Correspondence

Heart Failure

N Engl J Med 2003; 349:1002-1004September 4, 2003

Article

To the Editor:

In their article on heart failure (May 15 issue),1 Jessup and Brozena do not discuss heart transplantation, which has become a mainstay of therapy for patients with end-stage heart disease. Considerable effort on behalf of clinicians and researchers has been directed toward increasing the availability of donor hearts and reducing perioperative morbidity and mortality. For example, the introduction of interleukin-2–receptor antibodies has been associated with a decrease in the frequency of acute rejection.2 Similarly, it has been shown that ABO-incompatible heart transplantation can be performed safely in infants, thereby markedly reducing mortality among children with end-stage heart disease who are awaiting transplantation.3 Recent improvements in our understanding of the adaptive changes in the donor heart after transplantation4,5 may further contribute to a reduction in morbidity.

Holger K. Eltzschig, M.D.
University Clinic for Anesthesiology and Intensive Care Medicine, D-72076 Tübingen, Germany
heltzschig@partners.org

Raila Ehlers, M.D.
University Clinic for Cardiology, D-72076 Tübingen, Germany

Stanton K. Shernan, M.D.
Harvard Medical School, Boston, MA 02115

5 References

1
Jessup M, Brozena S. Heart failure. N Engl J Med 2003;348:2007-2018
Full Text | Web of Science | Medline

2
Beniaminovitz A, Itescu S, Lietz K, et al. Prevention of rejection in cardiac transplantation by blockade of the interleukin-2 receptor with a monoclonal antibody. N Engl J Med 2000;342:613-619
Full Text | Web of Science | Medline

3
West LJ, Pollock-Barziv SM, Dipchand AI, et al. ABO-incompatible heart transplantation in infants. N Engl J Med 2001;344:793-800
Full Text | Web of Science | Medline

4
Bengel FM, Ueberfuhr P, Schiepel N, Nekolla SG, Reichart B, Schwaiger M. Effect of sympathetic reinnervation on cardiac performance after heart transplantation. N Engl J Med 2001;345:731-738
Full Text | Web of Science | Medline

5
Quaini F, Urbanek K, Beltrami AP, et al. Chimerism of the transplanted heart. N Engl J Med 2002;346:5-15
Full Text | Web of Science | Medline

To the Editor:

Jessup and Brozena did not mention the increasing evidence that treatment with nasal continuous positive airway pressure (CPAP)1 has been beneficial in patients with heart failure. Studies have already shown that such treatment significantly improves the left ventricular ejection fraction and the quality of life in patients with2 or without3 evidence of concomitant sleep-disordered breathing. Use of CPAP for at least four hours overnight has been shown to be beneficial.3 Randomized, controlled trials involving large numbers of patients and addressing various factors, including but not limited to survival, cost effectiveness, heart size, hospitalizations, and ventricular volumes, are needed to establish the role of CPAP in the treatment algorithm for heart failure.

William Rodriguez, M.D.
San Juan Veterans Affairs Medical Center, San Juan, Puerto Rico 00921
william@prmail.net

3 References

1
Mehta S, Liu P, Fitzgerald FS, Allidina YK, Douglas Bradley T. Effects of continuous positive airway pressure on cardiac volumes in patients with ischemic and dilated cardiomyopathy. Am J Respir Crit Care Med 2000;161:128-134
Web of Science | Medline

2
Kaneko Y, Floras J, Usui K, et al. Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea. N Engl J Med 2003;348:1233-1241
Full Text | Web of Science | Medline

3
Martinez M, Alicea E, Torres A, Rodriguez W. Nasal CPAP in the treatment of heart failure due to ischemic cardiomyopathy: a safe alternative. Am J Respir Crit Care Med 2003;167:Suppl:A326-A326 abstract.

To the Editor:

Drs. Jessup and Brozena did not discuss the role of anemia in heart failure. Anemia is common in patients with heart failure, and such factors as increased cytokine production, renal insufficiency, and plasma volume overload may contribute to its pathogenesis. It is independently associated with decreased functional capacity, worsening symptoms, and increased mortality.1,2 Anemia confers a risk of death among patients with heart failure that is inversely correlated with the hematocrit and is equivalent to that associated with other traditional risk factors.3

More important, treatment of anemia with erythropoietin in patients with heart failure appears to be beneficial. Such treatment has been shown to increase exercise capacity and peak oxygen consumption.4 In a small randomized, controlled study, patients treated with erythropoietin in order to raise the hemoglobin level from between 10.5 and 11.0 g per deciliter to at least 12.5 g per deciliter had substantial improvements in the ejection fraction and New York Heart Association class and a reduced hospitalization rate, as compared with controls, despite less diuretic use.5 Nephrologists have long appreciated the major difference in patients' lives that even a modest increase in hemoglobin can make; maybe it is time for cardiologists to get on board.

Stephen M. Silver, M.D.
Rochester General Hospital, Rochester, NY 14621
stephen.silver@viahealth.org

5 References

1
Horwich TB, Fonarow GC, Hamilton MA, MacLellan WR, Borenstein J. Anemia is associated with worse symptoms, greater impairment in functional capacity and a significant increase in mortality in patients with advanced heart failure. J Am Coll Cardiol 2002;39:1780-1786
CrossRef | Web of Science | Medline

2
Ezekowitz JA, McAlister FA, Armstrong PW. Anemia is common in heart failure and is associated with poor outcomes: insights from a cohort of 12,065 patients with new-onset heart failure. Circulation 2003;107:223-225
CrossRef | Web of Science | Medline

3
Kosiborod M, Smith GL, Radford MJ, Foody JM, Krumholz HM. The prognostic importance of anemia in patients with heart failure. Am J Med 2003;114:112-119
CrossRef | Web of Science | Medline

4
Mancini DM, Katz SD, Lang CC, LaManca J, Hudaihed A, Androne AS. Effect of erythropoietin on exercise capacity in patients with moderate to severe chronic heart failure. Circulation 2003;107:294-299
CrossRef | Web of Science | Medline

5
Silverberg DS, Wexler D, Sheps D, et al. The effect of correction of mild anemia in severe, resistant congestive heart failure using subcutaneous erythropoietin and intravenous iron: a randomized controlled study. J Am Coll Cardiol 2001;37:1775-1780
CrossRef | Web of Science | Medline

To the Editor:

Patients with heart failure may have improvement with adequate therapy, but the syndrome is still associated with a reduced life expectancy. Jessup and Brozena comprehensively discuss various therapeutic approaches, but the content of care in end-stage heart failure is not addressed. Therefore, we want to stress the palliative dimension of care for patients with end-stage heart failure. During their last year of life, most patients have a poorer quality of life because of pain, severe dyspnea, or mental disturbances.1 Surveys have suggested that patients with end-stage heart failure who have distressing symptoms are less likely to receive formal palliative care than are patients with cancer who have such symptoms.2 Differences between patients with heart failure and those with cancer may make decisions about appropriate care more difficult (Table 1Table 1Differences between Heart Failure and Cancer That May Influence Decisions about Palliative Care.). An approach that includes symptom-oriented treatments and better communication about the patient's preferences in case of cardiac arrest should be promoted for patients with end-stage heart failure, just as it is for patients dying from other chronic diseases.3

Didier Schoevaerdts, M.D.
Christian Swine, M.D.
Dominique Vanpee, M.D., Ph.D.
Mont-Godinne University Hospital, 5530 Yvoir, Belgium
didier.schoevaerdts@intr.ucl.ac.be

3 References

1
McCarthy M, Lay M, Addington-Hall J. Dying from heart disease. J R Coll Physicians Lond 1996;30:325-328
Medline

2
Krumholz HM, Phillips RS, Hamel MB, et al. Resuscitation preferences among patients with severe congestive heart failure: results from the SUPPORT project: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Circulation 1998;98:648-655
Web of Science | Medline

3
Gibbs JS, McCoy AS, Gibbs LM, Rogers AE, Addington-Hall JM. Living with and dying from heart failure: the role of palliative care. Heart 2002;88:Suppl 2:ii36-ii39
Medline

Author/Editor Response

We are grateful for the comments that further amplify therapeutic alternatives in the management of heart failure. Dr. Eltzschig and colleagues correctly note that heart transplantation is a mainstay of therapy for end-stage heart failure.1,2 Unfortunately, it is available to only approximately 2000 patients per year in the United States, despite attempts to increase the donor pool.3 Nevertheless, heart transplantation is an important option and one that we included in Figure 3 of our article, which depicts the stages of heart failure and corresponding treatment. Ideally, the decision about a transplant or a mechanical assist device should be made at a specialized heart-failure center with a multidisciplinary team that would be available to primary care practices.

We, too, have been impressed by the ability of CPAP to reduce symptoms and improve cardiac function in patients with sleep apnea, as noted by Dr. Rodriguez. It is for this reason that we included sleep apnea as an important pathophysiologic mechanism in heart failure (Tables 1 and 2 of our article) and a common clinical problem (Table 3). We are discouraged, however, by the poor tolerance of currently available nasal CPAP devices in many cases.

Dr. Silver appropriately acknowledges the increased appreciation of the significance of anemia as a prognostic marker in heart failure. Moreover, correction of anemia with erythropoietin can result in a gratifying improvement of symptoms in selected patients. Disappointingly, it is often difficult to obtain approval by third-party payers for the use of erythropoietin for these patients in the absence of severe renal insufficiency. Nevertheless, the identification of anemia from any cause has always been a fundamental aspect of the overall evaluation of patients with heart failure.

Finally, we are in complete agreement with Dr. Schoevaerdts and colleagues about the important contribution of palliative care for the compassionate treatment of patients with refractory heart failure who are not candidates for other specialized treatment approaches. Hospice is the final step in Figure 3 in our review. We feel strongly that hospice care is underused for patients with end-stage heart failure. In our experience, hospice programs have been a valuable resource for patients, their families, and their medical caregivers.

Mariell Jessup, M.D.
Susan Brozena, M.D.
University of Pennsylvania, Philadelphia, PA 19104
jessupm@uphs.upenn.edu

3 References

1
Hunt SA. Current status of cardiac transplantation. JAMA 1998;280:1692-1698
CrossRef | Web of Science | Medline

2
Hunt SA. Who and when to consider for heart transplantation. Cardiol Rev 2001;9:18-20
CrossRef | Medline

3
Zaroff JG, Rosengard BR, Armstrong WF, et al. Consensus conference report: maximizing use of organs recovered from the cadaver donor: cardiac recommendations, March 28-29, 2001, Crystal City, Va. Circulation 2002;106:836-841
CrossRef | Medline

Citing Articles (1)