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Commencing Volume 19, Issue 1, MedReviews has ceased the publication of this journal. Reviews in Cardiovascular Medicine will continue to be published by IMRPress, Ltd. (www.imrpress.org)

Volume 7, Supplement 1, 2006

Volume 7, Supplement 1, 2006

Table of Contents

How Well Are Chronic Heart Failure Patients Being Managed? Monitoring and Management of CHF Patients
Heart failure (HF) remains a major public health problem, affecting 5 million patients in the United States. The personal burden of HF includes debilitating symptoms, activity limitations, frequent hospitalizations, arrhythmias, and increased mortality. Despite the compelling scientific evidence that angiotensin-converting enzyme inhibitors, betablockers, and aldosterone antagonists reduce hospitalizations and mortality in patients with HF, these life-prolonging therapies continue to be underutilized. Device therapy for HF, including implantable cardioverter defibrillators and cardiac resynchronization therapy, has recently been demonstrated to also result in substantial mortality reduction. Accurate evaluation of patients with HF is critical for the appropriate selection and monitoring of therapy to reduce symptoms as well as for the prevention of recurrent hospitalizations. A number of studies in a variety of clinical settings have documented that a significant proportion of patients with HF are not receiving treatment with guideline-recommended, evidence-based therapies. Treatment gaps have also been documented in providing other components of care for patients with HF, including assessment for congestion and patient education. Recent studies demonstrate that hospital-based systems can improve medical care and education of hospitalized HF patients and accelerate use of evidence-based, guideline-recommended therapies by administering them before hospital discharge. HF disease management programs have also been shown to improve HF treatment, resulting in substantial reduction in hospitalizations and mortality. Application of validated and reproducible noninvasive techniques to monitor patients with chronic HF is an important step in maximizing interventions to improve outcomes in this patient population. Further efforts are clearly needed to improve the monitoring of HF patients in the hospital and outpatient settings, as well as to ensure the implementation of effective strategies and systems that increase the use of evidence-based therapies, in order to reduce the substantial HF morbidity and mortality risk. [Rev Cardiovasc Med. 2006;7(suppl 1):S3-S11]
Congestion Is an Important Diagnostic and Therapeutic Target in Heart Failure Monitoring and Management of CHF Patients
Most hospitalizations for acute heart failure syndrome (AHFS) are related to clinical congestion as a result of high left ventricular diastolic pressure (LVDP) rather than to low cardiac output. Patients frequently develop “hemodynamic congestion” (high LVDP) several days to weeks before the onset of symptoms and signs of clinical congestion. By the time symptoms and signs are evident, patients generally require hospitalization. High LVDP increases left ventricular (LV) wall stress and possibly contributes to neurohormonal activation and LV remodeling, thereby contributing to progression of heart failure (HF). Congestion is a major predictor of both morbidity and mortality in HF. Some methods may aid in the evaluation of silent hemodynamic congestion, but these assessment tools are generally underused. Identification of hemodynamic congestion, before the clinical manifestations appear, may potentially prevent hospitalization and slow the progression of HF by allowing life-saving interventions to be implemented sooner. [Rev Cardiovasc Med. 2006;7(suppl 1):S12-S24]
Current Approaches to Monitoring and Management of Heart Failure Monitoring and Management of CHF Patients
Decompensation in patients with congestive heart failure remains a treatment problem. Earlier detection of decompensation may result in a lessened need for hospitalization and perhaps an interruption of the as-yet-undetermined processes during decompensation that lead to an adverse effect on the natural history of heart failure. B-type natriuretic peptide is produced by right and/or left ventricular tissue in response to an increase in ventricular wall stress and may be used as an indicator of decompensation. New directions in monitoring now include novel device-based algorithms that determine either intraventricular pressure or intrathoracic impedance. When combined with clinical assessment, weight monitoring, and symptom assessment, these newer monitoring platforms may yield improvements in the natural history of heart failure. [Rev Cardiovasc Med. 2006;7(suppl 1):S25-S32]
New Approaches to Monitoring Heart Failure Before Symptoms Appear Monitoring and Management of CHF Patients
Intrathoracic impedance monitoring (approved by the US Food and Drug Administration) and implantable hemodynamic monitoring (IHM), which is under investigation, are promising techniques for the improved management of heart failure by detecting early changes in fluid status or hemodynamic congestion. Routine outpatient surveillance of intrathoracic impedance data from implanted devices may significantly reduce the currently high rates of hospital admission/readmission for patients with heart failure. IHM systems may extend such monitoring capabilities. Both emerging approaches for monitoring patients with heart failure may alert clinicians (and possibly patients) to impending decompensation before symptoms appear. [Rev Cardiovasc Med. 2006;7(suppl 1):S33-S41]
Integrating Device Monitoring into the Infrastructure and Workflow of Routine Practice Monitoring and Management of CHF Patients
Monitoring strategies for patients with heart failure vary. Physical assessment and patient reporting are often unreliable and inconsistent. Continuous physiologic information from implanted devices identifies the progression to congestion in patients with chronic heart failure earlier in the process than traditional methods. Common themes of a successful system will require a means to provide device-based data to interested providers who then can interpret the information in the context of either remote or face-to-face clinical assessment. [Rev Cardiovasc Med. 2006;7(suppl 1):S42-S46]
Integrating Monitoring into the Infrastructure and Workflow of Routine Practice: OptiVol® Monitoring and Management of CHF Patients
New cardiac resynchronization devices that monitor intrathoracic impedance may be utilized to monitor intravascular fluid status in chronic heart failure patients. Incorporating these devices into a heart failure medical practice requires the integration of heart failure medical services and electrophysiology. These devices must be interrogated and the data analyzed if the diagnostic information is to be useful in the care of heart failure patients. Device generated time aligned trends should be interpreted in the context of clinical findings. Systems must be well designed to deal with the results of solicited and unsolicited data. [Rev Cardiovasc Med. 2006;7(suppl 1):S47-S55]
Case Studies in Advanced Monitoring With the Chronicle® Device Monitoring and Management of CHF Patients
Three case studies illustrate the utility of advanced implantable hemodynamic monitors (IHMs). The cases include a 70-year-old with ischemic cardiomyopathy, chronic kidney disease, and recurrent volume overload; a 53-year-old with ischemic heart disease, mild effort-related angina, and New York Heart Association class III chronic heart failure; and a 21-year-old with severe dilated cardiomyopathy, all 3 patients having an IHM. The outcomes in these cases illustrate the capability of the IHM system for monitoring and detecting early changes in hemodynamic data and the use of these data to adjust medical therapies and reduce morbidity and risk of hospitalization. When pathologic hemodynamic changes are observed, this alerts the cardiologist to search for underlying causes, even when a patient on initial questioning denies any change in compliance or symptoms. [Rev Cardiovasc Med. 2006;7(suppl 1):S56-S61]
Case Studies in Advanced Monitoring: OptiVol® Monitoring and Management of CHF Patients
Two cases of congestive heart failure with decompensation are presented. The OptiVol® fluid index (Medtronic, Inc., Minneapolis, MN) provides an objective gauge of fluid status that can be difficult to obtain with routine clinical history or even with physical examination. The Cardiac Compass® Report (Medtronic, Inc.) can identify a patient’s ability to achieve euvolemia and the need for pharmacologic and nonpharmacologic interventions. Future studies will help define diagnostic and management algorithms using the OptiVol index, as well as in combination with other parameters in the Cardiac Compass Report, to facilitate proactive monitoring of patients with congestive heart failure. [Rev Cardiovasc Med. 2006;7(suppl 1):S62-S66]