Elsevier

American Heart Journal

Volume 161, Issue 6, June 2011, Pages 1007-1011
American Heart Journal

Editorial
Projecting heart failure into bankruptcy in 2012?

https://doi.org/10.1016/j.ahj.2011.03.020Get rights and content

Section snippets

Reading between the guidelines

The outlook for patients with heart failure has improved dramatically over the past 20 years in response to an evolving basis of evidence supporting new therapies and the heart failure management teams that deliver them effectively.1 After initial validation of angiotensin-converting enzyme inhibition (ACEI) and β-blockers in relatively small trials, the ratio of benefit to both risk and cost has been remarkably robust across all subgroups.2 Their impact to decrease disease progression and

Basis of evidence for bankruptcy in 2012?

The authors have previously estimated that only 27% of outpatients with reduced ejection fraction are receiving all of the recommended therapies for which they are eligible.8 Applying their estimates, there would be almost 1.4 million people in the country who are not. Clearly, we would seek immediately to save the 68,000 of them who are projected in this article to die of lack of one of the optimal therapies, if only we knew which patients and which therapy. Without such knowledge, this is a

Quality of care without quality of life?

Broader use of defibrillators as primary prevention for sudden death has been advocated as a measure of improved quality of care. However, even if the projected 20,000 patients could be saved annually with this extended use, these devices will not improve either survival or quality of life for the remaining 800,000 patients proposed to receive them during the next 1 to 2 years. (This is in contrast to the priceless benefit of peace of mind that can be provided through secondary prevention for

Bail out before going over

Fortunately, we are not going to go over this precipice. Neither this year nor the next will see 852,000 more ICDs implanted, in addition to the approximately 80,000 new ICDs for primary prevention projected annually from recent implant rates.9 This is impossible even on a purely logistic basis, requiring over 3-fold increase in volume for the qualified electrophysiologists at the 1,500 current implanting centers, where the extra work could not be relegated to non–electrophysiology (EP)-trained

Life extended or death prolonged?

The target projections have, thus, overestimated the number of eligible patients for ICDs. Even in eligible patients, it is likely that fewer lives would be saved by devices than predicted in the accompanying article.7 Strong controversy remains over whether the benefits of ICD are realized equally among subgroups. Women constitute about 35% of the heart failure population with low ejection fraction20 and have not yet been shown to benefit.22 One trial suggested benefit only in class II

Other missed opportunities?

The authors question their own assumption that the lives saved by each added therapy would be unique lives; many missed opportunities probably overlap rather than add.7 However, it is still illustrative to challenge each therapy on its own. None of the therapies can be recommended for escalation without comparing the untreated patients carefully with the patients shown to benefit. For instance, the missed opportunity for CRT is calculated based on QRS duration >120 milliseconds, although the

Escalate heart failure education and management

The only measure from the IMPROVE-HF experience that is not reflected here is heart failure education.3 This is the only one of those measures for which there are no real contraindications, yet use was only 60% to 70%.8 Heart failure education is a key feature of heart failure management, which also includes ongoing connection for dynamic adjustment of medications to changing conditions. It is the personal contact with midlevel professionals that seems to be the most crucial component36 because

References (40)

  • A.E. Epstein et al.

    Implantable cardioverter-defibrillator prescription in the elderly

    Heart Rhythm

    (2009)
  • B. Bozkurt et al.

    Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines

    J Am Coll Cardiol

    (2003)
  • M. Svensson et al.

    How prevalent is hyperkalemia and renal dysfunction during treatment with spironolactone in patients with congestive heart failure?

    J Card Fail

    (2004)
  • P.A. Heidenreich et al.

    Hospital performance recognition with the Get With The Guidelines program and mortality for acute myocardial infarction and heart failure

    Am Heart J

    (2009)
  • R. Gupta et al.

    Patterns of beta-blocker utilization in patients with chronic heart failure: experience from a specialized outpatient heart failure clinic

    Am Heart J

    (2004)
  • F.A. McAlister et al.

    A systematic review of randomized trials of disease management programs in heart failure

    Am J Med

    (2001)
  • A.M. Clark et al.

    What is the strength of evidence for heart failure disease-management programs?

    J Am Coll Cardiol

    (2009)
  • Hunt S. ACC/AHA 2005 guidelines update for diagnosis and management of chronic heart failure in the adult. J Am Coll...
  • G.C. Fonarow et al.

    Improving evidence-based care for heart failure in outpatient cardiology practices: primary results of the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF)

    Circulation

    (2010)
  • J.P. Piccini et al.

    Use of cardiac resynchronization therapy in patients hospitalized with heart failure

    Circulation

    (2008)
  • Cited by (17)

    • The Limits of Cardiac Performance: Can Too Much Exercise Damage the Heart?

      2018, American Journal of Medicine
      Citation Excerpt :

      Replacement fibrosis is characterized by myocyte cell necrosis leading to focal areas of scar tissue. Interstitial fibrosis represents an expansion of the interstitium with collagen accumulation, in the absence of cell necrosis.48 Late gadolinium enhancement (LGE) on cardiac magnetic resonance reflects focal scar formation attributable to replacement fibrosis, whereas newer T1 mapping magnetic resonance imaging techniques permit quantification of interstitial fibrosis.

    • Rates and reasons for device-based guideline eligibility in patients with heart failure

      2014, Heart Rhythm
      Citation Excerpt :

      Factors associated with lower rates of device-based therapy include older age,10–13 nonwhite race,10,13,14 and female sex11,13,14 as well as practice location7,10,12 and insurance status.12 Implementing device guidelines is challenging for most health care jurisdictions and may not be logistically or financially feasible for all eligible patients with HF.15 In addition, in clinical practice, some patients may not be offered or may decline implantation of an ICD or CRT for reasons such as patient preference or severe comorbid medical disease not captured in registry data.

    • Cardiac matrix remodeling and heart failure

      2014, Cardiac Regeneration and Repair
    • Clinical utility of microvolt T-wave alternans testing in identifying patients at high or low risk of sudden cardiac death

      2012, Heart Rhythm
      Citation Excerpt :

      In addition, ICD implantation is itself associated with morbidity and mortality risk4 and thus should be avoided in patients unlikely to benefit from such therapy. It has also been estimated that based on current LVEF criteria for primary prevention ICD therapy, the cost to implant all eligible patients with ICDs would exceed $30 billion, a figure that would roughly equal the annual total expenditure for all heart failure–related care in this country.5 Based on these observations, it is clear that current ICD eligibility criteria are unsustainable from a health-care system perspective and more robust tools are necessary to identify which patients are most, or least, likely to benefit from ICD therapy.

    View all citing articles on Scopus

    Jerome L. Fleg, MD, served as guest editor for this article.

    View full text