2 cardiac studies back aggressive procedures
Many cases of heart failure are the product of our successes, attributable to medications and procedures such as angioplasty that have allowed more people to survive heart attacks and heart disease. The problem is, they must live with weakened hearts. Without sufficient blood pumping to other organs, they become fatigued and short of breath.
Two new studies have established more clearly that the progress of heart failure can be slowed, if not halted, with aggressive treatment, even among the sickest of the sick.
In the report expected to have the most impact, researchers refute a perception that has stood in the way of more patients getting valuable drugs called beta blockers. The medications can make patients feel better, keep them out of the hospital and help them live longer, but only 65% of heart failure patients get them. Although doctors had believed that beta blockers initially made patients worse before making them better, the study found that benefits start almost immediately.
The second study suggests that a type of specialized pacemaker known to improve quality of life for heart failure patients may save lives as well.
Heart failure is a growing problem. Nearly 5 million Americans have it, with 550,000 new cases diagnosed each year. As the population continues to age, the number of patients is expected to rise. Recent estimates put the lifetime risk of heart failure at 1 in 5.
The beta blocker research, an international study of 2,289 patients with severe heart failure, found that the drug carvedilol reduced deaths by 35%, reduced hospitalizations and often made patients feel better within two to three weeks. Despite the presumption that these very sick patients would have trouble tolerating the medication early on, “the benefits were as large in the first couple of months of therapy as they were long-term and people didn’t feel badly,” said Dr. Milton Packer, a lead author and head of the heart failure center at Columbia-Presbyterian Medical Center in New York.
Doctors who prescribe beta blockers have typically told patients to expect “an initial period of turbulence,” lasting weeks to months, in which their blood pressure can fall and their heart failure worsen. But the Carvedilol Prospective Randomized Cumulative Survival study found that the rate of worsening heart failure was the same for those getting the drug as for those on a dummy pill. The results appear in the current issue of the Journal of the American Medical Assn.
Dr. Uri Elkayam, director of the heart failure program at USC, said the biggest surprise of the study was that even the sickest patients can tolerate beta blockers. He said one of the keys to successful treatment is beginning with small doses and slowly increasing them, which requires a commitment of time and patience by doctor and patient.
The carvedilol study appeared in the same issue of JAMA in which Johns Hopkins researchers in Baltimore reviewed past studies of specialized pacemakers for heart failure. In analyzing studies of 1,634 men with advanced heart failure, most ages 63 to 66, they found the devices halved deaths and cut hospitalizations by a third. Some patients underwent cardiac resynchronization with a pacemaker that stimulates the heart’s left pumping chamber, which has been shown to improve heart function, exercise capacity and quality of life. Others got only standard medical treatment.
The lead author, Dr. David J. Bradley, said the findings demonstrated that these pacemakers, which can cost $20,000 to $50,000, save lives. But some colleagues, including Packer and Elkayam, aren’t convinced.
Elkayam, a member of the executive council of the Heart Failure Society of America, called the findings encouraging, but not conclusive. Elkayam cited several limitations: Two of the four studies reviewed haven’t been published, the studies tracked patients for a maximum of only six months, and many study subjects weren’t on beta blockers.
Given the expense and the possibility of mechanical failure, Elkayam said what’s now needed is a large, well-designed study that could show whether the pacemakers offer a lifesaving benefit for patients already getting the optimum therapy, which consists of beta blockers to reduce the workload on the heart, diuretics to remove excess fluid and ACE inhibitors, or angiotensin-converting enzyme inhibitors, to relax blood vessels and prevent retention of salt and water.
But treatment starts with the beta blockers for everyone with heart failure, even those who may not yet have symptoms, Elkayam said. “The majority of people in this country are being seen by non-cardiologists. We are really trying to educate the family practice physician, the general practitioner, the people who see most of the patients with heart failure to use beta blockers. These drugs are better tolerated than we ever anticipated.”
