Disclosure: Dr. Wingate has nothing to disclose
Pub Date: Wednesday, Sept. 5, 2012
Author: Sue Wingate RN, PhD, CRNP
Affiliation: Kaiser Permanente Mid-Atlantic States
Citation: Tracy CM, Epstein AE, Darbar D, DiMarco JP, Dunbar SB, Estes NAM 3rd, Ferguson TB Jr, Hammill SC, Karasik PE, Link MS, Marine JE, Schoenfeld MH, Shanker AJ, Silka MJ, Stevenson LW, Stevenson WG, Varosy PD. 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012: published online before print September 10, 2012, 10.1161/CIR.0b013e3182618569.
This guideline update raises several practical issues for clinicians caring for patients with heart failure: (1) use of guideline-directed medical therapy (GDMT), (2) patient/family education and decision-making, and (3) follow-up and collaboration.
Although previous professional guidelines1,2 as well as this current guideline update3 have noted the importance of GDMT, achieving this fundamental intervention in the clinical practice setting remains a challenge. Not only is it essential that patients receive target doses of recommended therapies before device implant, it is equally important for them to continue these therapies post-implant. Perhaps more widespread use of cardiac resynchronization therapy (CRT) will help to achieve this goal, as data from IMPROVE-HF indicated, patients with CRT-D or CRT-P devices more frequently received evidence-based medical therapy than did those without such devices; specifically, use of CRT-D and CRT-P was significantly associated with use of beta-blockers at or above target doses. However, no device therapies were associated with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or aldosterone antagonist dosing.4
The updated patient selection criteria in this guideline significantly impact patient/family education and decision-making regarding device implant. Previously only patients with marked limitation to activity (NYHA Class III or ambulatory Class IV symptoms) were selected for CRT. Per this guideline update, selected patients with no or mild symptoms (NYHA Class I and II) are potential candidates for CRT. An obvious outcome of this change is that existing patient education materials will need to be revised. Currently available teaching guides (and there are many of them, both web-based and print-based) generally note that CRT is indicated when patients have symptoms with or are unable to do activities of daily living—which is wording that will not resonate with patients with no or mild symptoms.
In terms of patient/family decision-making, different approaches will be needed to review the benefits and risks of an invasive procedure, which also requires long-term follow-up, when the patient has few or no symptoms. This is especially true for Class of Recommendation IIa and IIb levels, for which the benefit-to-risk ratio may be lower.3 This is not a small issue. There are challenges to teaching patients, who do not feel physical limitations, to have an invasive procedure with long-term (lower mortality, fewer hospitalizations) but not necessarily immediate (less symptoms) benefits. This type of discussion requires active patient/family participation and shared decision-making geared toward their learning style. More research is needed to assist clinicians to best frame this issue for patients and their caregivers. An additional resource is the recently published policy paper by The American College of Cardiology Foundation (ACCF) that offers further insight into the shared decision-making process with cardiovascular patients.5
Finally, there are implications for patient follow-up and multi-specialty collaboration. Expanded indications translate into more patients receiving CRT and thus more patients requiring appropriate device follow-up. This guideline update provides helpful information on the minimum frequency of in-person or remote monitoring. However, regardless of the format of follow-up, the sheer increase in volume dictates that out-patient practices need to develop appropriate workflows for this, if these are not already in place. For example, who will review the remote reports, respond to alerts, contact the patient if needed, share information with appropriate providers, and document these encounters?
The expanded patient selection criteria as well as the frequency of follow-up monitoring reinforce the need for continued collaboration between heart failure and electrophysiology clinicians.6,7 The collaboration is needed along the continuum of care, from patient selection, to review of device interrogation reports, to considerations of device adjustments with changes in patient preferences including end-of-life issues.
- Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009;119:e391– e479.
- Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Circulation 2008;117:2820-2840.
- Tracy CM, Epstein AE, Darbar D, DiMarco JP, Dunbar SB, Estes NAM III, Ferguson TB, Hammill SC, Karasik PE, Link MS, Marine JE, Schoenfeld MH, Shanker AH, Silka MJ, Stevenson LW, Stevenson WG, Varosy PD. 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012; published online before print September 10, 2012, 10.1161/CIR.0b013e3182618569.
- Heywood JT, Fonarow GC, Yancy CW, Albert NM, Curtis AB, Gheorghiade M, Inge, PJ, McBride ML, Mehra MR, O’Connor CM, Reynolds D, Walsh MN. Comparison of medical therapy dosing in outpatients cared for in cardiology practices with heart failure and reduced ejection fraction with and without device therapy. Circ Heart Fail 2010;3:596-605.
- Walsh MN, Bove AA, Cross RR, Ferdinand KC, Forman DE, Freeman AM, Hughes S, Klodas E, Koplan M, Lewis WR, MacDonnell B, May DC, Messer JV, Pressler SJ, Sanz ML, Spertus JA, Spinler SA, Teichholz LE, Wong JB, Byrd KD. ACCF 2012 health policy statement on patient-centered care in cardiovascular medicine. J Am Coll Cardiol 2012;59:2125– 2143.
- Tang WH.Collaboration among general cardiologists, heart failure specialists, and electrophysiologists: what are the barriers? Am J Cardiol 2007;21:41G-44G.
- Swedberg K, Cleland J, Cowie MR, Nieminen M, Priori SG, Tavazzi L, et al. Successful treatment of heart failure with devices requires collaboration. Eur J Heart Fail 2008;10:1229-1235.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --