© 2007 European Society of Cardiology
Stopping heart failure in its tracks
Preventative Cardiology, Baker Heart Research Institute 75 Commercial Rd, Melbourne, Victoria, 3004, Australia
* Tel.: +61 3 9276 2903. E-mail address: simon.stewart{at}baker.edu.au
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1. Introduction |
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 Top 1. Introduction 2. Expanding our approach...3. Stopping CHF in...4. ConclusionReferences |
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Anyone viewing a still rising tide of chronic heart failure (CHF) from a fatalistic perspective might be tempted to merely plot an increasing number of emerging cases and deal with consequences without attempting to understand the reasons behind the epidemic. In one sense, the most powerful factor driving the enormous pressure imposed by CHF on health care systems of developed countries around the world is the progressive ageing (and therefore hearts) of the population [1]. Naturally, the paradoxical side-effect of a combination of improved living standards, public health initiatives and specific health care interventions leading to prolonged longevity and, therefore, greater susceptibility to conditions such as CHF, will be tolerated by any society.
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2. Expanding our approach to CHF prevention |
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Top1. Introduction2. Expanding our approach...3. Stopping CHF in...4. ConclusionReferences |
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If we accept that CHF is the epidemic we had to have, the key question is what can we now do to minimise its current and future impact? Clearly, a long-term strategy is to prevent or delay the onset of acute and chronic forms of heart disease (HD) by targeting major modifiable risk factors (e.g. smoking, obesity and hypertension [2]) via more effective forms of primary prevention. There is also a strong argument to improve levels of access to cardiac rehabilitation programs to address the same list of risk factors in those who survive an acute coronary event [3].
Unfortunately, our historical tendency to view HD in distinct phases and respond to discrete events such an AMI or acute pulmonary oedema in a reactive rather proactive way has left significant gaps in our response. Whilst it is natural to focus on providing secondary prevention strategies to relatively young individuals who survive an acute cardiac event, there is also a merit in targeting modifiable risk factors to slow the progression of HD to improve quality of life, reduce costly morbid events and prolong survival in older individuals at particularly high risk for developing CHF. In recent times our major focus has "leapt" from traditional cardiac rehabilitation (often truncated programs with minimal follow-up [3]) to CHF management programs (CHF-MPs) that successfully prevent recurrent hospitalisations and prolong survival in high risk individuals [4]. These programs now form part of the gold-standard management of the syndrome [5].
As suggested by Fig. 1, however, HD is a truly dynamic and progressive process over the continuum of each affected individual's life (and ageing heart) that requires a more comprehensive approach to prevention and, if not, delayed progression. As such, there is a clear need to broaden our approach to "prevention" by developing cost-effective health care programs that fill-in the current gaps in active management and target the following individuals (each number corresponds to those on the solid arrow in Fig. 1):
- Those with early, but undetected, forms of HD in order to prevent the emergence of "symptomatic" (including sudden cardiac death) forms of disease via an enhanced form of primary prevention.
- Those individuals with chronic HD (most commonly CHF or asymptomatic left ventricular systolic dysfunction —LVSD) who still have much to gain from slowing the progression of disease via an enhanced form of secondary prevention.
- Those who derive no benefit from current therapeutics and would be best served by a change in focus from prolonging life to quality end of life via an enhanced form of palliative care [6].
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3. Stopping CHF in its tracks! |
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Top1. Introduction2. Expanding our approach...3. Stopping CHF in...4. ConclusionReferences |
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Building on the American Heart Association's proposal that we broaden the definition of the overall syndrome of HF to not only include those with asymptomatic LVSD (Stage II), but also those who have risk factors that will almost inevitably lead to its development (Stage I) [7]; in this issue of the European Journal of Heart Failure, McDonald and colleagues have outlined their vision for a more proactive approach to CHF management [8]. They outline an expanded model of disease management to encompass patients with milder forms of CHF to provide an appropriate mix of community-based and specialist management to those patients newly diagnosed with LVSD or CHF and on a routine basis thereafter; irrespective of hospitalisation status.
To date, there is mixed evidence in favour of such an approach with respect to improved clinical outcomes. DeBusk and colleagues specifically targeted patients with milder forms of CHF than those traditionally included in CHF-MPs with minimal success [9]. Alternatively, applying many of the principles inherent to successful disease management programs appears to reduce the incidence of CHF in chronically ill patients over the longer-term [10].
Overall, the evidence-base is thin and obviously in need of appropriately powered studies that focus on the most cost-effective and practical programs of care that might limit the rise in CHF at the population level. At this stage, we really don't know what specific components of management (be they pharmacological, life-style modification strategies or a combination of both) are likely to yield the best outcomes. Similarly, we should be carefully considering the cost and resource implications of screening large numbers of individuals with biomarkers such as the brain natriuretic peptides; particularly when they still have the potential to yield a level of "false negatives" for HF that would overwhelm already stressed echocardiographic services [11]. Ultimately, we may have to adopt a "defeatist" approach and revert to our current reactive rather than proactive response to this modern epidemic. Fortunately, there is a way to go and much promising research to be performed before this occurs.
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4. Conclusion |
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It is within this context that the proposed "STOP-HF" Trial to be undertaken by McDonald's group in Ireland and described in this issue of the journal [8], represents one of a number of logical steps in our attempts to limit the future impact of CHF within our ageing populations. Whether this program actually stops CHF in its tracks remains to be seen but is certainly worth the effort given the paucity of similar trials to date.
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References |
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Top1. Introduction2. Expanding our approach...3. Stopping CHF in...4. ConclusionReferences |
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- Stewart S., MacIntyre K., Capewell S., McMurray J.J.V. An ageing population and heart failure: an increasing burden in the 21st century? Heart (2003) 89:49–53.
[Abstract/Free Full Text] - Peeters A., Mamun A.A., Willekens F., et al. A cardiovascular life history: a life course analysis of the original Framingham heart study cohort. Eur Heart J (2002) 23:458–466.
[Abstract/Free Full Text] - Jackson L., Leclerc J., Erskine Y., et al. Getting the most out of cardiac rehabilitation: a review of referral and adherence patterns. Heart (2005) 91:10–14.
[Abstract/Free Full Text] - McAlister F.A., Stewart S., Ferrua S., McMurray J.J.V. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol (2004) 44(4):810–819.
[Abstract/Free Full Text] - Swedberg K., Cleland J., Dargie H., Drexler H., Follath F. Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): the Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Eur Heart J (2005) 26(11):1115–1140. [18].
[Free Full Text] - Stewart S., Inglis S., Hawkes. Chronic cardiac care: a practical guide to specialist nurse management. (2006) London: BMJ Books (Blackwell Publishing Group).
- Hunt SA, Baker DW, Chin MH, et alon behalf of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. International Society for Heart and Lung Transplantation; Heart Failure Society of America. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary (2001) 104(24):2996–3007. 11: Circulation.
- McDonald K, Conlon C, Ledwidge M. Disease management programs for heart failure: not just for the sick heart failure population. Eur J Heart Fail in this issue.
- DeBusk R.F., Miller N.H., Parker K.M., et al. Care management for low risk patients with heart failure: a randomized controlled trial. Ann Intern Med (2004) 141:606–613.
[Abstract/Free Full Text] - Pearson S., Inglis S., McLennan S., et al. Prolonged effects of a home-based intervention in chronically ill patients. Arch Intern Med (2006) 166:245–250.
- Nakamura M., Tanaka F., Sato K., et al. B-type natriuretic peptide testing for structural heart disease screening: a general population-based study. J Card Fail (2005) 11:705–712.[CrossRef][Web of Science][Medline]
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  M. J. Carrington, S. Stewart, and on behalf of the NIL-CHF Study Investigators Bridging the gap in heart failure prevention: rationale and design of the Nurse-led Intervention for Less Chronic Heart Failure (NIL-CHF) Study Eur J Heart Fail, November 18, 2009; (2009) hfp161v1. [Abstract] [Full Text] [PDF]
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