MJA
MJA

2011 Update to National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006

Henry Krum, Michael V Jelinek, Simon Stewart, Andrew Sindone and John J Atherton
Med J Aust 2011; 194 (8): 405-409. || doi: 10.5694/j.1326-5377.2011.tb03031.x
Published online: 18 April 2011
Pharmacological therapy
Treatment of symptomatic systolic heart failure
Drugs to avoid or use with caution in CHF

The 2006 guidelines listed a number of drugs to be avoided in treating patients with CHF. Based on recent trial evidence, the following drugs should be added to that list.

While the 2006 guidelines suggested that metformin should be avoided in patients with CHF, it appears to be safe in recent analyses of patients with heart failure, except in cases of concomitant renal impairment.25

Devices
Biventricular pacing

The 2006 guidelines stated that biventricular pacing, or cardiac-resynchronisation therapy (CRT), should be considered in patients who fulfil all the following criteria:

Three RCTs have reported favourable effects of CRT on left-ventricular remodelling in patients with relatively asymptomatic or mildly symptomatic heart failure associated with left-ventricular systolic dysfunction and a wide QRS complex.29-31 One of these trials found that prophylactic CRT in combination with an implantable cardioverter defibrillator (ICD) resulted in a 34% reduction in risk of death or heart failure events, with the benefit driven by a 41% reduction in heart failure events.29 All patients had a history of heart failure symptoms, with the majority being symptomatic at the time of enrolment. A significantly greater benefit was observed in patients with a QRS duration ≥ 150 ms. There was no difference in mortality; however, the study was not powered to determine this.

A more recent study reported a significant 25% reduction in risk of death and a 32% reduction in hospitalisation for heart failure with combined ICD–CRT, compared with ICD therapy alone, in patients with mild to moderately symptomatic systolic heart failure associated with a wide QRS complex. A significant benefit was seen in patients with NYHA Class II symptoms.32 Although there were more early adverse events with combined ICD–CRT, including lead dislodgement and coronary sinus dissection, a greater benefit was seen in patients with a QRS duration ≥ 150 ms and in the presence of a left bundle branch block pattern.32

In addition to the 2006 recommendations for CRT, for patients in whom implantation of an ICD is planned to reduce the risk of sudden death, it is reasonable to also consider CRT to reduce the risk of death and heart failure events if the LVEF is ≤ 30% and the QRS duration is ≥ 150 ms (left bundle branch block morphology), with associated mild symptoms (NYHA Class II) despite optimal medical therapy (Grade A recommendation).

Treatment of associated disorders
Cardiac arrhythmia
Atrial fibrillation

The 2006 guidelines indicated that pharmacotherapy remains an important mainstay for patients with CHF who develop atrial fibrillation (AF), although episodic electrical cardioversion may be required for those who experience symptomatic deterioration. Anti-arrhythmic therapy usually requires amiodarone, or occasionally sotalol, and long-term anticoagulation is required unless an acute, reversible cause of AF can be identified. If sinus rhythm cannot be maintained for prolonged periods, the guidelines advised that therapy should be directed at controlling ventricular response rate (with digoxin, β-blockers or amiodarone) and reducing thromboembolic risk with warfarin. While it was noted that electrophysiological ablation prevents recurrence of atrial flutter in about 95% of cases, the role of curative ablation for AF was considered controversial.

A large multicentre trial involving patients with CHF, an LVEF ≤ 35% and a history of AF recently showed that the control of ventricular rate with the use of digoxin and β-blockers, and the use of warfarin anticoagulation, was easier than and as effective on the primary end point of death from cardiovascular causes as therapy designed to restore and maintain sinus rhythm.38

Another small study found that pulmonary vein isolation therapy for AF in patients with CHF resulted in a high rate of freedom from AF, with improved symptomatic status, exercise tolerance and LVEF.39 For patients with CHF due to left-ventricular systolic dysfunction associated with drug-resistant symptomatic AF, the study demonstrated the superiority of a rhythm-control strategy based on pulmonary vein isolation compared with a ventricular rate-control strategy based on atrioventricular node ablation with biventricular pacing.

Rate control (rather than rhythm control), together with warfarin anticoagulation, is the preferred method of treating patients with CHF and AF if their condition permits this (Grade B recommendation). The role of atrioventricular node ablation and pulmonary vein isolation for these patients requires further research, and no specific recommendation can be made at this stage.


Provenance: Not commissioned; externally peer reviewed.

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