Heart failure’s shifting paradigms outpace changes in clinical practice
March 1, 1999 3 minutes read
Heart failure’s shifting paradigms outpace changes in clinical practice
New concepts about CHF are changing treatment
Can patients avoid the cascade of cardiac changes that come with a failing heart? And when those changes already have occurred, can they be reversed?
Some surgeons say it can happen. Patients may have advanced disease, yet still qualify for a procedure that reinforces the mitral valve. The technique can improve circulation through the heart, and possibly, the patient’s condition over time as well.
It may not end there. Getting a handle on the right neurohormonal cues could allow clinicians to single out candidates who show earlier signs of the disease. Then the valve operation may be able to stop the chain of events that lead to lower ejection fraction and reduced quality of life.
The excitement for this procedure comes at a time when other techniques are raising more questions than providing answers. Surgeons had hoped partial left-ventriculectomy (PLV) could be offered to a spectrum of CHF patients. But the different outcomes associated with hypertrophy, fibrosis, and stiffness suggest the procedure is more appropriate to develop as an option for patients in end-stage disease who are not transplantation candidates or when a new heart is not available.
Both the potential to prevent morbidity and the scarcity of transplant hearts can drive research in new directions. One possible goal is making transplantation the final surgical option, taken after surgeons first have tried — literally — to get more out of the patient’s own heart.
Meanwhile, cardiologists say they find themselves in a paradigm shift of their own. Reports have suggested beta-blockers can reduce patient mortality, but physicians have been reluctant to use them, as patients can have increased symptoms of CHF before long-term improvement can be seen.
Some hope the reports now in from larger studies will reassure clinicians the agents are part of the preferred course of drug therapy, despite what they may have learned in their early training.
In January, a group of 150 physicians published their recommendations in the American Journal of Cardiology that proper drug therapy includes not only a beta-blocker, but an ACE inhibitor, diuretics, and digitalis.
Recent studies also prompted The American Medical Association to release a Quality Care Alert. The two-page report outlines the benefits of beta-blockers as a preventive measure after myocardial infarction.
Heart failure is listed as a relative contraindication once considered to preclude beta-blocker use. But for some patients, the therapy may be appropriate. The individual practitioner should decide whether a beta-blocker could be helpful to a specific patient and if consultation should be sought. (See a copy of the alert, inserted in this issue.)
When it comes to treating CHF patients, physical therapists say that they are revising their training as well. No longer should stable CHF patients be discouraged from activity. Rehabilitation specialists note even debilitated patients with comorbidities can become more active when they are armed with the right workout strategy as part of their treatment.
New paradigms or not, observers say the real test is how long it will take the practices to make their way into everyday care of CHF patients. In this issue of CHF Disease Management, you will find articles providing more details on changing attitudes toward patient management.
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