Featured topics in the current and recent issues of the JACC family of journals
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Featured topics in the current and recent issues of the JACC family of journals
NCDR Study Examines Impact of LVEF and AVG on TAVR
Societies Release Focused Update for HF Management
Recommendations on two new heart failure ( HF ) medications are detailed in a focused update of the 2013 ACCF / AHA Guideline for the Management of Heart Failure , released May 20 by the ACC , American Heart Association ( AHA ) and Heart Failure Society of America and published in JACC .
The focused update includes the addition of an angiotensin receptorneprilysin inhibitor ( ARNI ) ( valsartan / sacubitril ), and a sinoatrial node modulator ( ivabradine ) to the list of treatment options for Stage C HF patients with a reduced ejection fraction . The previously determined drug options for these patients include angiotensin-converting enzyme ( ACE ) inhibitors , angiotensin II receptor blockers ( ARBs ), aldosterone antagonists , beta-blockers , the combination of isosorbide dinitrate and hydralazine and diuretics .
Of note , the writing committee recommended a therapeutic regimen of an ACE inhibitor or ARB or ARNI along with a beta-blocker and an aldosterone antagonist for patients with chronic symptomatic HF with reduced ejection fraction . ARNIs should replace ACE inhibitors ( or ARBs ) when stable patients with mild-to-moderate HF on these therapies have an adequate blood pressure and are otherwise tolerating standard therapies well . ARNIs , however , should not be used with an ACE inhibitor and should not be used by patients with a history of angioedema .
In addition , ivabradine may be beneficial in reducing HF hospitalizations in patients with symptomatic stable chronic HF with reduced ejection fraction who are receiving guidelinedirected evaluation and management , including a beta-blocker at a maximum tolerated dose , and who are in sinus rhythm with a heart rate of 70 beats per minute or greater at rest .
“ Not every patient is a good candidate for every drug ; these guidelines can help physicians decide who best fits which treatment ,” explained Clyde W . Yancy , MD , MSc , chair of the writing committee . “ This document details the benefits and risks of these new therapies so that patients at high risk can be directed towards alternative therapies .”
While a full update to the guideline is currently being developed , these recommendations were released early to coincide with the publication of similar recommendations from the European Society of Cardiology ( ESC ).
In an editorial released with the focused update , Elliott M . Antman , MD , et al ., wrote that “ The officers of the ACC , AHA , and ESC and their respective guideline oversight committees meet regularly to discuss opportunities for coordination and alignment on overlapping topics and evolution of the methodology used to gather and evaluate scientific evidence . The objective is to promote optimal care for patients with all forms of cardiovascular disease to improve outcomes and enhance quality of life around the world . The new documents represent an important step in this direction .”
Yancy C , Jessup M , Bozkurt B , et al . J Am Coll Cardiol . 2016 ; doi : 10.1016 / j . jacc . 2016.05.011
In patients undergoing transcatheter aortic valve replacement ( TAVR ), low aortic valve gradient ( AVG ), but not left ventricular ( LV ) dysfunction , was associated with higher mortality and a greater risk of recurrent heart failure ( HF ), according to a study recent study published in JACC . However , the study further suggested that “ neither severe LV dysfunction nor low AVG alone or in combination provide sufficient prognostic discrimination to preclude treatment with TAVR .”
Using data from the STS / ACC TVT Registry™ linked with Medicare claims data , researchers examined records from 11,292 patients who had the procedure performed between Nov 2011 and June 2014 . Results showed that at the 1-year mark , patients with severe LV dysfunction had the highest mortality rate , compared to patients with LV function closer to normal : 29.3 % vs . 21.9 %. Similarly patients with a low AVG had a higher one-year mortality rate than those with a high AVG : 27.1 % vs . 21.5 %.
Patients with a combination of preserved LV function and a high AVG had the most favorable clinical outcomes at 1 year , with a mortality rate of 23.6 % and HF at 11.2 %. Patients with severe LV and a low AVG had the least favorable clinical outcomes , with a mortality rate of 33.1 % and HF at 23.6 %.
According to Suzanne J . Baron , MD , MSc , the study ’ s lead author , the finding that LV dysfunction was not independently associated with long-term mortality after adjusting for clinical factors , “ provides important reassurance regarding the benefits of TAVR , even in patients with severe LV dysfunction .”
In an accompanying editorial , Philippe Pibarot , DVM , PhD , and John Webb , MD , noted that the presence of a low gradient , low LV ejection fraction and / or low flow “ should not preclude the consideration of aortic
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