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More effective treatment options for heart failure patients

It's possible the number of heart failure patients in the country may double to 10 million in less than a decade. The disease is approaching epidemic proportions. People who in the past would have died from heart attacks are now often being treated with drugs and surgery and continue to live for many years. But damage from the heart attack and the underlying conditions that contribute to heart disease, such as high blood pressure and atherosclerosis, persist, weakening the heart's function and compromising an individual's quality of life.

Fortunately, better treatments are appearing across the spectrum of the condition, from those at risk of developing the disease to those for whom a heart transplant appears the best choice. For decades, we had few effective options for dealing with heart failure, other than to make people as comfortable as possible during their inevitable decline.

There is still no known cure, but we have an ever-increasing number of treatment options to minimize symptoms and slow the progression of the disease. The combination of lifestyle changes and drug therapy—the foundation of almost all heart failure treatment regimens—can markedly improve both survival rates and quality of life.

Treatment options
Treatment varies according to the stage of heart failure and each individual's specific medical history. We counsel most patients to make adjustments in their lifestyle, including stopping smoking, reducing consumption of salt and saturated fat and increasing exercise. We also prescribe a variety of medications depending on the stage of the disease.

Old standbys for high blood pressure treatment, such as beta blockers and ACE inhibitors, have found new roles for heart failure patients. These have joined traditional treatments including diuretics and digoxin, an age-old drug that helps the heart beat more forcefully.

If medications do not adequately enhance heart function, however, certain patients with advanced heart failure may become candidates for other interventions, including surgery and implantable devices.

Resychronization pacemakers
Last year, the FDA approved a special kind of device, known as resynchronization or biventricular pacemakers, which are designed to induce a failing heart into beating more effectively. The pacemakers work by delivering an electrical pulse to prod the heart's ventricles into beating simultaneously, as they do in undamaged hearts. These devices are designed to work in patients with a specific electrocardiogram abnormality called “intraventricular conduction delay” (IVCD). Approximately one third of patients with heart failure have IVCD.

Though expensive, about $10,000, those devices have quickly found a place in the arsenal of heart failure experts looking for effective ways to treat the third of patients whose heart chambers fail to pump together. As the recent study published in The New England Journal of Medicine shows, these implanted devices have an immediate impact on the quality of life of some patients who have not been responsive to drug therapy—improved energy, less shortness of breath, fewer hospitalizations.

By the end of the study, it was clear that patients with the pacemaker did better than those treated with medication alone. Among those whose pacemaker was not turned on, 34 required hospitalization for worsening heart failure, compared to 18 in the pacemaker group. Those with pacemakers were able to exercise harder and walk farther than those treated with medication alone. And those in the pacemaker group reported a much higher quality of life than those who received medication alone.

The devices, like drug therapy, appear to reduce costs long-term by keeping patients out of the hospital. We do not yet know if these devices will result in prolonging a patient's life. Currently, only about 50 percent of patients with heart failure live for another five years after their diagnosis.

In addition, the patients implanted with the new devices run the risk of implantation and maintenance problems. In about 8 percent of the patients in the study, the pacemakers could not be implanted successfully; other patients experienced problems after implantation. The benefits are significant however, and I would suggest any heart failure patients discuss this option with their physicians to determine if they are appropriate candidates.

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Dr. Katz is the director of the Yale Cardiomyopathy Program. He is a cardiologist at Yale-New Haven Heart Center and Yale-New Haven Hospital, as well as an associate professor of internal medicine in the cardiovascular medicine section at the Yale School of Medicine.