World’s top heart failure doctors pledge united action

Members of the Heart Failure Association (HFA) Board and national Heart Failure Working Group Presidents signed a declaration designed to unanimously adopt a Call for Action in support of the HFA’s Global Heart Failure Awareness Programme. Preventing heart failure must become a strategic health priority for each and every country, they noted.

Heart failure affects 26 million people worldwide. It is estimated that one in five people in developed countries will get heart failure. Survival rates for patients with heart failure are worse than those for bowel, breast or prostate cancer. Up to 45% of patients admitted to hospital with heart failure die within 1 year of admission and the majority die within 5 years. But the condition can be prevented with a healthy lifestyle.

“Preventing heart failure must be a strategic health priority in all countries,” said HFA president Professor Gerasimos Filippatos. “The unanimous support for the declaration shows the widespread commitment of heart failure leaders to tackling heart failure.”

The declaration calls on members of the HFA to:

• Raise global awareness about heart failure and make it a universal health priority

• Promote prevention by encouraging healthy lifestyles

• Train healthcare professionals to achieve earlier diagnosis and intervention

• Expand the specialisation of heart failure amongst cardiologists and nurses

• Clarify the patient pathway for earlier detection and structured follow-up

• Support strategic and political initiatives to improve heart failure care at national level

The document was signed at the 5th National Heart Failure Societies’ Presidents’ Summit on 24 October in Ljubljana, Slovenia.

“We need to have political backing for our campaign; this is essential to achieve the financial support and health policy legislation needed to implement strategies that address heart failure,” said Professor Mitja Lainscak, coordinator of the declaration.

The statement supports the HFA’s Global Heart Failure Awareness Programme which seeks to engage politicians, regulators, health care professionals, patients and the public to improve awareness and prevention of the condition.

Professor Lainscak said: “We know how to prevent heart failure, and how to improve the quality of life and survival chances of patients with heart failure. As the world’s largest heart failure organisation, the HFA will work with our partners to reduce unnecessary suffering and improve quality of life.” Heart Failure Association


First-line catheter ablation superior to drug therapy for reducing atrial fibrillation

First-line treatment with catheter ablation is superior to drug therapy for reducing atrial fibrillation, according to five year results from the MANTRA-PAF trial presented for the first time at ESC Congress 2015.

Atrial fibrillation (AF) is the most common heart rhythm problem that requires medical treatment. Atrial fibrillation reduces quality of life and is associated with increased risk of stroke and disability. Atrial fibrillation is more common with higher age, and is observed in 2% of people aged 60 years and at least 5% of the population older than 70 years.

“In clinical practice most doctors choose antiarrhythmic drug therapy for initial treatment of symptomatic atrial fibrillation and catheter ablation is used for patients who fail drug therapy,” said principal investigator Professor Jens Cosedis Nielsen, consultant cardiologist at Aarhus University Hospital in Denmark. “We asked the question: is catheter ablation superior to antiarrhythmic drug therapy as first-line treatment?”

MANTRA-PAF (Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation) was an international multicentre trial conducted by heart rhythm specialists. A total of 294 patients with highly symptomatic paroxysmal atrial fibrillation were randomised to receive either catheter ablation or antiarrhythmic drug therapy as first-line treatment. The two-year results of the trial showed that both treatments reduced atrial fibrillation effectively, but none of the two treatment strategies were superior.

The five-year outcomes of MANTRA-PAF are presented at the ESC Congress. The primary endpoint was the burden of atrial fibrillation assessed by seven-day Holter recording. Secondary endpoints were burden of symptomatic atrial fibrillation, quality of life (using physical and mental component scores of the SF-36 questionnaire), and need for additional catheter ablation procedures since the two year follow up. Analysis was by intention-to-treat and imputation was used to compensate for missing Holter data.

Five-year follow up was achieved in 245 out of 294 patients (83%), of which 125 had been randomised to catheter ablation and 120 to antiarrhythmic drug therapy as first-line treatment.

Holter recording was available for 227 patients. More patients in the catheter ablation group were free from any atrial fibrillation (126/146 versus 105/148, p=0.001) and symptomatic atrial fibrillation (137/146 versus 126/148, p=0.015) than those in the antiarrhythmic drug therapy group.3 Atrial fibrillation burden was significantly lower in the catheter ablation group (any AF: p=0.003, symptomatic AF: p=0.02) compared to the antiarrhythmic drug therapy group. The results were similar when not compensating for missing Holter recordings.

“At five-year follow-up less atrial fibrillation was observed with catheter ablation as first line treatment,” said Professor Nielsen. “The findings indicate that first-line treatment with catheter ablation is superior to drug therapy for reducing atrial fibrillation. The different outcomes observed at two and five years may be because the two treatments have different modes of action.”

There was no difference between the two groups in the number of additional catheter ablation procedures since the two-year follow up. Quality of life scores at five years did not differ between groups (physical component score p=0.88, mental component score p=0.94), but remained improved from baseline (both components p<0.001) and did not differ from the two-year scores.

“Quality of life scores remained improved from before treatment initiation with either of the two treatments,” said Professor Nielsen. “This indicates that quality of life can be improved long-term by treatment aiming to withhold normal heart rhythm, either by antiarrhythmic drug therapy or catheter ablation.”

He concluded: “The results indicate that first-line catheter ablation is superior to drug therapy for suppressing atrial fibrillation in patients with paroxysmal AF. The choice of first-line treatment strategy still needs to be discussed with individual patients taking into account their disease burden and risks associated with the different treatment strategies.”

Changes in foetal hearts found in pregnant women with diabetes or obesity

Changes in foetal hearts have been found in pregnant women with diabetes or obesity, in research presented 3 December at EuroEcho-Imaging 2015 in Seville, Spain, by Dr Aparna Kulkarni, paediatric cardiologist from New York.

Dr Kulkarni said: “The main concept behind this study is of foetal programming. This refers to changes that occur in the structure and physiology of tissues in the foetus as a result of the mother’s health.” She continued: “Diabetes and obesity are major epidemics of the present century. I see a lot of mothers with one or both conditions in my clinical practice and wanted to investigate if these maternal conditions had any effect on the foetal hearts.”

In 2014 there were 387 million people in the world with diabetes and this is expected to increase to nearly 600 million by 2035. Worldwide obesity has more than doubled since 1980 and in 2014 more than 600 million adults were obese.

In the United States, pregnant women with diabetes and some with obesity are routinely referred for standard of care foetal echocardiograms, which show a picture of the baby’s heart. During 2012 to 2015, the study prospectively enrolled 82 pregnant women with diabetes and 26 pregnant obese women with a body mass index (BMI) of more than 30 kg/m2. A control group of 70 healthy pregnant women who volunteered to have a foetal echocardiogram was used for comparison.

The researchers examined the echocardiograms to see how well the heart muscle of each foetus was contracting and relaxing. Next they processed the pictures using a method called speckle tracking to generate more detailed information on heart muscle function by evaluating the heart muscle motion. “Speckle tracking echocardiography can detect heart abnormalities at the subclinical level, in other words before standard echocardiographic techniques may detect an abnormality.”

said Dr Kulkarni. “In our study, it highlights abnormalities without obvious functional heart problems in the foetus.”

The researchers found subclinical changes in the myocardium (heart muscle) of foetuses of mothers with diabetes and also foetuses of mothers with obesity, compared to the foetuses of healthy women. The changes were not apparent by routine echocardiographic techniques.

Dr Kulkarni said: “On routine standard echocardiographic images, it did not seem like these hearts were significantly affected.

But with speckle tracking we had evidence that the myocardial function was unfavourably altered in the hearts of foetuses of mothers with diabetes and obesity. “Our findings potentially have implications in a world where both diabetes and obesity are skyrocketing,” said Dr Kulkarni.

Further research

But she added that further studies were needed to find out if these foetal changes affect the cardiovascular health as a child or an adult, when during pregnancy the hearts are affected and whether anything can be done to alter this course. As an extension of the current study, Dr Kulkarni will examine the babies’ hearts at one year of age to see if the abnormalities are still present, get worse, or have disappeared.

Dr Kulkarni said: “These are important results but I don’t want pregnant women with diabetes or obesity to think that something will definitely go wrong with their pregnancy. We need more answers about what impact diabetes and obesity in the mother may have on the child after birth, before coming to firm conclusions about implications for the health of the baby.” Dr Alawi Alsheikh-Ali, Consultant Cardiologist and Cardiac Electrophysiologist at SKMC, added: “The first paediatric cardiac surgery assisted by 3D printed models in the UAE was performed by our team in June 2015, and it has become an important modality in our profession.”

The patient was born with hypoplastic left heart syndrome (HLHS), where the left ventricle of the heart is very underdeveloped and unable to pump blood to the body. Without surgical intervention, HLHS is fatal. After an initial surgery in the girl’s first weeks of life, she underwent a second stage of surgery at five months old, with surgeons using the lifesaving 3D technology in preparation.

Complex congenital heart diseases such as HLHS demand the best quality of medical imaging for the planning of paediatric open-heart surgery, Dr Alsheikh-Ali, who is the Chair of the Cardiac Sciences Institute at the hospital, said.

“The life-size, 3D-printed true model of the heart is used to plan intricate, detailed steps of the operation, and this translates into improved patient safety and outcomes. This novel technology has additional potential for teaching of young doctors and medical students.”

The Institute of Cardiac Sciences at SKMC offers cardiac care to patients from the neonatal stage to adulthood. SKMC’s paediatric cardiology program, which was rolled out in April 2007, is a referral centre for the region. For the paediatric patient population, it provides a paediatric cardiac operating room, an intensive care unit, and a high dependency unit, among other services.

 Date of upload: 13th Jan 2016


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