacy of a palliative intervention in this patient group&#46; Physicians need to be equipped with strategies for recognizing the need for this type of intervention without it resulting in neglecting the active treatment of the patient&#39;s heart failure&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A pesar de que la insuficiencia cardiaca es uno de los s&#237;ndromes cl&#237;nicos m&#225;s frecuentes en medicina y de su elevada mortalidad&#44; pocos son los pacientes que se benefician del acceso a unos cuidados paliativos adecuados a su situaci&#243;n cl&#237;nica&#46; Recientemente se han publicado varios ensayos para comprobar la utilidad de iniciar tratamiento paliativo junto con el tratamiento cardiol&#243;gico en pacientes con insuficiencia cardiaca avanzada&#46; En la presente revisi&#243;n se analizan aspectos sobre el diagn&#243;stico y el control de s&#237;ntomas de pacientes con insuficiencia cardiaca avanzada&#44; y se ofrece una recopilaci&#243;n de ensayos cl&#237;nicos que analizan la eficacia de una intervenci&#243;n paliativa en este grupo de pacientes&#46; Es preciso dotar al m&#233;dico de estrategias para reconocer la necesidad de este tipo de intervenciones sin que ello implique descuidar el tratamiento activo de su insuficiencia cardiaca&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Sol&#237;s Garc&#237;a del Pozo J&#44; Olmeda Brull C&#44; de Arriba M&#233;ndez JJ&#44; Corb&#237; Pascual M&#46; Medicina paliativa en pacientes con insuficiencia cardiaca avanzada&#58; Nuevas evidencias&#46; Rev Clin Esp&#46; 2019&#59;219&#58;332&#8211;341&#46;</p>"
      ]
    ]
    "multimedia" => array:1 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at1"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; ACP&#44; advance care planning&#59; EFFECT score&#44; Enhanced Feedback for Effective Cardiac Treatment score&#59; EQ-5D&#44; quality-of-life questionnaire&#59; ESAS&#44; Edmonton Symptom Assessment Scale&#59; FACIT-Pal&#44; Functional Assessment of Chronic Illness Therapy-Palliative Care&#59; GAD-7&#44; Generalized Anxiety Disorder Questionnaire&#59; GRACE&#44; Global Registry of Acute Coronary Events&#59; HADS&#44; Hospital Anxiety and Depression Scale&#59; KCCQ&#44; Kansas City Cardiomyopathy Questionnaire&#59; MLHFQ&#44; Minnesota Living with Heart Failure Questionnaire&#59; MQOL-HK&#44; McGill Quality of Life Questionnaire &#8211; Hong Kong&#59; PHQ-9&#44; 9-item Patient Health Questionnaire&#59; PPS&#44; Palliative Performance Status&#59; QOC questionnaire&#44; Quality Of Communication questionnaire&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Duration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Characteristics of the included patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Result&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Br&#228;nnstrom and Boman<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">25&#44;26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72 &#40;36&#58;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic heart failure NYHA III&#8211;IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multidisciplinary approach between palliative medicine and heart failure specialists Individual-focused care&#44; structured and at home&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">EQ-5D with improvement in the intervention group&#46; ESAS and KCCQ with improvement in some items but with no significant differences as a whole&#46; Fewer hospitalizations in the intervention group&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sidebottom et al&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">232 &#40;116&#58;116&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#8211;6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adult patients hospitalized with a diagnosis of heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consultations with the palliative care team&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ESAS&#44; PHQ-9&#44; MLHFQ&#44; ACP&#58; improvement with the intervention&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thoonsen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">134 &#40;57&#58;77&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The intervention was performed on the general practitioners&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Training to identify patients with palliative care needs&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No differences in the low patient identification rate&#46; The identified patients kept greater contact with their general practitioner&#44; had fewer hospitalizations and were more likely to die at home than at the hospital&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hopp et al&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85 &#40;43&#58;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients hospitalized with acute heart failure&#44; with a 1-year mortality risk &#8805;33&#37; and&#47;or NYHA III&#8211;IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consultation with palliative care in the hospital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The selection of hospice care or do-not-resuscitate orders increased for those where palliative care was consulted but was not statistically significant&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">34</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2016 &#40;2018<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84 &#40;43&#58;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NYHA III-IV&#44; life expectancy &#60;1<span class="elsevierStyleHsp" style=""></span>year&#44; readmitted&#44; presence of symptoms despite appropriate treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Transitional care palliative - end-stage heart failure &#40;TCP-ESHF&#41; with home visits and telephone calls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Improved readmission rate at 12 weeks for the intervention group&#46; ESAS&#44; MQOL-HK improved in the intervention group at 4 weeks&#46; No significant differences in PPS between the groups&#46; Improved QOL&#44; satisfaction of care and caregiver burden &#40;data published in 2018&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Denvir et al&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">32</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;25&#58;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with heart failure or acute coronary syndrome with a mortality rate &#8805;20&#37; at 12<span class="elsevierStyleHsp" style=""></span>months according to the GRACE or EFFECT scores&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Personalized interviews &#40;initial and home&#41;&#44; telephone support and discussion on future care planning&#46; Crossover trial with 2 groups&#58; Early intervention group after hospital discharge and another group with a late intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ESAS&#44; EQ-5D&#44; Kessler distress score&#44; no differences between the groups in these questionnaires&#59; however&#44; the patients with an early intervention after the hospital discharge reached a larger number of end-of-life decisions&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ritchie et al&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">31</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">478 &#40;233&#58;245&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with congestive heart failure or COPD who required hospitalization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8220;E-Coach&#8221; intervention through telephone calls and contact with a trained nurse&#44; if needed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No benefit was demonstrated in patients with heart failure in terms of rehospitalization or mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Doorenbos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">33</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80 &#40;41&#58;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Upon finishing the intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with heart failure with reduced &#40;&#8804;40&#37;&#41; or preserved &#40;&#60;50&#37;&#41; ejection fraction&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Telephone intervention by nursing to subsequently start a discussion about care objectives at the next visit&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Improvement in the number of conversations regarding the care objectives and Quality of Communication &#40;QOC questionnaire&#41; about the end of life&#46;No differences in PH-9&#44; GAD-7&#44; number of referrals to palliative care and completion of advance directives&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rogers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">38</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">150 &#40;75&#58;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with advanced heart failure and a high risk of death at 6<span class="elsevierStyleHsp" style=""></span>months &#40;Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Interdisciplinary intervention in palliative care along with the standard management of heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">KCCQ&#44; FACIT-Pal&#44; HADS&#58; improved in the intervention group compared with the nonintervention group&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bekelman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">23</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">314 &#40;157&#58;157&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#8211;12 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with symptomatic heart failure and deteriorated state of health&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intervention by nursing along with psychosocial intervention by a social worker in contact with the primary care physician&#44; cardiologist and palliative care physician&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">KCCQ no significant differences between the groups&#46; PHQ-9 significant improvement in the intervention group&#46; GAD-7 significant improvement in the intervention group at 3<span class="elsevierStyleHsp" style=""></span>months but not at 6<span class="elsevierStyleHsp" style=""></span>months&#46;General Symptom Distress Scale&#44; hospitalizations and mortality with no significant differences between groups&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2092918.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Studies included in the review&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:42 [
            0 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "La insuficiencia cardiaca en los servicios de medicina interna &#40;estudio SEMI-IC&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "Grupo de trabajo de insuficiencia cardiaca de la Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
                        "fecha" => "2002"
                        "volumen" => "118"
                        "paginaInicial" => "605"
                        "paginaFinal" => "610"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An&#225;lisis de 2 a&#241;os de actividad de Medicina Interna en los hospitales del Sistema Nacional de Salud"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46; Barba Mart&#237;n"
                            1 => "J&#46; Marco Mart&#237;nez"
                            2 => "J&#46; Emilio Losa"
                            3 => "J&#46; Canora Lebrato"
                            4 => "S&#46; Plaza Canteli"
                            5 => "A&#46; Zapatero Gaviria"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Clin Esp"
                        "fecha" => "2009"
                        "volumen" => "209"
                        "paginaInicial" => "459"
                        "paginaFinal" => "466"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19889315"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The utility of heart failure registries&#58; a descriptive and comparative study of two heart failure registries"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Members of the RICA and EAHFE Registries"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;C&#46; Trull&#224;s"
                            1 => "O&#46; Mir&#243;"
                            2 => "F&#46; Formiga"
                            3 => "F&#46;J&#46; Mart&#237;n-S&#225;nchez"
                            4 => "M&#46; Montero-P&#233;rez-Barquero"
                            5 => "J&#46; Jacob"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/postgradmedj-2015-133739"
                      "Revista" => array:7 [
                        "tituloSerie" => "Postgrad Med J"
                        "fecha" => "2016"
                        "volumen" => "92"
                        "paginaInicial" => "260"
                        "paginaFinal" => "266"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26739849"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0167527317313086"
                          "estado" => "S300"
                          "issn" => "01675273"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of heart failure in the Spanish general population aged over 45 years&#46; The PRICE Study"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "PRICE Study Investigators"
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46; Anguita S&#225;nchez"
                            1 => "M&#46;G&#46; Crespo Leiro"
                            2 => "E&#46; de Teresa Galv&#225;n"
                            3 => "M&#46; Jim&#233;nez Navarro"
                            4 => "L&#46; Alonso-Pulp&#243;n"
                            5 => "J&#46; Mu&#241;iz Garc&#237;a"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Cardiol"
                        "fecha" => "2008"
                        "volumen" => "61"
                        "paginaInicial" => "1041"
                        "paginaFinal" => "1049"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18817680"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "5"
              "referencia" => array:1 [
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2018.09.010

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