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New Heart Failure Guidelines Stress Early Diagnosis,
New Treatments
Aug. 16, 2005 – New guidelines for treating heart
patients were issued today that put greater emphasis on early diagnosis
and new treatments. The American College of Cardiology (ACC) and the
American Heart Association (AHA) say their new guide will help battle
the growing problem of heart disease, which causes about a million
hospital admissions per year.
Nearly any form of heart disease may ultimately
lead to heart failure. The guidelines stress that early recognition and
proper treatment of high blood pressure, diabetes, coronary artery
disease and other cardiovascular risk factors can help patients delay or
avoid heart failure.
The key to prevention is to get the risk factors
under control, they say. For instance, studies have shown controlling
hypertension can reduce the incidence of heart failure by 50 percent.
“More treatments have made our decision-making far
more complex since the last ACC/AHA heart failure guidelines only four
years ago,” said Sharon Ann Hunt, M.D., F.A.C.C., professor of
cardiovascular medicine at Stanford University Medical Center and chair
of the writing group.
From 1990-99, the number of people hospitalized
with a primary diagnosis of heart failure increased from 810,000 to more
than 1 million. This was due to the population aging and to more people
surviving heart attacks. Heart failure mostly affects the elderly, and
more Medicare dollars are spent for heart failure diagnosis and
treatment than for any other disease.
About 5 million U.S. residents are living with
heart failure, and more than 550,000 people are diagnosed with the
condition each year. In 2005 the disease will cost an estimated $27.9
billion in direct and indirect health care expenses, the authors write.
Some people may not realize one of the main
symptoms of heart failure is becoming easily exhausted.
“We know there are many people walking around who
think they are just out of shape or that they are just getting older, or
that their ankles are swelling because it’s hot,” said co-author Mariell
Jessup, M.D., F.A.C.C., medical director of the heart failure and
cardiac transplantation program and professor of medicine at the
University of Pennsylvania Medical Center in Philadelphia. “They don’t
appreciate that this may be due to heart failure.”
Noting that new treatment approaches may also
improve the quality of life for patients, the authors classified heart
failure on a scale from risk factors to end-stage disease:
>>> Stages A and B are when patients lack
early signs or symptoms of heart failure, but are at risk because of
risk factors or heart abnormalities, which could include a change in the
shape or structure of the heart.
>>> Stage C denotes patients with current or
past heart failure symptoms such as shortness of breath.
>>> Stage D designates patients with
refractory heart failure who might be eligible for specialized advanced
treatment — including cardiac transplantation — or compassionate
end-of-life care such as hospice.
The guidelines also change the name of the condition from congestive
heart failure (CHF) to heart failure (HF) to reflect the broad spectrum
of the disease. Congestion occurs when the heart cannot efficiently pump
or eject blood from its chambers. This causes fluid build-up in the
lungs and heart, resulting in stiff, fluid-filled lungs and shortness of
breath. The panel dropped the word ‘congestive’ because people can have
few or no symptoms of congestion, and still have a severely abnormal
heart with symptoms of fatigue and exercise intolerance caused by poor
cardiac output, Jessup said.
In recent years, doctors have recognized that many
people with normal ejection fraction have heart failure. This often
occurs because the heart pumps properly, but fails to fill adequately
with blood, a condition called diastolic heart failure. These patients
rarely have been included in clinical trials of new drugs and devices in
the past, but they are the subjects of several new, ongoing
trials. These trials should help settle the issue of whether their
treatment should be the same as that for patients with reduced ejection
fraction.
“The second major point is that heart failure does
not go away,” Jessup said. “There are drugs that need to be used and
medical care that needs to be done on a regular basis.”
The committee also recommended left ventricular
assist devices (LVADs) be considered as permanent or “destination”
therapy in selected patients.
LVADs are implanted mechanical devices that help
pump blood through the heart and can be used as a reasonable permanent
therapy in some end-stage heart failure patients who are not candidates
for transplants, don’t respond to standard treatment and have a one-year
survival outlook of less than 50 percent. The devices, which recently
received U.S. Food and Drug Administration approval as permanent or
“destination” therapy, were first used as a temporary measure to keep
patients alive while awaiting a heart transplant. “It’s going to be a
whole new era in treating heart failure,” Jessup said. “Eventually,
we’ll have portable artificial pumps that can take over the action of
the heart.”
Other recommendations:
>>> Expand the number of patients eligible
for implantable cardioverter-defibrillators (ICDs), devices implanted
under the skin that save lives by shocking chaotic heart rhythms back
into a healthy pattern. ***
>>> Provide information on end-of-life
issues. Although treatment advances can extend lives, heart failure is
often fatal. The guidelines recommend that cardiologists broach the
subject of hospice care — support and comfort for dying patients and
their families.
“There is a failure to recognize that end-stage
heart failure patients frequently come in and out of the hospital over
and over again and suffer a lot with really no impact on their ultimate
survival,” Jessup said. “I think using hospice is a way of improving the
remaining days that these patients have. Hospice can be a very positive
experience for patients and their families.”
She acknowledged that this represents a new role
for many cardiologists.
“Cardiologists aren’t used to talking about
hospice. They are more used to doing interventions. So it is a big
shift,” she said.
The guidelines also suggest that a new perspective
on treating end-stage heart failure could result in a smoother, less
stressful transition for patients and their families.
The document is available today on the Web sites of
the ACC (www.acc.org)
and the AHA (www.americanheart.org)
and will be published in the Sept. 20, 2005, issues of the Journal of
the American College of Cardiology,and Circulation: Journal of the
American Heart Association along with the ACC/AHA Clinical Performance
Measures for Adults with Chronic Heart Failureand the ACC/AHA Key Data
Elements and Definitions for Measuring Clinical Measurements and
Outcomes of Patients with Chronic Heart Failure.
Co-authors and members of the Heart Failure
Guidelines Writing Committee: William T. Abraham, M.D., F.A.C.C.;
Marshall H. Chin, M.D., M.P.H.; Arthur M. Feldman, M.D., Ph.D. F.A.C.C.;
Gary S. Francis, M.D., F.A.C.C.; Theodore G. Ganiats, M.D.; Marvin A.
Konstam, M.D., F.A.C.C.; Donna M. Mancini, M.D.; Keith Michl, M.D.; John
A. Oates, M.D.; Peter S. Rahko, M.D., F.A.C.C.; Marc A. Silver, M.D.,
F.A.C.C.; Lynne Warner Stevenson, M.D., F.A.C.C; and Clyde W. Yancy,
M.D., F.A.C.C.
Other organizations that participated in the
development of the guidelines were the American Academy of Family
Physicians, the American College of Physicians, the American College of
Chest Physicians, the Heart Failure Society of America and the
International Society for Heart and Lung Transplantation.
Editor’s note: The final version of these
guidelines have further expanded the number of patients who should be
considered for ICDs, by adding the recommendation that patients with
ishemic cardiomyopathy, functional class 1 with low ejection fraction be
considered for ICD placement (MADIT II trial).
The American Heart Association has many heart
failure tools and resources to assist patients, caregivers and
healthcare providers.
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