Investigation and management of congestive heart failure

The recent review of how to manage heart failure concentrates on the
well
described benefits of pharmacological heart failure therapy, whilst not
publicising the other, less well appreciated aspects to this condition. In

particular, the review does not draw attention to the importance of
clarifying
the aetiology. 1 Heart failure is not a diagnosis in its own right, but a
syndrome. 2 It is important to diagnose the aetiology of heart failure, as
often
this results in additional treatment options. For instance, ischaemic
heart
disease is one of the commonest causes of heart failure, and selected
patients
with ischaemic cardiomyopathies should be assessed for revascularisation.
3
Cardiovascular magnetic resonance has a very important role and is now
regarded as the gold standard investigation for heart failure, giving
information on the aetiology, prognosis and guiding further treatment. 4

Whilst the review discusses the role (or absence of role) of digoxin
in detail,
the role of cardiac resynchronisation therapy (CRT) in patients with
systolic
heart failure is not emphasised. CRT has revolutionised the lives of some
patients with moderate to severe heart failure and shown impressive
reduction
in absolute mortality in selected patients. 5 There is now evidence of
benefit
in patients with less severe symptoms. 6 Patients should have the
opportunity
to discuss whether they meet the primary prevention criteria for
implantation
of an implantable cardioverter defibrillator for the prevention of sudden
cardiac death. 7-9 Lethal ventricular arrhythmias are a common and often
preventable cause of death in patients with systolic heart failure. In
addition,
arrhythmic contributors to heart failure, such as atrial flutter and
atrial
fibrillation can often be treated with ablation therapy.

Nowadays, it is accepted practice that all patients with cancer see
an
oncologist. However, the role of a cardiologist should be emphasised as
the
prognosis of a patient with heart failure is worse than the majority of
cancers.
Patients with heart failure should have the opportunity to have a
consultation
with a cardiologist as further investigation and treatment options are
available, including those not included in the review.

1. Arroll B, Doughty R, Andersen V. Investigation and management of
congestive heart failure. BMJ 2010;341(Jul 14):c3657.

2. Patel KCR, Leyva F, Frenneaux MP. Heart failure is not a
diagnosis. Int J Clin
Practice 2008;62:526-528.

3. Lee KS, Marwick TH, Cook SA, Go RT, Fix JS, James KB, et al.
Prognosis of
patients with left ventricular dysfunction, with and without viable
myocardium
after myocardial infarction. Relative efficacy of medical therapy and
revascularization. Circulation 1994;90:2687-2694.

4. Karamitsos TD, Francis JM, Myerson S, Selvanayagam JB, Neubauer S.
The
Role of Cardiovascular Magnetic Resonance Imaging in Heart Failure. J Am
Coll
Cardiol 2009;54(15):1407-1424.

5. Cleland J, Daubert J, Erdmann E, Freemantle N, Gras D,
Kappenberger L, et
al. Longer-term effects of cardiac resynchronization therapy on mortality
in
heart failure [the CArdiac REsynchronization-Heart Failure (CARE-HF) trial

extension phase]. Eur Heart J 2006;27:1928-1932.

6. Moss AJ, Hall WJ, Cannom DS, Klein H, Brown MW, Daubert JP, et al.

Cardiac-Resynchronization Therapy for the Prevention of Heart-Failure
Events. N Engl J Med 2009;361(14):1329-1338.

7. Implantable cardioverter defibrillators for arrhythmias. Review of

Technology Appraisal 11. Technology Appraisal 95, 2006.

8. Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, III, Freedman
RA, Gettes
LS, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac

Rhythm Abnormalities: A Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for
Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) Developed
in
Collaboration With the American Association for Thoracic Surgery and
Society
of Thoracic Surgeons. J Am Coll Cardiol 2008;51(21):e1-62.

9. Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M,
et al.
ACC/AHA/ESC 2006 guidelines for management of patients with ventricular
arrhythmias and the prevention of sudden cardiac death: A report of the
American College of Cardiology/American Heart Association Task Force and
the European Society of Cardiology Committee for Practice Guidelines
(Writing
Committee to Develop Guidelines for Management of Patients With
Ventricular
Arrhythmias and the Prevention of Sudden Cardiac Death) Developed in
collaboration with the European Heart Rhythm Association and the Heart
Rhythm Society. Europace 2006;8(9):746-837.

Competing interests:
PF has received research support
from Medtronic Inc and St Jude. FL
has received funding for research
from Medtronic, St Jude and Sorin