Contemporary medical,surgical, and device therapies for end-stage heart failure

Opinion statement Despite recent advances in medical therapy, mortality remains high following the diagnosis of heart failure (HF). Cardiac transplantation is still the standard surgical treatment option for highly selected patients with severe end-stage HF; however, it is only available to a small percentage of patients. The small number of available donor hearts is an inherent limitation on the ability of cardiac transplantation to greatly impact the management of advanced HF. The increased incidence and prevalence of HF in an ever aging and medically complex population has paved the way for alternative surgical and device treatment strategies. Some of these treatment options include ventricular reduction/remodeling surgery, mitral valve repair, mechanical ventricular assist device implantation, implantable cardioverter-defibrillators, and cardiac resynchronization therapy. Several recent trials have demonstrated the effectiveness of these therapies with regard to improvement in primary cardiac end points, HF symptoms, and survival. Surgical and device techniques are usually combined with optimal medical management of HF. The total cost and actual cost-effectiveness of employing these new therapeutic modalities in a growing population of HF patients remains to be determined.     

Positive airway pressure therapy for heart failure

Heart failure (HF) is a life-threatening disease and is a growing public health concern. Despite recent advances in pharmacological management for HF, the morbidity and mortality from HF remain high. Therefore, non-pharmacological approaches for HF are being developed. However, most non-pharmacological approaches are invasive, have limited indication and are considered only for advanced HF. Accordingly, the development of less invasive, non-pharmacological approaches that improve outcomes for patients with HF is important. One such approach may include positive airway pressure (PAP) therapy. In this review, the role of PAP therapy applied through mask interfaces in the wide spectrum of HF care is discussed.     

Intravenous therapy for chronic heart failure exacerbations

Chronic heart failure (HF) will be the disease of the new millennium. The last decade has seen major developments in the management of HF, with beta-blockers and ACE inhibitors becoming the cornerstones of therapy by virtue of the reductions in total mortality. However, significant gaps remain. Hospitalization for exacerbations of HF are frequent and account for more than 6 million hospital days from this disease related group. Although a variety of intravenous (IV) agents are available for the management of exacerbations of HF, readmission rates are as high as 20%-47% at 6 months. Acute IV therapy for acute decompensation of chronic HF consists of inotropic agents most of which also have vasodilator properties, vasodilator, and diuretics. In addition, there are newer agents in various developmental stages, especially, calcium sensitizing drugs, vasopressin receptor antagonists, and natriuretic peptides. Despite the multiplicity of agents, there are no well designed, randomized, placebo controlled trials to guide IV inpatient therapy for HF exacerbations. (c)1999 by CHF, Inc.     

Echocardiography in heart failure: applications, utility, and new horizons

Echocardiography is well qualified to meet the growing need for noninvasive imaging in the expanding heart failure (HF) population. The recently-released American College of Cardiology/American Heart Association guidelines for the diagnosis and management of HF labeled echocardiography "the single most useful diagnostic test in the evaluation of patients with HF...," because of its ability to accurately and noninvasively provide measures of ventricular function and assess causes of structural heart disease. It can also detect and define the hemodynamic and morphologic changes in HF over time and might be equivalent to invasive measures in guiding therapy. In this article we will discuss: 1) the clinical uses of echocardiography in HF and their prognostic value; 2) the use of echocardiography to guide treatment in HF patients; and 3) promising future techniques for echocardiographic-based imaging in HF. In addition, we will highlight some of the limitations of echocardiography.     

Bioimpedance to prevent heart failure hospitalization

Transthoracic and whole-body bioimpedance monitoring has been commercially available for years; however, attention to its use as a diagnostic and event-monitoring modality has not been routinely applied in patients with heart failure (HF). In 2005, intrathoracic bioimpedance monitoring via an implantable cardioverter defibrillator brought new awareness of bioimpedance technology. In addition, new knowledge about congestion in HF, including length of time a patient is congested before seeking emergency care, lack of sensitivity of common signs and symptoms used to monitor congestion and diagnose HF exacerbation, and poor clinical outcomes when hypervolemia is present, heightened the need for more aggressive assessment and management. Bioimpedance device monitoring provides data needed to make treatment decisions that promote euvolemia and optimal cardiac performance. This review summarizes three options for measurement of bioimpedance hemodynamic data, discusses its use in preventing HF hospitalization, and describes issues that need to be overcome before bioimpedance monitoring can be routinely used in HF management.     

Echocardiography in heart failure: applications, utility, and new horizons.

Echocardiography is well qualified to meet the growing need for noninvasive imaging in the expanding heart failure (HF) population. The recently-released American College of Cardiology/American Heart Association guidelines for the diagnosis and management of HF labeled echocardiography "the single most useful diagnostic test in the evaluation of patients with HF...," because of its ability to accurately and noninvasively provide measures of ventricular function and assess causes of structural heart disease. It can also detect and define the hemodynamic and morphologic changes in HF over time and might be equivalent to invasive measures in guiding therapy. In this article we will discuss: 1) the clinical uses of echocardiography in HF and their prognostic value; 2) the use of echocardiography to guide treatment in HF patients; and 3) promising future techniques for echocardiographic-based imaging in HF. In addition, we will highlight some of the limitations of echocardiography.     

Ambulatory pulmonary artery pressure monitoring in advanced heart failure patients

Heart failure(HF) is an emerging epidemic associate with significant morbidity,mortality,and health care expenditure. Although there were major advances in pharmacologic and device based therapies for the management of HF,mortality of this condition remains high. Accurate monitoring of HF patients for exacerbations is very important to reduce recurrent hospitalizations and its associated complications. With the failure of clinical signs,tele-monitoring,and laboratory bio-markers to function as early markers of HF exacerbations,more sophisticated techniques were sought to accurately predict the circulatory status in HF patients in order to execute timely pharmacological intervention to reduce frequent hospitalizations. Cardio MEMSTM(St. Jude Medical,Inc.,Saint Paul,Minnesota) is an implantable,wireless pulmonary arterial pressure(PAP) monitoring system which transmits the patient's continuous PAPs to the treating health care provider in the ambulatory setting. PAP-guided medical therapy modification has been shown to significantly reduce HF-related hospitalization and overall mortality. In advanced stages of HF,wireless access to hemodynamic information correlated with earlier left ventricular assist device implantation and shorter time to heart transplantation.     

心力衰竭与脑啡肽酶的研究进展

心力衰竭是一种机制复杂的临床综合征。对心力衰竭病生理机制的深入认识提示脑啡肽酶在其发生发展中起重要作用,脑啡肽酶抑制为心力衰竭治疗提供了新的方向和证据。目前血管紧张素受体脑啡肽酶抑制剂在射血分数减少心力衰竭中的治疗取得了较大进步,而射血分数保留心力衰竭尚无有效的治疗方法。2016年美国及欧洲心力衰竭指南已将血管紧张素受体脑啡肽酶抑制剂作为治疗慢性射血分数减少心力衰竭的推荐药物。本文将对心力衰竭与脑啡肽酶的研究进展作一综述。     

Palliative care in heart failure

Palliative care (PC) is now recommended by all major cardiovascular societies for advanced heart failure (HF). PC is a philosophy of care that uses a holistic approach to address physical, psychosocial, and spiritual needs in patients with a terminal disease process. In HF, PC has been shown to improve symptoms and quality of life, facilitate advanced care planning, decrease hospital readmissions, and decrease hospital-associated healthcare costs. Although PC is still underutilized in HF, uptake is increasing. Specific strategies for successfully implementing PC in HF include early PC involvement, multidisciplinary collaboration, exploring patient values for end-of-life care, medical therapy (including both the addition of symptom-directed medications, as well as the removal of life-prolonging medications), and considerations regarding device therapy and mechanical support. Barriers to PC in HF include difficulties predicting the disease trajectory, patient and physician misconceptions, and lack of PC-trained physicians. Moving forward, PC will continue to be a key part of advanced HF care as our knowledge of this area grows.     

Left ventricular assist device as bridge to recovery for anthracycline-induced terminal heart failure

?2012 Wiley Periodicals, Inc. Anthracycline treatments are hampered by dose-related cardiotoxicity, frequently leading to heart failure (HF) with a very poor prognosis. The authors report a case of a 19-year-old man developing HF after anthracycline treatment for Ewing sarcoma. Despite medical treatment, his condition deteriorated to terminal HF, leading to implantation of a mechanical left ventricular assist device (LVAD). His heart function recovered, allowing explantation of the device 14?months after implantation. Heart transplantation is often contraindicated in the first years after treatment for cancers, and LVAD as "bridge to recovery" may be warranted in similar patients.     

2011年心力衰竭新进展

本文综述了2011年心力衰竭领域的最新临床试验及其进展,包括SHIFT、CARVIVA-HF、EM-PHASIS-HF、CUPID、TARGET、SMART-AV、EVERESTⅡ、CADUCEUS、Late-TIMI、CELLWAVE、REPAIR-AMI和CHAMPION等研究。在药物治疗领域,伊伐布雷定可能有助于逆转慢性心力衰竭患者的左室重构、改善其生活质量;依普利酮能够减少新发心房颤动或心房扑动;新型正性肌力药Omecamtiv mecarbil、Mydicar显示出初步的有效性和安全性。在器械治疗领域,通过超声心动图斑点示踪技术和QLV测量电学不同步指导左室电极植入有助于提高心脏再同步化治疗(CRT)的应答率,经皮导管MitraClip系统疗法正逐步成为不能耐受手术或对CRT治疗无效的严重二尖瓣反流患者的一种替代治疗手段。在细胞治疗领域,缺血性心力衰竭患者干细胞治疗的疗效结果不一,尚无定论。慢性心力衰竭患者的远程监测系统尚处于早期探索阶段。     

NT-proBNP and BNP: biomarkers for heart failure management

Guidelines for the pharmacological treatment of heart failure (HF) are based on results from large clinical trials demonstrating benefit. State of the art pharmacological management of HF assumes that target doses should be the same as those used in trials. Thus equal doses are recommended for all in practical guidelines, but this strategy might not fit individual needs. NT-proBNP and BNP emerged as potential biomarkers of clinical interest in HF management. NT-proBNP and BNP are related to HF severity and to clinical status. NT-proBNP and BNP are strongly associated with prognosis across the whole spectrum of HF patients. A pilot study has shown that NT-proBNP-guided therapy is associated with improved outcome in HF. Although at present there are still few data to make firm recommendations on the use of NT-proBNP or BNP levels as biomarkers for HF management, future studies will provide further insight on this issue.     

Phase II trials in heart failure: the role of cardiovascular imaging

The development of new therapies for heart failure (HF), especially acute HF, has proven to be quite challenging; and therapies evaluated in HF have greatly outnumbered treatments that are eventually successful in obtaining regulatory approval. Thus, the development of therapies for HF remains a vexing problem for pharmaceutical and device companies, clinical trialists, and health care professionals. Nowhere is this more apparent than in the phase II HF clinical trial, in which the goal is to determine whether an investigational agent should move forward to a phase III trial. Recent advancements in noninvasive cardiovascular imaging have allowed a new era of comprehensive phenotyping of cardiac structure and function in phase II HF trials. Besides using imaging parameters to predict success of subsequent phase III outcome studies, it is essential to also use imaging in phase II HF trials in a way that increases understanding of drug or device mechanism. Determination of the patients who would benefit most from a particular drug or device could decrease heterogeneity of phase III trial participants and lead to more successful HF clinical trials. In this review, we outline advantages and disadvantages of imaging various aspects of cardiac structure and function that are potential targets for therapy in HF, compare and contrast imaging modalities, provide practical advice for the use of cardiovascular imaging in drug development, and conclude with some novel uses of cardiac imaging in phase II HF trials.     

Ethics in the treatment of advanced heart failure: palliative care and end-of-life issues

Advanced heart failure (HF) is a life-shortening condition, yet there are increasing treatments and implantable devices available to clinicians to manage patients with advanced HF. Planning for adverse events and the end of life, formulated as "preparedness planning," can be integrated into HF care early in illness. Discussions that acknowledge the uncertainty of HF course and length of life and incorporate patient and family goals and values facilitates this planning. Clear processes for weighing potential benefits and burdens of interventions and therapies should accompany decision-making. Device implantation decision-making can acknowledge alternative avenues of care to the device and identify situations in which the device might be deactivated in the future. Symptom assessment and management potentially improve quality of life in patients with advanced HF. Management of symptoms should integrate HF therapies as well as other treatments. Collaboration between HF providers, palliative care clinicians, and, if appropriate, hospice clinicians will improve care for HF patients and their families.     

Exercise therapy for elderly heart failure patients

Exercise intolerance is one of the hallmark symptoms of heart failure (HF). Exercise training in this condition was not explored as a therapeutic modality until the past two decades. In fact, bed rest was promoted as a treatment for certain forms of HF in the 1970s. Over the past two decades, however, data have shown convincingly that exercise training can be implemented safely in patients who have HF, with significant improvement in functional capacity, various other physiologic variables, and quality of life. This article reviews the accumulated literature in this area, with specific emphasis on the effects of exercise training in older patients who have HF, a subset that may have the most to gain from such training.     

Sudden death prophylaxis in heart failure

Sudden cardiac death (SCD) is the leading cause of mortality in heart failure (HF). Today the implantable cardioverter-defibrillator (ICD) has become a commonplace therapy around the world for patients with both ischemic and non-ischemic cardiomyopathy and an ejection fraction (EF) < or = 35%. However, EF alone does not discriminate between the modes of death from HF (sudden arrhythmic death vs. non-sudden death). Other risk statifiers, such as electrophysiologic study and microvolt T-wave alternans testing, should therefore be used in the appropriate settings to minimize the number of unnecessary device implants. In addition, left ventricular mechanical dyssynchrony has now become recognized as an additional major marker of cardiac mortality. Its assessment should entail echocardiography rather than measurement of the QRS duration. This will allow us to better integrate the ability of cardiac resynchronization therapy (CRT) in enhancing cardiac function with the ability of an ICD in preventing SCD. This review aims to: 1) give a synthesis of the published evidence regarding the value of implantable ICDs and CRT in the primary prophylaxis of SCD in HF; 2) discuss controversial clinical issues in this area; and 3) recommend practical device-based management strategies.     

Exercise therapy for elderly heart failure patients

Exercise intolerance is one of the hallmark symptoms of heart failure (HF). Exercise training in this condition was not explored as a therapeutic modality until the past two decades. In fact, bed rest was promoted as a treatment for certain forms of HF in the 1970s. Over the past two decades, however, data have shown convincingly that exercise training can be implemented safely in patients who have HF, with significant improvement in functional capacity, various other physiologic variables, and quality of life. This article reviews the accumulated literature in this area, with specific emphasis on the effects of exercise training in older patients who have HF, a subset that may have the most to gain from such training.