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Devices for Cardiac Rhythm Abnormalities: A Guideline Update

Devices for Cardiac Rhythm Abnormalities: A Guideline Update

According to recent estimates, about 400,000 pacemakers and implantable cardioverter defibrillators (ICDs) are surgically implanted each year in the United States. In 2008, the American College of Cardiology Foundation (ACCF), American Heart Association (AHA), and the Heart Rhythm Society (HRS) released guidelines for using device therapy to manage cardiac rhythm abnormalities. Since the release of the 2008 guidelines, many clinical research advances relating to device-based therapies have emerged, says Andrew E. Epstein, MD, FAHA, FACC, FHRS. “In an effort to help clinicians keep pace with these advances, the ACCF, AHA, and HRS jointly released updated guidelines in 2012 for the use of device-based therapy in treating heart rhythm disorders. The guidelines can help in clinical decision making in most circumstances.” The 2012 update writing group included experts in device therapy, cardiovascular care, internal medicine, cardiovascular surgery, and pediatric and adult electrophysiology. The guidelines were also developed in collaboration with the American Association for Thoracic Surgery, Heart Failure Society of America, and Society of Thoracic Surgeons. Building on Earlier Cardiac Device Guidelines For the 2012 update, the writing group began by reviewing the 2008 recommendations. The latter are largely unchanged for standard pacing and ICD indications. However, given new data on cardiac resynchronization therapy (CRT), the 2008 guidelines were updated with CRT as its focus, especially with regard to expanding indications for this treatment (Figure 1). “CRT can significantly improve quality and quantity of life by delaying or avoiding worsening heart failure.” —Andrew E. Epstein, MD, FAHA, FACC, FHRS “Despite our improvements in managing patients with device-based therapies, it can still be challenging for physicians to select patients in whom...

Analyzing Preventive CRT in the Elderly

Published studies have shown that the prevalence of congestive heart failure (CHF) increases as people age, rising from 2% to 3% in the total population to 10% to 20% after patients reach age 75. When compared with younger patients, CHF in the elderly has been associated with higher mortality rates. “Even when medical management is optimized, elderly patients with CHF still require frequent healthcare utilization, including those with the early stages of disease,” says David T. Huang, MD. “While medical therapy can sometimes help, there are concerns about disease recurrence.” Cardiac resynchronization therapy (CRT) can be used in conjunction with implantable cardioverter defibrillators (ICDs), an approach that has been shown to reduce hospitalizations and mortality relative to CHF. “CRT and ICDs have become important components for qualified patients with class III or IV heart failure,” adds Dr. Huang. “CRT has been used in patients of many age ranges in the past, but mostly in the most severe late-stage cases. Symptoms can improve with this therapy, but questions have been raised about whether or not CRT should be used in earlier stages of CHF in order to better prevent symptoms.” When patients with CHF are properly selected, age should not be used as a sole discriminator to exclude device therapy. —David T. Huang, MD The Effect of Age on CRT Outcomes The Multicenter Automatic Defibrillator Implantation Trial with CRT (MADIT-CRT) recently found that CRT utilizing defibrillators (CRT-D) was associated with a 34% reduction in the risk of heart failure or death when compared with ICD-only therapy in asymptomatic or mildly symptomatic patients. However, limited data are available on the benefits...

Conference Highlights: American Heart Association’s 2010 Scientific Sessions

The American Heart Association held its 2010 Scientific Sessions from November 13 to 17 in Chicago. The features below highlight some of the news emerging from the meeting. » Benefits Observed With Experimental Cholesterol Drug » A New Approach for Difficult Hypertension Cases » PTSD Linked to Death, Atherosclerosis » Smoking Rates Decline, But Cessation Efforts Still Warranted » Scanning Matters When Managing Diabetics With Heart Disease » Combination Therapy Effective in Heart Failure Benefits Observed With Experimental Cholesterol Drug The Particulars:  Elevated LDL and low HDL cholesterol levels are risk factors for cardiovascular disease (CVD). Statins have been shown to reduce LDL and lessen CVD risk. Despite statin therapy, many patients still have a high risk of CVD. Anacetrapib is an experimental cholesteryl ester transfer protein (CETP) inhibitor. It is intended to block the ability of the CETP enzyme to transfer cholesterol particles from HDL to LDL cholesterol. Data Breakdown: The DEFINE study (Determining the Efficacy and Tolerability of CETP Inhibition with Anacetrapib) was a randomized, double-blind trial of 1,623 patients who took either 100 mg anacetrapib or a placebo for 18 months. Patients were already being treated with a statin and/or other lipid-lowering medicine. Anacetrapib reduced LDL by 40%—from 81 mg/dL to 49 mg/dL. It also more than doubled the level of HDL cholesterol—from 40 mg/dL to 101 mg/dL—without raising blood pressure. Take Home Pearls: Anacetrapib appears to more than double the level of HDL cholesterol and reduce LDL cholesterol without the blood pressure increase that has been linked to other CETP inhibitors. The full efficacy and safety of anacetrapib must be evaluated in a larger, phase...
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