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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