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Heart Failure Society of America (HFSA) 15th Annual Scientific Meeting
September 18-21, 2011, Boston, Massachusetts
SUMMARY/HIGHLIGHTS REPORT - PART II

Stavros G Drakos, MD
UTAH Cardiac Transplant Program, Salt Lake City, UT


stavros drakosThe 2011 Heart Failure Society of America Meeting (Scientific Program Chairs: Lynne Warner Stevenson, MD, Steve R. Houser, PhD, Barbara J. Riegel, RN, DNSc) was very rich in topics and it is definitely worth highlighting some of the presented information for those who did not get to attend. This is the second part of a report summarizing only a sample of the most interesting talks and discussions that took place during the meeting (the first part of the report was published in the December issue of the ISHLT Links).

Dr. Daniel B. Mark (Duke Clinical Research Institute, Durham, NC) presented the Surgical Treatment for Ischemic Heart Failure (STICH) trial's quality-of-life results. The STICH trial randomized 1212 patients with an LVEF <35% and HF who were considered candidates for CABG to receive or not receive the surgery on top of optimal medical therapy. The results referring to its hard endpoints were recently published. Over a median of 56 months, the trial failed to show a significant difference in its primary end point of all-cause mortality: 36% in the CABG group vs. 41% for the optimal medical therapy group (p=0.12). Secondary clinical end points showed benefits for the CABG group: a 19% decrease in risk of cardiovascular death (p<0.05) and a 26% decrease in the composite of all-cause mortality or cardiovascular hospitalization (p<0.0001). Study subjects prospectively completed quality-of-life tests at 4, 12, 24, and 36 months after randomization. These consisted of multiple queries about symptoms, physical and social limitation, and the Kansas City Cardiomyopathy Questionnaire (KCCQ), scored from 0 to 100, with a higher score indicating more favorable conditions. A statistically significant difference was also considered clinically significant if it was different by at least 5 KCCQ points. Quality-of-life scores became both statistically and clinically significant in the CABG group at 12 and 24 months. When the measure was proportion of patients who showed a clinically significant >5-point improvement in KCCQ summary scores the CABG group also showed significant benefits at the studied time points. However, both the presenter and Dr. Eugene Braunwald (Brigham and Women's Hospital, Boston, MA), a co-moderator for the session, acknowledged that a placebo effect should be considered given that blinding to treatment assignment was impossible, a problem with many randomized trials that include surgery.

In the session, Guideline Update 2011: What's Current, Controversial, and Coming Next?, Dr. Joseph G. Rogers (Duke University Heart Center, Durham, NC) gave a talk titled, Use of LVADs in HF. The presenter initially described the challenges in developing evidence in the field of chronic mechanical circulatory support: a small and very ill patient population, a limited number of investigative sites, and non-traditional trial designs among others. He then reviewed in a systematic way all of the trials that investigated the role of LVADs in end stage HF (either as bridge to transplant or destination therapy) and suggested that the level of evidence supporting LVADs in the treatment of advanced systolic HF is sufficient for guideline documents to be altered and indicate the highest level of recommendation with the highest level of evidence. Dr. Rogers also reviewed the available data investigating the role of LVADs in less sick HF patients. He concluded that currently the data is insufficient to support LVAD use in this patient population and pointed out that new initiatives (REVIVE-IT and ROADMAP trials and the MEDAMACS Registry) will help us better understand the impact of LVAD therapy in this patient population.

Dr. Garrick C Stewart (Brigham and Women's Hospital, Boston, MA) in a talk titled, Who Wants an LVAD for Ambulatory HF, addressed the intriguing issue of LVAD use in 'less sick' HF patients. In an effort to address this issue from the patients' perspective, Dr Stewart and his coworkers enrolled 150 ambulatory HF patients who read a short, nonspecific description of an LVAD and its potential risks and were asked through a structured questionnaire how open they were to the idea of receiving one. The participating patients were in NYHA class III or IV HF and had a history of at least two HF hospitalizations in the past year or one such HF hospitalization plus poor functional capacity (maxVO2<55% predicted or 6-minute walk test < 300m). They excluded patients already listed for heart transplant, on home inotrope infusion, and with recent or planned resynchronization therapy. They found that 24% of the patients would "definitely want" an LVAD and 32% "probably want" (25% "do not know", 13% "probably not" and 7% "definitely not"). The greatest concerns the study subjects expressed regarding the LVAD therapy included stroke risk, infection risk and device durability. The take home message was that ambulatory patients with advanced HF were open to considering LVAD prior to becoming inotrope dependent and the enthusiasm for LVAD increased as INTERMACS profile worsened and HF hospitalizations became more frequent. Based on these findings, Dr. Stewart recommended "engaging patients early about thresholds for considering elective LVAD and give priority to patient education about both LVAD therapy and survival with HF".

Dr. Josef Stehlik (University of Utah, Salt Lake City, UT) presented a talk titled, Beyond Levels: How Can We Tailor Immunosuppression?, in which he summarized approaches to optimize immunosuppression intensity in individual heart transplant recipients. He illustrated the opportunity by showing that while survival after heart transplantation has improved over the past three decades, most of this improvement has been limited to the first post-transplant year. He also reviewed the leading causes of death after heart transplant and showed that their distribution varied significantly among cohorts of patients grouped by simple clinical variables, such as age. Dr. Stehlik suggested that despite these differences in mortality risk, the current clinical care has not embraced formal personalized approaches to immunosuppression tailoring. He then discussed two tests designed to assess the immune status of transplant recipients - the ImmuKnow test (evaluates activation of lymphocytes by quantifying ATP release with their stimulation) and the Allomap test (quantifies expression of genes involved in rejection), and reviewed studies that examined the utility of these tests in heart transplant recipients. Dr. Stehlik concluded that we currently have tools that can help us to better tailor immunosuppression, but also suggested that prospective studies should be done to confirm that these approaches will result in better outcome.

Dr. Dirk J. van Veldhuisen (University of Groningen, the Netherlands) presented the Diagnostic Outcome Trial in Heart Failure (DOT-HF) which investigated the effectiveness of the impedance-monitoring function and audible-alert system (OptiVol, Medtronic) in improving HF outcomes. The enrolled patients were implanted with a defibrillator featuring a monitor that emitted an audible beep when intrathoracic impedance rose (suggesting volume overload). Inclusion criteria were NYHA functional class ?? to ?V on optimal medications, left ventricular ejection fraction (LVEF) <35%, implantation of a defibrillator or biventricular pacemaker-defibrillator no more than six months previously, and a history of a HF event within 12 months of the implantation. The 335 enrolled patients were followed for an average of 15 months. Surprisingly, compared to patients who did not receive the monitors, patients with the implanted study device showed an increase in HF hospitalizations (hazard ratio 1.79, p=0.022). No significant difference in mortality was noted. Patients with OptiVol monitors had also three times as many unscheduled outpatient clinic visits as those without the monitor. Of note, when these patients were seen in the clinic, they tended to have fewer signs or symptoms of HF decompensation compared to patients randomized to no monitors who were seen in clinic. Dr. James E. Udelson (Tufts Medical Center, Boston, MA), designated discussant for the DOT-HF presentation, commented that it may have been the audible beeps that drove up HF hospitalizations, but there are other plausible explanations as well. While the idea that decompensated HF is preceded by a prolonged period of subclinical worsening amenable to intervention is attractive, other mechanisms may be involved, such as sudden shifts in central blood volume. He suggested that it may well be that the relationship of changes in intrathoracic impedance to clinical HF is more complicated than initially thought. Overall, the trials investigating the role of impedance reached weak results as opposed to pressure-monitor trials (CHAMPION, COMPASS-HF) that have generally been positive. Interestingly, in the pressure-monitor trials patients were blinded to the device readouts and that information went directly to the physicians.

Overall, the meeting provided a great forum and ample opportunities for presentation of original science, summary topics, didactic presentations, networking and discussions regarding the current challenges and future directions in the field. The above is only a sample of a number of stimulating presentations the 2011 HFSA annual meeting offered to the participants.

Conflict of Interest Statement: The author has no conflicts of interest to disclose.