Penn's Transplant Cardiologists Review Treatment
Methods for NEJM
(Philadelphia, PA) --
Scientists and physicians studying heart failure should
focus on crucial questions surrounding the control of
hypertension and other vascular risk factors, say two
experts in heart disease at the University of Pennsylvania
School of Medicine, writing in the May 15 issue
of the New England Journal of Medicine.
In their review of heart failure therapies, Mariell
Jessup, MD, and Susan Brozena, MD, say that
controlling those aspects of heart disease represents
the best method of staving off the most common forms
of heart failure in patients. The researchers acknowledge,
however, that the illness will always remain "the final
pathway for myriad diseases that affect the heart."
Nearly five million Americans suffer from heart failure.
Ten of every 1,000 individuals over 65 have been diagnosed
with the disease, and it is the cause of 20 percent
of all hospital admissions for patients in that age
group. In their review, Jessup and Brozena examine national
data from clinical trials, and mortality statistics
for patients with both systolic heart failure (resulting
from disease-weakened left ventricles), and diastolic
heart failure (in which the heart contracts normally
but cannot fully relax between beats).
The researchers, both members of the Heart Failure/Transplant
Program at the Hospital of the University of Pennsylvania,
note in their review the dichotomy that exists between
clinical study findings and overall mortality outcomes
for the nation's heart-failure patients.
Formal clinical studies indicate a significant drop
in mortality rates for patients admitted to hospitals
with heart failure and dilated cardiomyopathy (disease-enlarged
hearts); the lower death rates result from advances
in drugs and other medical interventions, including
beta-blockers, biventricular pacemakers, coronary bypass
surgery and multi-disciplinary heart-failure teams.
For the same period, however, statistics from large
epidemiological surveys show no meaningful change overall
in heart-failure death rates. The Penn researchers note:
"Symptomatic heart failure continues to confer a prognosis
worse than the majority of cancers in this country,
averaging a 45 percent one-year mortality."
They say the disparity between clinical findings and
national statistics results, in part, because most patients
enrolled in investigational drug trials have been, until
recently, middle-aged white men with ischemic cardiomyopathy,
which is loss of blood to part of the heart because
of a constriction or blockage in blood vessels. They
also note that therapies are not given to all heart-failure
patients, and that for some patients, therapy is discontinued.
At the same time, however, Jessup and Brozena point
out, many heart-failure patients are elderly women who
suffer from hypertension -- a portion of the population
that is seldom included in clinical trials.
The researchers also note in their review:
~ Although heart failure is a major public health problem,
there are no national screening efforts to detect the
disease at its earlier stages.
~ Heart failure is largely preventable through controlling
blood pressure and other vascular risks, but until recently
the factors that render a patient at-risk for heart
failure had not been clearly identified or publicized.
New diagnostic guidelines for the American College
of Cardiology and the American Heart Association have
addressed the latter issue. They classify four progressive
stages of heart failure, from Stage A, which identifies
a patient with high risk but no apparent structural
abnormality of the heart, to Stage D, in which the patient
has end-stage symptoms of heart failure that do not
respond to standard treatment.
The guidelines underscore the progressive nature of
the disease, in contrast to the method of classification
for heart failure that physicians have traditionally
used, which addresses only the heart's functional limitations,
the researchers say.
hey say intervention should begin with Stage A patients,
noting: "Results from trials have shown that the effective
treatment of hypertension decreases the occurrence of
left ventricular hypertrophy and cardiovascular mortality,
as well as reducing the incidence of heart failure by
30 to 50 percent."
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