Applying HF Guidelines to Adult Congenital Heart Disease Patients
Applying HF Guidelines to Adult Congenital Heart Disease Patients
As is well known, there are excellent randomized, controlled clinical trial data supporting the use of neurohormonal antagonists to decrease morbidity and mortality in congestive heart failure in the setting of acquired heart disease. Angiotensin-converting enzyme (ACE) inhibitors have been shown to decrease mortality in a wide range of heart failure patients, whether with severe symptoms, mild-to-moderate symptoms or no symptoms. In these patients with heart failure of various causes, 1-year mortality was reduced by an average of 16%. The use of ACE inhibitors also reduced symptoms, hospitalizations and recurrent myocardial infarction. Other medications that are recommended for the treatment of heart failure in adults include aldosterone antagonistis, angiotensin receptor blockers (in those intolerant to ACE inhibitors), and digoxin for the treatment of current or past symptoms of heart failure. Since the adult heart failure trials that proved efficacy of these medications failed to include any adults with CHD, it is not clear that they will have the same efficacy in this population. Adults with CHD commonly have heart failure due to or associated with valvular heart disease. Current recommendations for the use of afterload-reducing agents or calcium channel blockers can be applied to these patients. Of course, all patients with heart failure and fluid overload should be appropriately diuresed.
β-blockers have also been conclusively demonstrated to reduce morbidity and mortality in chronic heart failure due to acquired heart disease. β-blockers have proven their efficacy in reducing mortality in mild-to-moderate heart failure or in patients with severe symptoms. β-blockers also reduce the risk of sudden death. On average, β-blockers reduce 1-year mortality of heart failure patients by 36%. The use of β-blockers is associated with fewer hospitalizations, fewer heart failure symptoms and protection from recurrent myocardial infarction.
Appealing though it may be to extrapolate these data to patients with CHD, there are major differences in the populations studied. Much of the heart failure literature deals with patients above 60 years of age. Mortality rates in the placebo group of heart failure trials range between 7 and 52% per year, considerably higher than for most ACHD patients. Additionally, the most common cause of heart failure in the adult trials was ischemic heart disease, although a significant percentage of patients in many of these studies had nonischemic cardiomyopathy. ACHD patients with heart failure are generally younger, do not have coronary disease and have a lower annual mortality rate.
As is well known, there are excellent randomized, controlled clinical trial data supporting the use of neurohormonal antagonists to decrease morbidity and mortality in congestive heart failure in the setting of acquired heart disease. Angiotensin-converting enzyme (ACE) inhibitors have been shown to decrease mortality in a wide range of heart failure patients, whether with severe symptoms, mild-to-moderate symptoms or no symptoms. In these patients with heart failure of various causes, 1-year mortality was reduced by an average of 16%. The use of ACE inhibitors also reduced symptoms, hospitalizations and recurrent myocardial infarction. Other medications that are recommended for the treatment of heart failure in adults include aldosterone antagonistis, angiotensin receptor blockers (in those intolerant to ACE inhibitors), and digoxin for the treatment of current or past symptoms of heart failure. Since the adult heart failure trials that proved efficacy of these medications failed to include any adults with CHD, it is not clear that they will have the same efficacy in this population. Adults with CHD commonly have heart failure due to or associated with valvular heart disease. Current recommendations for the use of afterload-reducing agents or calcium channel blockers can be applied to these patients. Of course, all patients with heart failure and fluid overload should be appropriately diuresed.
β-blockers have also been conclusively demonstrated to reduce morbidity and mortality in chronic heart failure due to acquired heart disease. β-blockers have proven their efficacy in reducing mortality in mild-to-moderate heart failure or in patients with severe symptoms. β-blockers also reduce the risk of sudden death. On average, β-blockers reduce 1-year mortality of heart failure patients by 36%. The use of β-blockers is associated with fewer hospitalizations, fewer heart failure symptoms and protection from recurrent myocardial infarction.
Appealing though it may be to extrapolate these data to patients with CHD, there are major differences in the populations studied. Much of the heart failure literature deals with patients above 60 years of age. Mortality rates in the placebo group of heart failure trials range between 7 and 52% per year, considerably higher than for most ACHD patients. Additionally, the most common cause of heart failure in the adult trials was ischemic heart disease, although a significant percentage of patients in many of these studies had nonischemic cardiomyopathy. ACHD patients with heart failure are generally younger, do not have coronary disease and have a lower annual mortality rate.
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