Public Release:  New journal focuses on progress, problems in treating heart failure

American Heart Association journal report

American Heart Association

DALLAS, May 21 -- Findings about how the day of admission influences the length of a patient's hospitalization for heart failure, and questions about the effectiveness of two drugs to treat heart failure patients are featured in the inaugural issue of Circulation: Heart Failure.

The new journal features scientific articles charting advances and challenges in diagnosing and treating heart failure - a growing disease problem that afflicts 5.3 million Americans.

Circulation: Heart Failure is the second of six new specialized publications of Circulation: Journal of the American Heart Association that will be introduced by the American Heart Association to intensify the focus on research developments aimed at combating the major cardiovascular diseases.

"Knowledge in the field of heart failure has grown substantially over recent years, as has the breadth of research, both paralleling the growth of the clinical problem," said James E. Udelson, M.D., of Tufts Medical Center in Boston, editor of the new Circulation: Heart Failure journal. Better survival after heart attack and an aging population will mean heart failure "has and likely will continue to occupy a greater share of clinicians' focus," Udelson said in a preface to the journal.

"The array of potential therapies has expanded," he said, "and the coming years will likely see the emergence of advances in devices and regenerative therapies as well as more focused therapies based on pharmacogenomics (the interaction of drugs and genetics) . . . "

Hospital discharges for heart failure in the United States rose from 400,000 annually in 1979 to 1,084,000 in 2005 -- an increase of 171 percent, according to the American Heart Association's Heart Disease and Stroke Statistics -- 2008 Update. Total mention mortality for heart failure claimed 284,400 lives in 2004, the most recent data available. The disease costs the United States $34.8 billion annually.

Highlights from the inaugural issue of Circulation: Heart Failure include these findings:

  • Length of hospital stay for heart failure patients may depend on day of admission.

    Theorizing that differences in hospital staffing levels may influence outcomes for patients with acute episodes of heart failure (HF), researchers prospectively collected follow-up data on a pre-specified 10 percent sample of 48,612 patients in 259 hospitals. The findings from The Organized Program to Initiate Lifesaving Treatment In Hospitalized Patients with Heart Failure or (OPTIMIZE-HF) suggest that the length of hospital stay (LOS) for heart failure patients is "significantly influenced" by the day of admission, even after adjusting for other LOS risk factors. Heart failure hospitalizations that began on Thursday and Friday were associated with prolonged LOS (5.75 and 5.88 days, respectively), while patients who were admitted on Tuesdays had the shortest LOS (5.39 days). The in-hospital mortality rate was 3.8 percent, and no differences in mortality by day of admission or discharge were evident, the investigators report. Patient characteristics were similar for weekday and weekend admissions. The scientists conclude: "Understanding the factors responsible for the increased LOS and potential adjustments in staffing to facilitate weekend discharges may improve the efficiency of HF hospital care."

    Gregg C. Fonarow, M.D., Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles; Calif. (310) 206-9112; gfonarow@mednet.ucla.edu.

  • Benefits demonstrated, effectiveness questioned in two drugs for heart failure

    In two new studies weighing risks and benefits from using two medicines to treat heart failure, researchers have found both favorable results and questionable value:

    In the first study, confirming that low systolic blood pressure (SBP, the "upper" number) is a risk factor for adverse outcomes in patients with heart failure, Minnesota researchers evaluated the SBP-lowering effects of the drug valsartan versus its cardiovascular protective effects in 5,010 patients in Val-HeFT. They compared valsartan's effects on morbidity and mortality according to quartiles of SBP. They found that the drug reduced SBP in patients in the upper three quartiles but not in patients in the lowest quartile with a baseline SBP below 110 mmHg. Compared to patients with higher SBP, patients in the lowest quartile had more severe heart failure and a higher risk of death, first event and hospitalization. The scientists found that while baseline SBP and decrease in SBP over time were risk factors for adverse events in heart failure, the beneficial effects of valsartan did not vary significantly with baseline SBP -- and the decreases in SBP did not counteract valsartan's beneficial effects on heart failure outcomes. Researchers recommend the judicious use of valsartan be considered for patients who present with low SBP and have the highest risk of hospitalization and death.

    Inder S. Anand, M.D., D.Phil., VA Medical Center, Cardiology, Minneapolis, Minn.; (612) 467-3663; anand001@umn.edu.

  • In the second study, Texas doctors also published results of FUSION II, a randomized, double-blind, placebo-controlled trial of outpatient infusions of nesiritide. The drug is a natriuretic peptide that has shown it can relieve breathing stress and reduce lung congestion in patients with advanced heart failure but has an uncertain risk profile. In the trial, 911 heart failure patients received either nesiritide or a placebo for four to six hours once or twice weekly for 12 weeks. The primary endpoints, time to all-cause death, or cardiovascular or renal hospitalization at 12 weeks, were almost identical for the two groups (nesiritide 36.8 percent, placebo 36.7 percent). Researchers found no significant differences between the groups in secondary endpoints, and adverse events also were similar for both groups. Nesiritide was associated with more hypotension (low blood pressure) but less predefined worsening kidney function. Thus, the researchers conclude, serial outpatient nesiritide infusions do not provide a demonstrable clinical benefit over intensive outpatient management of patients with advanced American College of Cardiology/American Heart Association Stage C/D heart failure. "Pending more research, the current goal should be optimization of guideline-driven, evidence-based therapy, with the recognition that even patients with advanced disease may still derive a benefit from further improvements in therapy," researchers conclude.

    Clyde W. Yancy, M.D., Baylor University Medical Center, Dallas; (214) 820-7357; clydey@baylorhealth.edu.

  • An editorial accompanying the nesiritide study recounts the drug's "tumultuous journey" since the discovery of natriuretic peptides nearly 30 years ago. The finding of no clinical benefit from nesiritide raises more questions relating to dose, duration of infusion and frequency of administration, the editorial said. The authors conclude that nesiritide development is "incomplete." While the idea that one of the heart's own protective peptides can be turned into an effective heart failure drug is "exciting," they said nesiritide has yet to realize its potential.

    John C. Burnett Jr., M.D., and Josef Korinek, M.D., Division of Cardiovascular Diseases, the Mayo Clinic, Rochester, MN; (507) 284-4343; burnett.john@mayo.edu.

An ongoing series planned in the new journal will include "Development of Therapeutics in Heart Failure," "Advances in Heart Failure," "Controversies in Heart Failure," and "Challenges to the Basis of Practice." Another series, "Cases and Images in Heart Failure" will highlight real-life scenarios that call for clinical thinking beyond guidelines, and is intended to be highly interactive with readers working alongside 'experts' to propose solutions to complex issues.

"As the heart failure field grows and new directions unfold, it is our hope that Circulation: Heart Failure will provide a forum for continuing expansion of new knowledge that ultimately will increase our understanding of pathophysiology, and translate into improved care for our patients," Udelson said.

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Each bimonthly issue of Circulation: Heart Failure and the other new journals will be available in both print and online formats. The journal Web site, http://circheartfailure.ahajournals.org will also present "Publish Ahead of Print" articles and other online features.

The journal Circulation: Arrhythmia and Electrophysiology debuted in April and four other publications will be launched later this year. Full issues of the specialty journals will be published every other month, and papers from each issue will be published online -ahead of print - as they become available.

Statements and conclusions of study authors that are published in the American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect association policy or position. The American Heart Association makes no representation or warranty as to their accuracy or reliability.

NR08-1064 (Circ HF debut)

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