Medical Device Daily National Editor

TORONTO – The well-known anticipatory tune from the popular quiz show Jeopardy filled one of the big halls in this city's convention center Sunday morning as a (sort of) theme during the first satellite symposium of the 12th annual scientific meeting of the Heart Failure Society of America (Minneapolis).

The tune was played as the audience – heavy on clinicians treating this deadly disease – considered questions thrown up on the screen, to be answered before and after speaker presentations, and then punched in their answers (their correct answers usually coming in the high 80% range – the remaining 10% to 15% somewhat troubling, at least to this reporter).

This interesting emphasis on electronics in these first sessions (satellite symposia billed as industry-sponsored, but CME regulations do not allow mention of manufacturer names) was used to highlight the mortality and morbidity jeopardies offered by heart failure.

But electronic and device technologies were not then emphasized in the session itself, titled "The Impact of Atrial Fibrillation [AF] on Heart Failure Patients."

Rather, the presentations underlined the first-line use of drugs for this increasingly common heart arrhythmia, and new drug therapy developments, rather than the increasing emphasis on the primary device therapy to treat AF, catheter ablation. And this may reflect the membership bias of the HFSA (in contrast to that of the Heart Rhythm Society [Washington], predominantly featuring electrophysiologists).

Nevertheless, the initial symposium (supported by Sanofi-aventis [Paris]) clearly indicated that both drug and device therapies for AF – and their frequent use in combination – will be a necessary and ever-increasing therapies, for two reasons: the growing awareness of AF as associated with heart failure; and the increase of both problems, described as ballooning to epidemic proportions, given the double conundrum of aging demographics and lengthening life spans.

Opening the session was Barry Massie, MD, of San Francisco, an ex officio member of the HFSA's executive council (and a participant in a trial studying the use of irbesartan, an angiotensin receptor blocker, with disclosed ties to two drug firms). He said that the "intersection between heart failure and atrial fibrillation makes our life miserable on both [patient and physician] sides."

Further expanding on this intersection was Lynn Stevenson, MD, (disclosing a consultant role with Medtronic [Minneapolis]), who highlighted the frequency of AF in heart failure patients, saying "the more sick [heart failure patients] are, the more likely they are to have atrial fibrillation." And among heart failure patients who die of cardiac causes, "half of those patients have AF before death."

Once AF is "present," she said, "the more worried we are in terms of outcomes, even with no symptoms of heart failure. AF contributes to the risk of asymptomatic heart failure."

Despite the use of the word "contributes" in the above quote, Stevenson went on to acknowledge a key unsolved question concerning AF and heart failure: Is AF something that works to cause heart failure or one of its key effects and symptoms?

"There's nothing to demonstrate either possibility, but both are in play," she said.

Of course, the emphasis on drugs in treating heart failure is natural: It's easier to prescribe a drug than utilize a therapeutic device, and devices target late stage heart failure, mostly stages III and IV disease.

But it does not explain the gap in the use of devices for cardiac conditions, which is even greater than the gap in the use of pharmacologic therapies for heart failure, according to Gregg Fonarow, MD, professor of medicine at the University of California at Los Angeles and the Eliot Corday Chair in Cardiovascular Medicine and Science, just two of his titles.

At a session titled "Improving the Quality of Care and Outcomes in Heart Failure: a Call to Action," Fonarow described various studies that have shown a failure to use drug and device therapies based on medical guidelines.

"Life-prolonging drug and device therapies have been developed and are now widely available for managing patients with heart failure," Fonarow said. But he went on to assert that, "despite overwhelming clinical trial evidence," they are not being used consistently.

Perhaps even more disturbing, he cited studies showing that those "at higher risk for dying are less likely to be treated," and, as well, that "Those deriving greatest benefit [from drug and device therapies] are less likely to be treated."

Additionally, he cited drug studies demonstrating a failure to provide beneficial dosages or to up-titrate dosages when necessary to patients.

The "call to action" part of the session came in presenters' recommendations to develop rigorous hospital programs to systematize the use of evidence-based guidelines and provide improved documentation.

Fonarow cited the recent IMPROVE HF trial – the results published in July in the New England Journal of Medicine – showing some improvements in guidelines-based therapies delivered in out-patient settings, but also continuing significant gaps, especially in educational programs and the use of appropriate documentation necessary to determine and quantify the match between patient and therapy.

Fonarow said that gaps in the use of devices – primarily implantable cardioverter devices (ICDs) and cardiac resynchronization (CRT) devices – are even larger than the inconsistent use of available drugs.

The IMPROVE HF study says that the decision to use a device therapy "often requires in-depth and multiple discussions with patients but may not always be documented in the medical record, especially when the decision is to forego use of an otherwise indicated device."

Underlining another disparity in the treatment of heart failure, Fonarow cited a recent study in Circulation, "Use of Cardiac Resynchronization Therapy in Patients Hospitalized with Heart Failure," finding less use of CRT devices in black patients (though no disparity between men and women, found in other studies).

Study authors say the conclusion about this disparity "is particularly concerning because black patients have a higher incidence of nonischemic cardiomyopathy, which has been shown to be associated with greater rates of clinical response to CRT."

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