In patients with advanced heart failure (HF) who are ineligible for orthotopic heart transplantation (OHT), there are a variety of treatment options available to patients to improve their quality of life (QoL), decrease hospitalizations, and potentially improve mortality, according to results published in the Canadian Journal of Cardiology.
With so many people living with HF worldwide, there is an increasingly large proportion of the population that eventually deteriorates and requires advanced therapies, such as OHT. But for those patients who are ineligible for OHT, there are other options available including palliative care (PC), device therapy (cardiac resynchronization therapy and mitral clip), exercise-based cardiac rehabilitation (ExCR), and mechanical circulatory support (MCS). The purpose of this study was to evaluate the benefits of each of these therapeutic strategies.
Early introduction of PC interventions shortly after an HF diagnosis offers patients optimal symptom management and allows the patient and physician to address goals of care together, resulting in improved patient-centered outcomes. Core components of PC include evaluation and management of both physical and psychosocial patient concerns as well as healthcare coordination and decision-making, with an overarching goal of improving QoL. Efficient provision of PC will necessitate an increased capacity to deliver such care on the part of providers.
Cardiac resynchronization therapy (CRT), using either pacemaker- or defibrillator-based devices, is recommended for most HF patients who are in normal sinus rhythm with a left ventricular ejection fraction <35%. The benefits of CRT include improvements in functional capacity, symptoms, QoL, HF hospitalizations, and mortality, as well as several echocardiographic features. Those patients with more moderate disease may derive the most benefit from CRT, secondary to a higher potential for successful ventricular remodeling.
Participation in ExCR by patients with advanced HF can help safely improve their functional capacities and overall health-related QoL. ExCR may also aid patients in terms of managing symptoms and avoiding future HF hospitalizations, in addition to helping with cardiac remodeling and autonomic balance. Extended courses of ExCR have demonstrated reductions in mortality as well. However, greater referral and adherence rates are necessary for HF patients to derive the maximum benefit from ExCR.
For end-stage HF patients ineligible for OHT, therapy with MCS involving left ventricular assist devices can help lower the rate of adverse events while improving patient outcomes, beyond the impact of medical management alone. Such MCS therapy can increase patients’ QoL and enhance survival, with mortality rates nearly as low as with OHT. Healthcare infrastructure should consolidate expertise for MCS within specialized centers to maximize potential benefits.
“Development of integrated HF care that considers options for transplant-ineligible patients
is especially important for achieving positive outcomes for the majority of these interventions and controlling costs for this growing population,” noted the authors.
Disclosure: Robert S. McKelvie, MD, PhD, has received honoraria and participated in advisory boards for Novartis.
Huitema AA, Harkness K, Malik S, Suskin N, Mckelvie RS. Therapies for advanced heart failure patients ineligible for heart transplantation: beyond pharmacotherapy. Can J Cardiol. 2020;36(2):234-243.