Roy S. Gardner

UK guidelines for referral and assessment of adults for heart transplantation

Patients with advanced heart failure have a dismal prognosis and poor quality of life. Heart transplantation provides an effective treatment for a subset of these patients. This article provides cardiologists with up-to-date information about referral for transplantation, the role of left ventricular assist devices prior to transplant, patient selection, waiting-list management and donor heart availability. Timing is of central importance; patients should be referred before complications (eg, cardiorenal syndrome or secondary pulmonary hypertension) have developed that will increase the risk of, or potentially contraindicate, transplantation. Issues related to heart failure aetiology, comorbidity and adherence to medical treatment are reviewed. Finally, the positive role that cardiologists can play in promoting and facilitating organ donation is discussed.

Heart failure in younger patients: The meta-analysis global group in chronic heart failure (MAGGIC)

AIM Our understanding of heart failure in younger patients is limited. The Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) database, which consisted of 24 prospective observational studies and 7 randomized trials, was used to investigate the clinical characteristics, treatment, and outcomes of younger patients. METHODS AND RESULTS Patients were stratified into six age categories: <40 (n = 876), 40-49 (n = 2638), 50-59 (n = 6894), 60-69 (n = 12 071), 70-79 (n = 13 368), and ≥80 years (n = 6079). Of 41 926 patients, 2.1, 8.4, and 24.8% were younger than 40, 50, and 60 years of age, respectively. Comparing young (<40 years) against elderly (≥80 years), younger patients were more likely to be male (71 vs. 48%) and have idiopathic cardiomyopathy (63 vs. 7%). Younger patients reported better New York Heart Association functional class despite more severe left ventricular dysfunction (median ejection fraction: 31 vs. 42%, all P < 0.0001). Comorbidities such as hypertension, myocardial infarction, and atrial fibrillation were much less common in the young. Younger patients received more disease-modifying pharmacological therapy than their older counterparts. Across the younger age groups (<40, 40-49, and 50-59 years), mortality rates were low: 1 year 6.7, 6.6, and 7.5%, respectively; 2 year 11.7, 11.5, 13.0%; and 3 years 16.5, 16.2, 18.2%. Furthermore, 1-, 2-, and 3-year mortality rates increased sharply beyond 60 years and were greatest in the elderly (≥80 years): 28.2, 44.5, and 57.2%, respectively. CONCLUSION Younger patients with heart failure have different clinical characteristics including different aetiologies, more severe left ventricular dysfunction, and less severe symptoms. Three-year mortality rates are lower for all age groups under 60 years compared with older patients.

The incremental prognostic and clinical value of multiple novel biomarkers in heart failure

In recent years there has been an increase in the number of biomarkers in heart failure (HF). The clinical role for these novel biomarkers in combination is not clear.

The Emerging Potential of the Apelin-APJ System in Heart Failure

The apelin-APJ system is a novel neurohormonal pathway, with studies to date suggesting that it may be of pathophysiologic relevance in heart failure and may indeed be a viable therapeutic target in this syndrome. This interest is driven primarily by the demonstration of its vasodilator, inotropic, and aquaretic actions as well as its apparent antagonistic relationship with the renin-angiotensin system. However, its promise is heightened further by the observation that, unlike other and more established cardioprotective pathways, it appears to be down-regulated in heart failure, suggesting that augmentation of this axis may have a powerful effect on the heart failure syndrome. We review the literature regarding the apelin-APJ system in heart failure and suggest areas requiring further research.

Falling Cardiovascular Mortality in Heart Failure With Reduced Ejection Fraction and Implications for Clinical Trials

OBJECTIVES This study examined the trends in the relative contributions of cardiovascular and noncardiovascular mortality to total mortality according to use of beta-blockers in clinical trials of patients with heart failure with reduced ejection fraction (HF-REF). BACKGROUND With the increasingly widespread use of disease-modifying therapies, particularly beta-blockers, in HF-REF, the proportion of patients dying from cardiovascular causes is likely to be decreasing. METHODS In a systematic review, 2 investigators independently searched online databases to identify clinical trials including >400 patients with chronic heart failure published between 1986 and 2014 and that adjudicated cause of death. Trials were divided into 3 groups on the basis of the proportion of patients treated with a beta-blocker (<33% [low], 33% to 66% [medium], and >66% [high]). Percentages of total deaths adjudicated as cardiovascular or noncardiovascular were calculated by weighted means and weighted standard deviations. Weighted Student t tests were used to compare results between groups. RESULTS Sixty-six trials met the inclusion criteria with a total of 136,182 patients and 32,140 deaths. There was a sequential increase in the percentage of noncardiovascular deaths with increasing beta-blocker use from 11.4% of all deaths in trials with low beta-blocker use to 19.1% in those with high beta-blocker use (p < 0.001). CONCLUSIONS In trials of patients with HF-REF, the proportion of deaths adjudicated as cardiovascular has decreased. Cardiovascular mortality, and not all-cause mortality, should be used as an endpoint for trials of new treatments for HF-REF.

Congestive heart failure. Advances in management.

Arroll and colleagues’ review of the management of congestive heart failure1 disregards much of the progress made since the previous BMJ review of this topic in 2002.2 They concentrated on established pharmacotherapy …

Use of implantable cardioverter defibrillators in patients with left ventricular assist devices.

Patients with left ventricular assist devices (LVADs) are at high risk of sustained ventricular arrhythmias, but these may be remarkably well tolerated and the association with sudden death is unclear. Many patients who receive an LVAD already have an implantable cardioverter defibrillator (ICD). While it is standard practice to reactivate a previously implanted ICD in an LVAD recipient, this should include discussion of the revised risks and benefits of ICD therapy following LVAD implantation. In particular, patients should be warned that they might receive a significant number of ICD shocks that may not be life saving. When ICDs are reactivated, device programming should minimize the risk of repeated shocks for non‐sustained or well‐tolerated ventricular arrhythmias. Implantation of a primary prevention ICD after implantation of an LVAD is not supported by current evidence, poses potential risks, and should be the subject of a clinical trial before it becomes standard practice.

Spectral microvolt T‐wave alternans testing has no prognostic value in patients recently hospitalized with decompensated heart failure

Microvolt T‐wave alternans (MTWA) testing identifies beat‐to‐beat fluctuations in T‐wave morphology, which have been linked to ventricular arrhythmias. However, clinical studies have produced conflicting results and data in heart failure (HF) have been limited. The aim of this study was to determine the prevalence and incremental prognostic value of spectral MTWA testing in an unselected cohort of patients recently hospitalized with HF.

Clinical characteristics and outcomes of patients with angina and heart failure in the CHARM (Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity) Programme

To investigate the relationship between angina pectoris and fatal and non‐fatal clinical outcomes in heart failure with reduced and preserved ejection fraction (HF‐REF and HF‐PEF, respectively).

LGE and NT-proBNP Identify Low Risk of Death or Arrhythmic Events in Patients With Primary Prevention ICDs

OBJECTIVES The aim of this study was to investigate whether late gadolinium enhancement (LGE) magnetic resonance imaging or N-terminal pro-B-type natriuretic peptide (NT-proBNP) could identify patients with a low risk of death or use of implantable cardioverter-defibrillator (ICD) in patients receiving a primary prevention ICD. BACKGROUND ICDs reduce mortality in patients with heart failure (HF), although two-thirds may never use their device. Current risk stratification, based on New York Heart Association functional class and left ventricular ejection fraction, still leads to implantation of ICDs in patients who may never need their device. METHODS We examined 157 patients with HF (61 with ischemic cardiomyopathy and 96 with dilated cardiomyopathy; mean age 50.5 years; 78% male) who underwent primary prevention defibrillator implantation. Presence and volume of LGE was measured before device implantation, and serum NT-proBNP level was measured before ICD implantation. The combined primary endpoint was cardiovascular death or appropriate ICD therapy (either appropriate shock or antitachycardia pacing). RESULTS The primary outcome occurred in 32 patients (20.4%) over a median follow-up period of 915 days. Percentage of LGE (hazard ratio [HR]: per 1% increase: 1.06; 95% confidence interval [CI]: 1.04 to 1.09; p < 0.001) and (ln) NT-proBNP (HR: 1.44; 95% CI: 1.04 to 1.98; p = 0.027) were predictors of death or appropriate ICD activation and remained significant when entered into multivariable analysis. When the cohort was stratified into tertiles based on LGE percentage and NT-proBNP, we were able to identify a low-risk group (event rate 3% per year, compared with the intermediate- and high-risk groups [6% and 10% per year, respectively]). CONCLUSIONS Both percentage of LGE and NT-proBNP were associated with higher risk of death or appropriate ICD activation. The use of these markers in combination may be useful in identifying individuals most likely to benefit from this costly intervention, and more specifically, in the identification of a group at lower risk in whom ICD implantation may be deferred.