Optimizing therapy for complex or refractory heart failure: a management algorithm.
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Algorithms↗
Biomedical subjects
L W Stevenson
Publications and source records attributed to L W Stevenson.
Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials. Studies of Left Ventricular Dysfunction.
OBJECTIVE: This study undertook to determine if the presence of atrial fibrillation in patients with asymptomatic and symptomatic left ventricular dysfunction was associated with increased mortality and, if so, whether the increase could be attributed to progressive heart failure or arrhythmic death. BACKGROUND: Atrial fibrillation is a common condition in heart failure with the potential to impact hemodynamics and progression of left ventricular systolic dysfunction as well as the electrophysiologic substrate for arrhythmias. The available data do not conclusively define the effect of atrial fibrillation on prognosis in heart failure. METHODS: A retrospective analysis of the Studies of Left Ventricular Dysfunction Prevention and Treatment Trials was conducted that compared patients with atrial fibrillation to those in sinus rhythm at baseline for the risk of all-cause mortality, progressive pump-failure death and arrhythmic death. RESULTS: The patients with atrial fibrillation at baseline, compared to those in sinus rhythm, had greater all-cause mortality (34% vs. 23%, p < 0.001), death attributed to pump-failure (16.7% vs. 9.4%, p < 0.001) and were more likely to reach the composite end point of death or hospitalization for heart failure (45% vs. 33%, p < 0.001), but there was no significant difference between the groups in arrhythmic deaths. After multivariate analysis, atrial fibrillation remained significantly associated with all-cause mortality (relative risk [RR] 1.34, 95% confidence interval [CI] 1.12 to 1.62, p=0.002), progressive pump-failure death (RR 1.42, 95% CI 1.09 to 1.85, p=0.01), the composite end point of death or hospitalization for heart failure (RR 1.26, 95% CI 1.03 to 1.42, p=0.02), but not arrhythmic death (RR 1.13; 95% CI 0.75 to 1.71; p=0.55). CONCLUSIONS: The presence of atrial fibrillation in patients with asymptomatic and symptomatic left ventricular systolic dysfunction is associated with an increased risk for all-cause mortality, largely explained by an increased risk for pump-failure death. These data suggest that atrial fibrillation is associated with progression of left ventricular systolic dysfunction.
Adult↗
The mechanism of decrease in dynamic mitral regurgitation during heart failure treatment: importance of reduction in the regurgitant orifice size.
OBJECTIVES: The purpose of this study was to quantify and characterize the regurgitant flow pattern and regurgitant orifice area in patients undergoing therapy for severe heart failure using contemporary echocardiographic techniques. BACKGROUND: Mitral regurgitation may be dynamic in patients with heart failure and ultimately correlate with outcome in a group of patients. METHODS: Fourteen patients with severe heart failure felt to require hemodynamic monitoring for the optimization of medical therapy were enrolled. Two-dimensional and Doppler echocardiograms were performed before and following invasively guided therapy. Hemodynamics and standard echocardiographic dimensions were determined as well as regurgitant volume and regurgitant orifice area derived from color M-mode and Doppler measurements. RESULTS: Invasively guided therapy for heart failure was associated with a reduction in weight, filling pressures of the left and right heart, systemic vascular resistance, and echocardiographic left atrial, left ventricular and mitral annular dimensions. The mitral regurgitant volume decreased from 47+/-27 ml before therapy to 14+/-14 ml after therapy; p < 0.001. While therapy for heart failure markedly attenuated the volume of regurgitation, the pattern of regurgitant flow across the mitral valve was not significantly altered. In contrast, there was no difference in the velocity time integral of the continuous-wave Doppler spectra of mitral regurgitation with therapy (128+/-23 cm to 123+/-25 cm, p = 0.23). In all patients, the regurgitant orifice area decreased with therapy from 0.55+/-0.38 cm2 to 0.21+/-0.20 cm2 (p < 0.001). CONCLUSIONS: Pharmacologic reduction in filling pressure and systemic vascular resistance leads to a reduction in the dynamic mitral regurgitation of heart failure through a reduction in the regurgitant orifice area but not through a change in the gradient across the mitral valve. Reduction of the regurgitant orifice area is likely related to decreased left ventricular volumes and decreased annular distention.
Echocardiography, Doppler↗
Sustained hemodynamic efficacy of therapy tailored to reduce filling pressures in survivors with advanced heart failure.
BACKGROUND: During therapy to relieve congestion in advanced heart failure, cardiac filling pressures can frequently be reduced to near-normal levels with improved cardiac output. It is not known whether the early hemodynamic improvement and drug response can be maintained long term. METHODS AND RESULTS: After referral for cardiac transplantation with initially severe hemodynamic decompensation, 25 patients survived without transplantation to undergo hemodynamic reassessment after 8+/-6 months of treatment tailored to early hemodynamic response. Initial changes included net diuresis, increased ACE inhibitor doses, and frequent addition of nitrates. After 8 months of therapy, early reductions were sustained for pulmonary wedge pressure (24+/-9 to 15+/-5 mm Hg early; 12+/-6 mm Hg late) and systemic vascular resistance (1651+/-369 to 1207+/-281 dynes x s(-1) x cm(-5) early; 1003+/-193 dynes x s(-1) x cm(-5) late). Acute response to doses persisted at reevaluation. Sustained reduction in filling pressures was accompanied by a progressive increase in stroke volume (42+/-10 to 56+/-13 mL early; 79+/-20 mL late), improved functional class, and freedom from resting symptoms. Study design did not control for amiodarone, which was initiated for arrhythmias in 12 patients and associated with greater improvement in cardiac index (1.8 to 3.2 L min(-1) x m(-2) late on amiodarone versus 2.0 to 2.6 L x min(-1) x m(-2), P<.05). CONCLUSIONS: During chronic therapy tailored to early hemodynamic response in advanced heart failure, acute vasodilator response persists, and near-normal filling pressures can be maintained in patients who survive without transplantation. Stroke volumes at low filling pressures increase further over time. Chronic hemodynamic improvement was accompanied by symptomatic improvement, but the contributions of the monitored hemodynamic approach, increased vasodilator doses, and comprehensive outpatient management have not yet been established.
Amiodarone↗
Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure.
OBJECTIVES: To assess the impact of a comprehensive heart failure management program, functional status, hospital readmission rate and estimated hospital costs were determined and compared for the 6 months before and the 6 months after referral. BACKGROUND: The course of advanced heart failure is characterized by progressive clinical deterioration reflected in frequent hospital admissions, which comprise the major financial cost. METHODS: Over a 3-year period, 214 patients were accepted for heart transplantation and discharged after evaluation, which included adjustments in medical therapy and intensive patient education. Patients were in New York Heart Association functional class III or IV (94 and 120 patients, respectively), with a mean left ventricular ejection fraction of 0.21, peak oxygen consumption of 11 ml/kg per min and a total of 429 hospital admissions in the previous 6 months (average 2.0 per patient). Changes in the medical regimen included a 98% increase in angiotensin-converting enzyme inhibitor dose and a flexible diuretic regimen after 4.2-liter net diuresis, with counseling also regarding diet and progressive exercise. RESULTS: During the 6 months after referral, there were only 63 hospital readmissions (85% reduction), with 0.29/patient (p < 0.0001). Functional status improved as assessed by functional class (p < 0.0001) and peak oxygen consumption (15.2 vs. 11.0 ml/kg per min, p < 0.001). The same results were seen after excluding the 35 patients without full 6-month follow-up (9 deaths, 14 urgent transplant procedures during hospital readmission, 12 elective transplant procedures from home); 34 hospital admissions occurred after referral, compared with 344 before referral. Even when adding in the initial hospital admission after referral for these 179 patients, there was a 35% decrease in total hospital admissions in the 6-month period. The estimated savings in hospital readmission costs after subtracting the initial hospital costs for management was $9,800 per patient. CONCLUSIONS: Comprehensive heart failure management led to improved functional status and an 85% decrease in the hospital admission rate for transplant candidates discharged after evaluation. The potential to reduce both symptoms and costs suggests that referral to a heart failure program may be appropriate not only for potential heart transplantation, but also for medical management of persistent functional class III and IV heart failure.
Comprehensive Health Care↗
Voluntary control of vascular tone by using skin-temperature biofeedback-relaxation in patients with advanced heart failure.
BACKGROUND: Advanced heart failure is characterized by activation of the sympathetic nervous system and intense vasoconstriction. Biofeedback-relaxation techniques have been used successfully to treat conditions with similar pathophysiological features. OBJECTIVES: The purpose of this study was to determine if conscious control of skin temperature via a biofeedback-relaxation technique could produce vasodilation and alter central hemodynamic status and circulating levels of catecholamines in patients with heart failure. METHODS: Forty patients with advanced heart failure were randomly assigned to either an intervention or a control group. The study was done in a special cardiac step-down unit accepting patients for hemodynamic monitoring. The patients in the intervention group had one session of skin-temperature biofeedback augmented by imagery of hand warmth and modified progressive muscle relaxation. Skin temperature, systemic vascular resistance, cardiac output, plasma levels of norepinephrine and epinephrine, oxygen consumption, respiratory rate, and pulmonary wedge pressure were measured before and after the biofeedback session. Control patients had the same measurements made but were not given instruction in biofeedback-relaxation techniques. RESULTS: Patients in the biofeedback-relaxation and control groups had comparable clinical profiles at baseline. Patients undergoing biofeedback-relaxation showed the following changes: (1) increase in skin temperature of 3.1 +/- 2.8 degrees F (1.7 +/- 1.5 degrees C) in the finger and 1.5 +/- 5.2 degrees F (0.4 +/- 1.2 degrees C) in the foot, (2) increase in cardiac output of 0.30 +/- 0.33 L/min, (3) decrease in systemic vascular resistance of 152 +/- 225 dyne.sec.cm-5, and (4) decrease in respiratory rate of 4.5 +/- 3.2 breaths per minute. The biofeedback group exhibited no changes in catecholamine levels or oxygen consumption. No changes in any of these parameters were seen in the control group. DISCUSSION: Despite the presence of marked vasoconstriction in patients with advanced heart failure, a single session of biofeedback-relaxation can increase finger temperature and cardiac output and decrease systemic vascular resistance and respiratory rate, apparently without effect on systemic levels of catecholamines or oxygen consumption.
Biofeedback, Psychology↗
Six-minute walk test and heart rate variability: lack of association in advanced stages of heart failure.
BACKGROUND: The 6-minute walk and heart rate variability have been used to assess mortality risk in patients with heart failure, but their relationship to each other and their usefulness for predicting mortality at 1 year are unknown. OBJECTIVE: To assess the relationships between the 6-minute walk test, heart rate variability, and 1-year mortality. METHOD: A sample of 113 patients in advanced stages of heart failure (New York Heart Association Functional Class III-IV, left ventricular ejection < 0.25) were studied. All 6-minute walks took place in an enclosed, level, measured corridor and were supervised by the same nurse. Heart rate variability was measured by using (1) a standard-deviation method and (2) Poincaré plots. Data on RR intervals obtained by using 24-hour Holter monitoring were analyzed. Survival was determined at 1 year after the Holter recording. RESULTS: The results showed no significant associations between the results of the 6-minute walk and the two measures of heart rate variability. The results of the walk were related to 1-year mortality but not to the risk of sudden death. Both measures of heart rate variability had significant associations with 1-year mortality and with sudden death. However, only heart rate variability measured by using Poincaré plots was a predictor of total mortality and risk of sudden death, independent of left ventricular ejection fraction, serum levels of sodium, results of the 6-minute walk test, and the standard-deviation measure of heart rate variability. CONCLUSIONS: Results of the 6-minute walk have poor association with mortality and the two measures of heart rate variability in patients with advanced-stage heart failure and a low ejection fraction. Further studies are needed to determine the optimal clinical usefulness of the 6-minute walk and heart rate variability in patients with advanced-stage heart failure.
Death, Sudden↗
Secular trends in cardiac transplant recipient and donor management in the United States, 1990 to 1994. A multi-institutional study. Cardiac Transplant Research Database Group.
BACKGROUND: The growth of the US cardiac transplant waiting list has outpaced the increase in donors, resulting in a widening gap between the number of waiting recipients and available donors. These trends have generated concern that longer waiting times may result in more patients deteriorating to urgent status and that transplanting only patients who are in an advanced state of decompensation will reduce posttransplant survival. Furthermore, the shortage of donors may result in extending the guidelines for donor acceptability to a degree that increases graft failure and posttransplant mortality. We measured these secular trends in the Cardiac Transplant Research Database to provide current data on time-dependent changes in US cardiac transplant practice and survival. METHODS AND RESULTS: At the time of this analysis, the Cardiac Transplant Research Database included all 2749 patients transplanted from January 1, 1990, to June 30, 1994, in the 25 participating transplant centers. During this 4.5-year period, the median waiting time for recipients who received a transplant increased from 2.7 to 3.5 months (P < .0001), and the proportion of recipients whose status was urgent at transplantation increased from 41% to 60% (P < .0001). Donor ischemic time increased from 150 to 166 minutes (P < .0001), and the proportion of donors requiring pressor support increased from 68% to 85% (P < .0001). Despite these changes in practice, the 1-year survival rate remained constant at 84% during this 4.5-year interval. There was no significant difference in 1-year survival rate between urgent status patients (83%) and nonurgent status patients (85%) (P = .08). CONCLUSIONS: The widening gap between the number of waiting recipients and the number of donors has resulted in a continuing trend toward transplanting urgent status recipients and to a liberalization of donor acceptance criteria. Despite these changes, posttransplant survival has remained constant.
Adult↗
Improving survival for patients with atrial fibrillation and advanced heart failure.
OBJECTIVES: We attempted to determine whether changes in heart failure therapy since 1989 have altered the prognostic significance of atrial fibrillation. BACKGROUND: Atrial fibrillation occurs in 15% to 30% of patients with heart failure. Despite the recognized potential for adverse effects, the impact of atrial fibrillation on prognosis is controversial. METHODS: Two-year survival for 750 consecutive patients discharged from a single hospital after evaluation for heart transplantation from 1985 to 1989 (Group I, n = 359) and from 1990 to April 1993 (Group II, n = 391) was analyzed in relation to atrial fibrillation. In Group I, class I antiarrhythmic drugs and hydralazine vasodilator therapy were routinely allowed. In Group II, amiodarone and angiotensin-converting enzyme inhibitors were first-line antiarrhythmic and vasodilating drugs. RESULTS: A history of atrial fibrillation was present in 20% of patients in Group I and 24% of those in Group II. Patients with atrial fibrillation in the two groups had similar clinical and hemodynamic profiles. Among patients with atrial fibrillation, those in Group II had a markedly better 2-year survival (0.66 vs. 0.39, p = 0.001) and sudden death-free survival (0.84 vs. 0.70, p = 0.01) than those in Group I. In each time period, survival was worse for patients with than without atrial fibrillation in Group I (0.39 vs. 0.55, p = 0.002) but not in Group II (0.66 vs. 0.75, p = 0.09). CONCLUSIONS: The prognosis of patients with advanced heart failure and atrial fibrillation is improving. These findings support the practice of avoiding class I antiarrhythmic drugs in this group and may reflect recent beneficial changes in heart failure therapy.
Adult↗
Beta-adrenergic blockers and survival in heart failure.
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Adrenergic beta-Antagonists↗
Modern management of heart failure.
If symptom-oriented treatment does not alleviate disease, patients may benefit from adjustments in the drug regimen that are aimed at specific hemodynamic goals, most notably the reduction of left ventricular filling pressure. Growing experience with such tailoring suggests that medical intervention in heart failure does not need to compromise between relief of symptoms and improvement of cardiac function.
Diuretics↗
Patient selection for mechanical bridging to transplantation.
BACKGROUND: Patients with advanced heart failure often cannot undergo cardiac transplantation soon enough to prevent fatal hemodynamic deterioration or sudden death. The approach to these patients includes tailoring of medical therapy with vasodilators and diuretics, which allows stabilization of 60% to 80% of potential candidates. Current criteria for mechanical support before transplantation currently focus on the identification of hospitalized patients with at least 30% chance of death before transplantation. The much larger question relates to the potential use of mechanical support to bridge ambulatory patients, who represent 90% to 95% of the transplant waiting list, with waiting times frequently exceeding 2 years. METHODS: From 1988 to 1993, 265 potential candidates were discharged after evaluation for transplantation with New York Heart Association class IV status and left ventricular ejection fraction of 0.25 or less. Patients were analyzed for clinical hemodynamic and echocardiographic profiles that would identify ambulatory patients unlikely to survive without urgent transplantation. RESULTS: After tailored medical therapy, presenting hemodynamic parameters are not useful for predicting 2-year survival without urgent transplantation, which was 45% at 2 years. Left ventricular diastolic dimension of 80 mm or greater was associated with only 29% two-year survival without urgent transplantation. Serum sodium level less than 132 mEq/L predicted 35% two-year survival without urgent transplantation. Peak oxygen consumption less than 10 mL.kg-1.min-1 identified poor outcome but was often not measured in patients with resting symptoms. CONCLUSIONS: Although definition of indications for urgent bridging requires complex clinical assessment based on immediate risk, it should be possible to identify a larger ambulatory population for whom improved devices will offer extended survival without transplantation.
Aged↗
Heart transplant centers: no longer the end of the road for heart failure.
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Heart Failure↗
Thyroid hormone abnormalities in heart failure: possibilities for therapy.
Though thyroid hormone abnormalities have been identified in many cardiac conditions, the role of thyroid hormones in congestive heart failure has not been well defined. In a population of patients with advanced heart failure, a reduction in triiodothyronine (T3) with an increase in reverse T3 was identified in many patients, with an abnormally low ratio of T3/reverse T3 being the strongest predictor of mortality. Normalization of thyroid indices appeared to be necessary for prolonged survival to occur. To address the concern of T3 administration possibility exacerbating a hypermetabolic state, basal metabolic rate was measured in a group of advanced heart failure patients and was found to be generally within the normal range. A preliminary safety study of short-term intravenous T3 administration (bolus +/- 6 h infusion, total dose 0.15-2.7 micrograms/kg) was then performed in 23 patients under hemodynamic and electrocardiographic monitoring. There were neither adverse events nor substantial hemodynamic changes, but some patients had an increase in cardiac output, consistent with a peripheral vasodilatory effect. With this foundation, further investigation into the possible role of T3 and its analogs in congestive heart failure therapy may be pursued.
Heart Failure↗
Selection and management of candidates for heart transplantation.
The increasing discrepancy between the donor hearts available and the number of patients with advanced heart failure underscores the need to optimize medical therapy and restrict the option of cardiac transplantation to patients with heart failure refractory to maximal conventional therapy. New medical and surgical therapies should be studied specifically in this population. The need for heart transplantation in ambulatory patients with severe heart failure is better assessed by the serial evaluation of objective measures of clinical stability and peak exercise oxygen consumption, than by assessment of standard risk factors at the time of patient referral. Among comorbidities which may preclude transplantation, psychosocial risk factors have recently undergone stricter scrutiny. The successful outcome of candidates for heart transplantation requires serial assessment and continuity of care by a dedicated team of health professionals specialized in heart failure and transplantation.
Contraindications↗
Timing of adult cardiac transplantation.
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Adult↗
Improving survival for patients with advanced heart failure: a study of 737 consecutive patients.
OBJECTIVES: This study sought to determine whether survival and risk of sudden death have improved for patients with advanced heart failure referred for consideration for heart transplantation as advances in medical therapy were systematically implemented over an 8-year period. BACKGROUND: Recent survival trials in patients with mild to moderate heart failure and patients after a myocardial infarction have shown that angiotensin-converting enzyme inhibitors are beneficial, type I antiarrhythmic drugs can be detrimental, and amiodarone may be beneficial in some groups. The impact of advances in therapy may be enhanced or blunted when applied to severe heart failure. METHODS: One-year mortality and sudden death were determined in relation to time, baseline variables and therapeutics for 737 consecutive patients referred for heart transplantation and discharged home on medical therapy from 1986 to 1988, 1989 to 1990 and 1991 to 1993. Medical care was directed by a single team of physicians with policies established by consensus. From 1986 to 1990, the hydralazine/isosorbide dinitrate combination or angiotensin-converting enzyme inhibitors were the initial vasodilators, and class I antiarrhythmic drugs were allowed. After 1990, captopril was the initial vasodilator, given to 86% of patients compared with 46% of patients before 1989. After mid-1989, class I agents were routinely withdrawn, and amiodarone was used for frequent ventricular ectopic beats or atrial fibrillation (53% of patients after 1990 vs. 10% before 1989). RESULTS: The total 1-year mortality rate decreased from 33% before 1989 to 16% after 1990 (p = 0.0001), and sudden death decreased from 20% to 8% (p = 0.0006). Adjusted for clinical and hemodynamic variables in multivariate proportional hazards models, total mortality and sudden death were lower after 1990. CONCLUSIONS: The large reduction in mortality, particularly in sudden death, from advanced heart failure since 1990 may reflect an enhanced impact of therapeutic advances shown in large randomized trials when they are incorporated into a comprehensive approach in this population. This improved survival supports the growing practice of maintaining potential heart transplant candidates on optimal medical therapy until clinical decompensation mandates transplantation.
Adult↗
Target heart failure populations for newer therapies.
BACKGROUND: The scarcity of donor hearts has created a large population of heart failure patients who are unlikely to undergo transplantation. Newer surgical therapies that might sustain such patients at home previously have been applied in critical situations in which early outcome is jeopardized by multiorgan failure. The optimal population for studies of extended support would be ambulatory patients with low operative risk but high risk of later unfavorable outcome. METHODS AND RESULTS: Baseline clinical, echocardiographic, and hemodynamic data were collected prospectively between 1988 and 1993 in 500 patients who were discharged on tailored medical therapy after evaluation for transplantation. Specific criteria were examined to identify high risk of death or need for urgent transplantation during the next 2 years. In 265 patients with ejection fraction < or = 25% and initial New York Heart Association class IV symptoms, survival at 2 years was 55% (without urgent transplantation, 45%). Lower cardiac index or higher filling pressures at the time of referral did not confer higher risk, which was predicted by persistence of higher pressures after therapy. Serum sodium below 133 was associated with 34% 2-year survival without urgent transplantation, and ventricular dimension > 80 mm with a rate of 25%. Patients with initial peak oxygen consumption > 10 mL/kg per minute had a 2-year event-free rate of 72% compared with 48% for those with < 10 mL/kg per minute and 32% for those unable to exercise at referral. Demonstration of a 30% decrease in mortality with a controlled trial of new therapy in patients with ejection fraction < or = 25% would require 600 patients with class III symptoms or almost 300 patients with class IV symptoms unless another criterion were added. CONCLUSIONS: Ambulatory populations with high predicted event rates can be identified at initial evaluation, when hemodynamic criteria may be less useful than ventricular dimension, serum sodium, and ability to exercise. The use of outcome data from previous eras may lead to overestimation of benefits from newer therapies and underestimation of the sample size required in a prospective trials.
Cardiac Output, Low↗