Managing heart failure and transplants: Here's how

The International Society for Heart & Lung Transplantation (ISHLT) has released the first international guidelines for managing heart failure (HF) patients prior to heart transplantation. HF is a serious condition in which the heart is unable to pump blood at a rate sufficient to meet the needs of the body. "The new guidelines will enhance the effectiveness of patient care, optimize patient outcomes, and improve overall cost by focusing resources on the most effective strategies," said Mariell Jessup, M.D., ISHLT task force chair and professor of medicine at the University of Pennsylvania Medical Center.

According to Mandeep Mehra, M.D., ISHLT task force chair and chief of the division of cardiology at the University of Maryland School of Medicine in Baltimore, ISHLT convened three task forces to develop heart transplantation guidelines: one group developed criteria for heart transplantation, the second task force focused on creating guidelines for optimal pharmacologic and nonpharmacologic management of cardiac transplant candidates, and a third panel developed recommendations for heart rhythm considerations in heart transplant candidates and for ventricular assist devices.

"The guidelines offer evidence-based treatment approaches for both compensated and decompensated heart failure patients," stated Lucky Anighoro, R.Ph., at Newark Beth Israel Medical Center in Newark, N.J.

In citing results of the African-American Heart Failure Trial (A-HeFT), the committee also advocated that a combination of hydralazine and nitrates be considered for patients with persistent symptoms despite therapy with neurohormonal antagonists, or when progressive renal impairment or hyperkalemia limits treatment with an ACE inhibitor or ARB.

Jessup reported that the task force also made recommendations for pharmacologic management of patients with decompensated HF. The group recommended that intravenous vasodilators be considered before inotropic therapy in patients with decompensated HF and adequate blood pressure.

The effectiveness of IV vasodilators, such as nitrates and sodium nitroprusside, when combined with diuretics, for the treatment of acute HF has been well defined.

Another agent approved for the management of acute decompensated HF is nesiritide (Natrecor, Scios), a recombinant human brain natriuretic peptide (BNP). Results of a study published in the Journal of the American Medical Association in 2002 demonstrated that nesiritide produced faster relief of dyspnea in decompensated HF patients, when compared with IV nitroglycerin.

While the task force recognizes the beneficial effects of nesiritide in decompensated HF patients, it cautioned that the drug's short-term safety relative to standard therapy is not well established. Because hypotension is the most common adverse event associated with nesiritide, the guidelines advise that IV administration of nesiritide should be done under close blood pressure monitoring.

According to the guidelines, inotropic therapy should be used in patients with decompensated HF and hypoperfusion in spite of adequate filling pressure. The experts stressed that the need for continued inotropic therapy should be reevaluated frequently and that long-term therapy with inotropes should be used as a pharmacologic link to transplantation or for palliation.

"While several agencies worldwide address guidelines for the management of heart failure, none is comprehensive," said Mehra. "With its international membership, ISHLT is in the ideal position to advocate comprehensive guidelines for the global medical community."

THE AUTHOR is a writer and hospital pharmacist in New Jersey.