Features May 2012 Issue

Newer Treatments are Keeping Heart Failure Patients Healthier, Longer

The use of pacemakers, defibrillators and beta blockers earlier in heart failure patients are making.

While the number of patients with heart failure (HF) in the U.S. continues to rise, there is some encouraging news on this front. HF-related mortality and hospitalization rates are stabilizing.

Bi-ventricular pacemakers have leads connecting to the two ventricles and the right atrium to help the heart beat properly.

Improvements in medication and device therapies are helping to make HF a more manageable condition, according to a statement released by the American Heart Association (AHA) in February. The AHA noted that the quality of life for HF patients in general has also improved.

Eileen Hsich, MD, director of the Women’s Heart Failure Clinic at Cleveland Clinic, has done considerable research in this area, and agrees that many of these vulnerable patients are living longer and better lives because of how and when they are being treated.

For example, she cites advancements in implantable cardioverter defibrillators (ICDs), devices that use electric shocks to help the heart beat at a normal rhythm.

“We’re using more defibrillators, which is helping to prevent more sudden death in these patients,” Dr. Hsich says. “What’s also changed over time is our understanding of the importance of beta blockers and aldosterone antagonists.”

Beta blockers help lower blood pressure and control heart rate by reducing the effects of the hormone adrenaline, while aldosterone antagonists help minimize the effects of the hormone aldosterone. HF patients with high levels of aldosterone tend to waste too much magnesium and potassium in urine, leaving them vulnerable to certain abnormal heart rhythms.

Other key devices in the treatment of HF include bi-ventricular pacemakers, which were first identified as potentially helpful for this condition around 10 years ago, Dr. Hsich says. As more and more doctors are getting used to working with these devices, more patients are receiving them. Studies are also validating the expanded use of these pacemakers.

“They’ve gotten so experienced in putting these in,” Dr. Hsich says. “The technique gets easier with more experience and more data is supporting their use.”

Treatment Timing
One of the biggest dilemmas facing physicians treating heart failure patients is when to implant a left-ventricular assist device (LVAD). Traditionally, LVADs were implanted only in patients with severe HF and who were awaiting transplants. The devices were considered a “bridge” to help patients awaiting a heart transplant.

And because only very sick patients received LVADs, the mortality rate with the devices tended to be very high. “No one was embracing these things as a destination,” Dr. Hsich notes, adding that things changed around 2002 with the introduction of Thoratec’s HeartMate VE Left Ventricular Assist System (LVAS). It was approved as destination therapy for end-stage HF patients after it was shown to improve survival and quality of life better than standard medication therapy.

Then, in 2010, the HeartMate II was approved by the U.S. Food and Drug Administration as destination therapy for patients who were not good candidates for a heart transplant. Dr. Hsich says that in addition to being quieter than other LVADs, the HeartMate II had the significant advantage of being smaller, which meant more women could receive these life-changing devices.

“It’s a relatively new device, so we’re still learning how long you can live with it,” she explains.

But the newness of the technology has also complicated matters for doctors trying to decide when a patient should receive an LVAD.  “Determining who is the right cohort is very controversial,” Dr. Hsich says. “Should we be putting these in earlier?”

At issue is whether the risk of surgery to implant an LVAD in a patient with a weak heart is worth the benefit that the device will provide, or whether a patient’s current regimen of medications and healthy lifestyle will provide a comparable quality of life and longevity without the trauma of surgery.

Dr. Hsich says it’s difficult to ignore the positive feedback seen so far in patients receiving devices while their HF is still relatively mild.

“If people are getting their lives back, why are we waiting until the end to put these devices in?” Dr. Hsich says. “But there’s always a risk with any surgery. How do you predict survival? Unfortunately, our survival models aren’t perfect.”

There is currently a major multi-center study under way called the Randomized Evaluation of VAD InterVEntion before Inotropic Therapy (REVIVE-IT) trial, which is examining whether HF patients with less-advanced HF than traditional LVAD recipients will do better with an implanted device than with standard medical therapy. Dr. Hsich says the results of REVIVE-IT should provide guidance for doctors treating patients who may benefit from device therapy, but aren’t necessarily transplant candidates.