MD Conference Express AHA 2013 - (Page 14)

FEATURE AHA/ACC Updates in the Treatment of Patients With Heart Failure Written by Emma Hitt Nichols, PhD The American Heart Association (AHA)/American College of Cardiology (ACC) clinical practice guidelines for chronic heart failure (HF) were updated for 2013 including expanded indications for cardiac resynchronization therapy (CRT), the use of biomarkers in diagnosis and treatment guidance, emerging agents, cell therapy, and the use of mechanical support. Lynne Warner Stevenson, MD, Brigham and Women's Hospital, Boston, Massachusetts, USA, discussed the updates to the recommendations of the 2013 AHA/ACC guidelines for CRT [Yancy http://circ. ahajournals.org/content/128/16/e240.full.pdf+html]. The new guidelines endorse CRT for patients with Stage C, HF NYHA Class II or III/IV symptoms with a left ventricular ejection fraction (LVEF) of ≤35%, in sinus rhythm, left bundle-branch block (LBBB) with a QRS duration of ≥150 ms. In patients with NYHA symptom Class III to ambulatory IV HF, the addition of CRT to medical therapy appears to improve function and quality of life, as well as decrease hospitalizations by 30% and improve survival by 24% to 36%. In NYHA ambulatory IV patients from the COMPANION trial, the addition of CRT to optimized medical therapy resulted in stable disease for ≥1 month with no hospitalizations related to HF and no IV inotropic therapy (Figure 1) [Lindenfeld J et al. Circulation 2007]. In patients with end-stage HF that required inotropic therapy, CRT resulted in improved ventricular assist device (VAD)- and transplant-free survival compared with inotropic therapy or medical therapy over 60 months [Bhattacharya S et al. J Cardiac Failure 2010]. 2. HF Figure 1. Benefit of CRT Therapy In the COMPANION Trial. Figure 1. Benefit of Cardiac Resynchronization Therapy in the COMPANION Trial Official Peer-Reviewed Highlights From the Patients Event Free (%) 100 CRT vs OPT: HR, 0.57; 95% CI, 0.37 to 0.87; p=0.01 CRT-D vs OPT: HR, 0.49; 95% CI, 0.32 to 0.75; p=0.001 CRT-D vs CRT: HR, 0.86; 95% CI, 0.58 to 1.28; p=0.45 75 50 CRT-D CRT OPT 25 0 0 100 200 300 400 500 600 700 800 Time (Days) Treatment CRT-D (n=83) CRT (n=79) OPT (n=55) Events (%) 47 (57%) 51 (65%) 40 (73%) Censored (%) 36 (43%) 28 (35%) 15 (27%) Median Follow-up Times 14.1 months 14.2 months 7.2 months CRT=cardiac resynchronization therapy; CRT-D=cardiac resynchronization therapy plus implantable defibrillator; OPT=optimized medical therapy. Reproduced from Lindenfeld J et al. Effects of cardiac resynchronization therapy with or without a defibrillator on survial and hospitalizations in patients with New York Heart Association class IV heart failure. Circulation 2007;115:204-212. With permission from Lippincott, Williams and Wilkins. In 4213 patients with mild HF, a systematic review and meta-analysis indicated that although CRT did not significantly reduce mortality (p=0.24), it did decrease HF events and left-ventricular end-diastolic volume while increasing 6-minute walk test and EF (p<0.001 for all) [Santangeli P et al. J Interv Card Electrophysiol 2011]. 14 December 2013 www.mdconferencexpress.com  http://circ.ahajournals.org/content/128/16/e240.full.pdf+html http://circ.ahajournals.org/content/128/16/e240.full.pdf+html http://www.mdconferencexpress.com

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