Title: Anthracycline-Induced Cardiomyopathy: Clinical Relevance and Response to Pharmacologic Therapy
Topic: Heart Failure/Transplant
Date Posted: 3/2/2010
Author(s): Cardinale D, Colombo A, Lamantia G, et al.
Citation: J Am Coll Cardiol 2010;55:213-220.
Clinical Trial: No
Related Resources
JACC Article: Anthracycline-Induced Cardiomyopathy: Clinical Relevance and Response to Pharmacologic Therapy
Study Question: What is the clinical relevance of anthracycline-induced cardiomyopathy (AC-CMP) and its response to heart failure (HF) therapy?
Methods: The study cohort was comprised of 201 consecutive patients with a left ventricular ejection fraction (LVEF) <45% due to AC-CMP. Enalapril and, when possible, carvedilol were promptly initiated after detection of LV systolic dysfunction. LVEF was measured at enrollment, every month for the first 3 months, every 3 months during the first 2 following years, and every 6 months afterward (mean follow-up 36 ± 27 months). Patients were considered responders, partial responders, or nonresponders according to complete, partial, or no recovery in LVEF, respectively. They also evaluated major adverse cardiac events during follow-up.
Results: Forty-two percent of the patients (n = 85) were responders, 13% (n = 26) were partial responders, and 45% (n = 90) were nonresponders. The percentage of responders progressively decreased as the time from the end of chemotherapy to the start of HF treatment increased; no complete recovery of LVEF was observed after 6 months. Responders showed a lower rate of cumulative cardiac events than partial and nonresponders (5%, 31%, and 29%, respectively; p < 0.001).
Conclusions: The study investigators concluded that in cancer patients developing AC-CMP, LVEF recovery and cardiac event reduction may be achieved when cardiac dysfunction is detected early and a modern HF treatment is promptly initiated.
Perspective: This is an important study, which confirms that early initiation of therapy with angiotensin-converting enzyme inhibitors (Circulation 2006;114:2474-81) and beta-blockers (J Am Coll Cardiol 2006;48:2258-62) in AC-CMP is beneficial. Ragavendra R. Baliga, M.B.B.S.
Title: Triage After Hospitalization With Advanced Heart Failure: The ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) Risk Model and Discharge Score
Topic: Heart Failure/Transplant
Date Posted: 3/5/2010
Author(s): O’Connor CM, Hasselblad V, Mehta RH, et al.
Citation: J Am Coll Cardiol 2010;55:872-878.
Clinical Trial: No
Related Resources
JACC Article: Triage After Hospitalization With Advanced Heart Failure: The ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) Risk Model and Discharge Score
Study Question: What are the predictors of morbidity and mortality at hospital discharge?
Methods: The investigators used data from the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) trial to develop a predictive model, and internally validated their approach by the bootstrapping method. They used model coefficients to generate an additive risk score. They also used data from FIRST (Flolan International Randomized Survival Trial) to externally validate this model.
Results: This study found that among patients discharged with complete data (n = 423), the 6-month mortality and death and rehospitalization rates were 18.7% and 64%, respectively. Risk factors for mortality at discharge included B-type natriuretic peptide, per doubling (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.15-1.75), cardiopulmonary resuscitation or mechanical ventilation during hospitalization (HR, 2.54; 95% CI, 1.12-5.78), blood urea nitrogen, per 20-U increase (HR, 1.22; 95% CI, 0.96-1.55), serum sodium, per unit increase (HR, 0.93; 95% CI, 0.87-0.99), age >70 years (HR, 1.05; 95% CI, 0.51-2.17), daily loop diuretic, furosemide equivalents >240 mg (HR, 1.49; 95% CI, 0.68-3.26), lack of beta-blocker (HR, 1.28; 95% CI, 0.68-2.41), and 6-minute walk, per 100-foot increase (HR, 0.955; 95% CI, 0.99-1.00; c-index 0.76). A simplified discharge score discriminated mortality risk from 5% (score = 0) to 94% (score = 8). Bootstrap validation demonstrated good internal validation of the model (c-index, 0.78; 95% CI, 0.68-0.83).
Conclusions: The authors concluded that the ESCAPE study discharge risk model and score refine risk assessment after in-hospital therapy for advanced decompensated systolic heart failure, allowing clinicians to focus surveillance and triage for early life-saving interventions in this high-risk population.
Perspective: This is an important study because it identifies patients with risk ‘at the time of discharge.’ Further studies are needed to determine whether this score adds incremental value to currently used yardsticks such as the Heart Failure Survival Score developed by Aaronson et al., the MUSIC risk score (see Journal Scan), or the Seattle Heart Failure Model (Circulation 2006;113:1424-33). Overall, it is becoming increasingly clear that clinicians would be expected to calculate mortality risk for all heart failure patients at the time of hospital discharge to better manage their patients. Ragavendra R. Baliga, M.B.B.S.