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Acute Coronary Syndrome in an Older Adult with Recent or Ongoing Cancer Treatment: A Geriatric Perspective
These two cases of patients in their late 70s who have both cardiac disease and cancer, illustrate how personal goals of care can be integrated into patient care.
The first, a woman with angina and lung cancer in remission, presented with a clearly focused problem that was amenable to a definitive treatment, coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) with stents. Although the choice of procedures was guided, at least partially, by her prior cancer history, her goal was symptom control of pain due to a cardiac lesion. This goal was concordant with both the treatment team's goals and skills. Thus, the care provided was indistinguishable from usual processes of care, a disease-specific goal, and targeted therapy. Although the patient later succumbed when her tumor recurred, that progression was unexpected at the time of the decision-making process.
The second case, a man with metastatic bladder cancer receiving active treatment, presented with cardiac symptoms. However, his cancer was the major determinant of his future health. In this case, cardiac intervention might have improved his cardiac symptoms, which were minimal, but would not have been expected to improve his survival, which was estimated to be short due to his incurable cancer. Under these circumstances, the goals of care needed to be identified by the patient and care planned to achieve these goals regardless of whether the cardiologist could provide a better cardiac outcome. Rather than being disease-specific, the goals of treatment needed to be personal and span across conditions.1 Such overarching goals are often non-medical (though sometimes medical control of symptoms is required to attain them) and include recreational and life choices (in this case, traveling and camping), living long enough to participate in family events (e.g., weddings), and a dignified, comfortable end-of-life.
In the course of care of older patients who have both cardiac and oncologic diseases, the first step is to determine the severity of the two co-existing morbidities. Is one the predominant driver of disability or survival and, if treatable, would the patient's life be improved by the treatment? If so, then the patient should be asked if there is any personal preference not to aggressively pursue the disease-specific treatment.
However, if both conditions are contributing or one disease is so severe that the potential overall benefit is unlikely, it is time to switch the discussion towards what does the patient specifically want to achieve (overarching personal goals), how realistic is the possibility of achieving these, and what would be required to attain them.2 Often, these goals and the care provided to reach them will not utilize the full range of therapeutic options available to the cardiologist. Indeed, sometimes restraint, though frustrating because more could be done, may be the best course for the patient.
References
- Reuben DB, Tinetti ME. Goal-oriented patient care: an alternative health outcomes paradigm. N Engl J Med 2012;366:777-79.
- Reuben DB, Jennings LA. Putting goal-oriented patient care into practice. J Am Geriatr Soc 2019;67:1342-44.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardio-Oncology, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and SIHD, Interventions and ACS
Keywords: Acute Coronary Syndrome, Percutaneous Coronary Intervention, Angina Pectoris, Coronary Artery Bypass, Heart Diseases, Patient Care Planning, Patient Care, Terminal Care, Geriatrics, Cardiotoxicity, Cardio-oncology
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