Principles of rationalising cardiovascular drugs in palliative care
Follow the principles of medication rationalisation when rationalising cardiovascular drugs in palliative care.
Cardiovascular drugs can be used for many indications. Before considering deprescribing, consider the conditions the cardiovascular drug may be treating. For example, indications for beta blockers include hypertension, heart failure, ischaemic heart disease, atrial fibrillation and other tachyarrhythmias, anxiety, tremor and migraine prophylaxis.
Deprescribe cardiovascular drugs used for disease prevention when time to benefit exceeds life expectancy; in most cases, this is by the last year of life. Continue cardiovascular drugs used to prevent distressing symptoms of chronic disease (eg symptomatic angina, pulmonary oedema, significant peripheral oedema, arrhythmias) until the burdens of therapy outweigh the benefits. Consider deprescribing drugs that may worsen quality of life (eg beta blockers causing symptomatic bradycardia).
The general approach to deprescribing cardiovascular drugs (common exceptions are amiodarone, digoxin and lipid-modifying drugsLiacos, 2020) is to sequentially taper and withdraw each drug and monitor for withdrawal effects or symptom recurrence. It is particularly important to slowly taper beta blockers and alpha agonists; stopping these drugs suddenly can cause rebound hypertension and other adverse effects.
For principles of palliative care for patients with heart failure, see Principles of palliative care for patients with heart failure.