A case-based self-critique
By Dr. Hendrik Bachmann
Mr. R. first met his cardiologist about ten years earlier during an acute anterior-wall myocardial infarction. The blocked vessel was opened and stabilized with a stent, and initially his prospects seemed good.
In the following years, however, Mr. R. repeatedly suffered stent thromboses and further infarctions despite intensified medication. Eventually the affected vessel was bypassed. Although the bypass and stent remained open, repeated heart muscle damage had already begun to change the geometry and function of the heart.
The article explains cardiac remodelling: after myocardial necrosis, muscle is replaced by connective tissue that cannot contract. The heart dilates, wall tension increases, oxygen demand rises and further damage becomes more likely. The patient experiences a gradual decline in cardiac capacity, classified by the New York Heart Association stages of heart failure.
Mr. R. was highly engaged in his own care, took guideline-based medication and participated in cardiac exercise. Yet an index event occurred: worsening breathlessness, orthopnea, night urination, persistent bronchitis and finally acute decompensated heart failure. Later examinations showed a ventricular aneurysm. Surgery was considered but deferred after temporary stabilization.
His condition progressed to NYHA III and then IV. He lost weight and muscle, became dependent on his daughters, and developed cardiac cachexia. He received a defibrillator, expecting it might help him live better. Bachmann criticizes that patients are often inadequately informed: a standard ICD can prevent sudden cardiac death from arrhythmia, but it does not improve pump function or quality of life.
The article contrasts the strong integration of palliative thinking in oncology with its weak presence in cardiology. Heart failure at advanced stages carries a high mortality and heavy symptom burden, yet remuneration systems reward technology such as defibrillators more than psychosocial, palliative or social interventions.
Mr. R. later received additional devices, including a CCM device and finally a ventricular assist device. Instead of a bridge to recovery, it became destination therapy. He lived with cables, infection risks, anticoagulation problems and repeated hospital admissions. When the long-expected final crisis came, his advance directive was not initially honored, and he was transferred and resuscitated until relatives intervened.
Bachmann concludes that patients with heart failure, COPD, Parkinson’s disease and similar chronic progressive illnesses need more than tablets and devices. Classical somatic specialties must open the door to palliative approaches. Cardiology and palliative medicine should not be seen as opposites, but as synergistic ways of caring for the whole person.
