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It's time to adopt new management strategies
MJA 1997; 167: 61-62
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©MJA1997
Most epidemiological data on heart failure have come from the United
States and Europe. In Australia, carefully conducted studies of the
incidence, prevalence and hospitalisation rates of CHF have been
sadly lacking. Thus, the report by Blyth et al. in this issue of the
Journal5 is
welcome as it provides us with local data on the impact of CHF in the
hospital setting. Their findings confirm the massive burden that
heart failure imposes on the patient and the health care system. What
can we do to contain or even reverse this situation?
The current approach to managing heart failure comprises
non-pharmacological interventions (sodium restriction, alcohol
abstention, exercise), drug therapies and, in selected patients,
surgery.
Surgery has a limited role: if objective evidence exists of
reversible ischaemia and/or hibernating myocardium, coronary
artery bypass grafting should be considered. Several new surgical
approaches may also be useful as long-term therapy in some patients,
including cardiomyoplasty, ventriculectomy and insertion of a left
ventricular assist device. Transplantation is an extremely
effective therapy, but limited by donor organ availability, and the
age and comorbidities of many patients with CHF.
Drug therapies have a substantial impact on disease outcomes.
Angiotensin-converting enzyme (ACE) inhibitors relieve symptoms,
improve quality of life and prolong survival.6,7 Digoxin has no overall effect on
mortality,8 but may be of
symptomatic benefit in patients receiving ACE inhibitor therapy.9
New drugs are continually being evaluated in CHF. Many provide
short-term symptomatic benefit, but at the expense of long-term
increases in mortality: these include non-digitalis inotropic
agents (milrinone, xamoterol, ibopamine, vesnarinone) and
direct-acting vasodilator drugs (flosequinan).10
New drugs that appear to offer symptomatic benefit without adverse
mortality outcomes include b -adrenoceptor-blocking agents
(specifically, carvedilol) and angiotensin II receptor
antagonists (specifically, losartan). Recent studies have
suggested prolonged survival in chronic heart failure with both
agents.11-12
Despite these therapeutic advances, CHF remains a disease with
unacceptably high mortality rates, poor quality of life and massive
socioeconomic cost. Effective new management strategies are
urgently required.
In most patients heart failure is a complex disorder requiring an
integrated treatment strategy. Physicians, general
practitioners, nurse practitioners, nutritionists,
physiotherapists and psychologists need to be drawn together to
maximise thera peutic benefits to the patient.
One approach has been to establish multidisciplinary clinics where
patients have access to dedicated physicians, dietary expertise,
literature about the disease, behaviour modification
interventions and exercise programs. Patients are encouraged to
become active participants in managing their disease. They are asked
to weigh themselves regularly, monitor dietary sodium intake, watch
closely for signs of fluid accumulation or changing symptoms and to
interact frequently by telephone with members of the
multidisciplinary team. The nurse practitioner regularly checks on
patient status and addresses specific enquiries.
This approach brings together the skills of multiple health care
providers in an environment of frequent and regular appraisal of the
patient. Outcomes from pilot studies of this approach have included
reduced dietary salt intake, improved compliance with drug
therapies, improved patient well-being, and reduced
hospitalisations.13,14 In
one study, emergency department visits were reduced by 67% and
hospitalisations by 87%.14
This was found to be highly cost-effective.
Heart failure remains a major clinical challenge for health care
professionals in the 1990s. It is no longer sufficient to manage the
hospitalised patient well; the real goal of treatment is to address
the health of people with heart failure in the community so that they do
not require hospital admission.
Henry Krum
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©MJA 1997
<URL: http://www.mja.com.au/>
© 1997 Medical Journal of Australia.
Chronic heart failure (CHF) is a major public health problem.1 The disease is associated with poor
prognosis2 and markedly
reduced quality of life. Unlike other cardiovascular conditions, it
is increasing in incidence and prevalence.1,3 Its management imposes a
substantial burden on the health care system, accounting for 1%-2% of
total health care costs in industrialised nations.4 About 70% of these costs are related
to hospitalisation.
Despite therapeutic
advances, CHF
remains a disease with
unacceptably high mortality rates, poor quality of life and
massive
socioeconomic cost.
However, mortality remains high even in CHF patients receiving the
best available drug therapy. In the CONSENSUS study of patients with
severe heart failure, 12-month mortality was almost 50% despite
patients receiving diuretics, digoxin and high doses of ACE
inhibitors.7
Associate Professor of Medicine, Clinical Pharmacology Unit
Department of Epidemiology and Preventive Medicine, and Department
of Medicine
Monash University, Alfred Hospital, Melbourne, VIC