European Heart Journal Advance Access originally published online on October 4, 2005
European Heart Journal 2005 26(22):2473-2474; doi:10.1093/eurheartj/ehi551
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The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology: Guidelines for the Diagnosis and Treatment of Chronic Heart Failure: reply
Writing Committee, ESC Guidelines on the Diagnosis and Treatment of CHF
Department of Medicine
Sahlgrenska University Hospital/Östra
Goteborg SE 416 85
Sweden
Tel: +46 31 3434000
Fax: +46 31 258933
E-mail address: karl.swedberg{at}hjl.gu.se
Academic Cardiology Unit
University of Hull—Castle Hill Hospital
Castle Road
Kingston upon Hull
East Yorkshire HU16 5JQ
UK
Cardiac Research
Level 4 Western Infirmary
Dumbarton Road
Glasgow G11 6NT
Scotland
UK
Abt. Kardiologie u. Angiologie
Zentrum Innere Medizin
Med. Hochschule Hannover (MHH)
Carl-Neubergstrasse 1
DE-30625 Hannover
Germany
Department of Internal Medicine
University Hospital
Ramistrasse 100
CH-8091 Zurich
Switzerland
Département de Cardiologie
CHU Pitié-Salpêtrière
47, blvd de l'Hôpital
75651 Paris
France
Department of Cardiology
Rikshospitalet, University Hospital
Pilestredet 32
NO-0027 Oslo
Norway
Divisione di Cardiologia
Policlinico San Matteo, IRCCS
Piazzale Golgi 2
IT-27100 Pavia
Italy
Dr Krum suggests changes to the ESC Guidelines on the diagnosis and treatment of chronic heart failure and of Figure 4 in particular. We appreciate the opportunity to clarify the role of the figure. As stated in the legend, the figure should be viewed as an example for decision-making. The figure is designed to complement the explanatory text, but is no substitute for it. In the text and in Table 18, it is stated (as pointed out by Krum) that the addition of an angiotensin receptor blocker (ARB) should be considered in symptomatic patients regardless of background angiotensin-converting enzyme (ACE)-inhibitor therapy. The reason for not stating that ACE-inhibitor/ARB should be used in combination in the figure is that these patients require re-evaluation after the institution of basic therapy and only those with persisting NYHA class-II symptoms should, in the absence of an indication for an ARA, then receive an ARB.
Similarly, Figure 4 uses the term ‘post MI’ and this is clarified as meaning ‘recent MI’ in both tables and text.
Dr Gasparini and co-workers propose that the recommendations for the benefits of ICDs should be extended to include ‘all-cause’ mortality and not only applied to sudden death. In the full text document (www.escardio.org/knowledge/guidelines), the background documentation on all-cause mortality is expanded. The statistical evidence for a reduction in sudden death and all-cause mortality in patients with heart failure and reduced left ventricular function cannot refute the size of the benefit, the fact that most patients who receive such a device will not benefit and because all patients will be exposed to the considerable morbidity associated with defibrillators. Much of these data are new, including the DINAMIT study which was included through a meta-analysis, and have yet to be placed in the context of other treatments that can reduce mortality in patients with heart failure, including pharmacological therapy and cardiac resynchronization devices. These constitute important gaps in knowledge about an intervention, which has a modest effect on mortality and considerable morbidity. Accordingly, the Task Force felt strongly that the selection of patients in whom the benefits of a defibrillator outweighed the adverse effects required considerable expertise and fine judgement on the part of the clinician and that no general mandate could be given at present.
Every clinician and medical system has to interpret this new and innovative technology in the light of their competence, resources, and priorities. The difficulties have been recognized in a recent review.1 Guidelines can guide on such matters, but not decide for individual patient care.
More information exists on the diagnosis and treatment of heart failure than most other areas of medicine. This abundance of evidence is complex to interpret, may be conflicting at times, but does provide a basis for making some strong recommendations. However, the information is still imperfect, reflecting the need for further research.2 Clinical judgement is always important for the final decision. Guidelines provide a framework for clinical practice and training, but are no substitute for personal expertise.
References
- Kadish A, Mehra M. Heart failure devices: implantable cardioverter-defibrillators and biventricular pacing therapy. Circulation 2005;111:3327–3335.
[Free Full Text] - Al-Khatib SM, Sanders GD, Mark DB, Lee KL, Bardy GH, Bigger JT, Buxton AE, Connolly S, Kadish A, Moss A, Feldman AM, Ellenbogen KA, Singh S, Califf RM. Implantable cardioverter defibrillators and cardiac resynchronization therapy in patients with left ventricular dysfunction: randomized trial evidence through 2004. Am Heart J 2005;149:1020–1034.[CrossRef][Web of Science][Medline]
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