UAB Synopsis, Vol. 27, No. 31, August 11, 2008
UAB cardiologist Andrew E. Epstein, MD, FAHA, FACC, FHRS, chaired the writing committee for new, comprehensive cardiac device-based therapy guidelines issued in May. The “ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities” incorporate major advances in device technology and findings of recent studies. The American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) jointly released the recommendations and posted the full text on their Web sites (www.acc.org, www.americanheart.org, www.hrsonline.org).
ACC/AHA/HRS Task Force on Practice Guidelines Chair Sidney C. Smith Jr, MD, FAHA, FACC, says, “Nominations for chair of a clinical practice guideline writing committee require specific characteristics, including a strong sense of leadership and commitment to the ACC and AHA methodology and scientific rigor.
“We also aim for a senior practicing clinician who, in addition to being a leader in their field of expertise, can drive consensus when faced with varying points of view,” Dr. Smith says. “Dr. Epstein epitomizes these important characteristics. He masterfully led all phases of this important guideline and continues to be a valuable resource to both the ACC and the AHA.”
Prestigious Panel
The writing committee was composed of a “who’s who” of experts from prestigious academic medical institutions across the nation and included authorities on device therapy, cardiovascular medicine and surgery, internal medicine, ethics, and socioeconomics.
The guidelines cover device-based therapy indications for life-threatening cardiac arrhythmias, heart failure, congenital heart disease, and sudden cardiac arrest. “The recommendations are thoroughly evidence-based, incorporating the latest data on efficacy and clinical outcomes from dozens of clinical trials and advances in pacemaker and implantable cardioverter-defibrillator [ICD] therapy,” Dr. Epstein says.
Cardiac device technology is a rapidly evolving area of clinical practice. In 2005 US patients with cardiac rhythm abnormalities received an estimated 180,000 pacemakers and 91,000 ICDs. “The expansion of indications for device implantation necessitates education and guidance to ensure that their prescription is evidence based,” he says.
Patient-specific Modifiers
The patient-centered approach the task force adopted considers patient-specific modifiers such as comorbidities, patient preferences, frequency of follow-up, and cost-effectiveness of devices.
Throughout the document, the writing committee emphasized the need for optimization of medical therapy before device implantation is considered.
“Given the enthusiasm for cardiac resynchronization therapy, the committee gave guidance that these devices should be prescribed only when patients with heart failure are still experiencing significant symptoms while being treated with optimal recommended medical therapy,” Dr. Epstein says.
The authors encourage optimized pacemaker programming to minimize unneeded right ventricular pacing, which can worsen heart failure.
Revised ICD indications reflect new developments and consider voluminous literature related to device efficacy in the treatment and prevention of sudden cardiac death (SCD) due to life-threatening ventricular arrhythmias. Because of overlap between primary and secondary indications for ICDs, guideline authors combined recommendations for all such devices.
Humanistic Approach
Dr. Epstein describes the recommendations, rewritten “from stem to stern,” as humanistic and patient oriented. The authors formally articulated the importance of discussing risks and benefits of implanted devices, life expectancy, and quality of life issues with patients and families to ensure that their expectations are appropriate. “Lack of patient understanding and adherence may adversely affect treatment outcomes,” the authors write.
As physicians, patients, and families increasingly are faced with decisions about device-based therapies in elderly patients, consideration must be given to life expectancy estimates, comorbidities, procedural risk, and patient preference.
“Indications for ICDs and cardiac resynchronization therapy device implantation will evolve as technology advances and guidelines change. These guidelines extend and clarify current best practices and offer the best evidence available for treating patients with heart disease,” Dr. Epstein says.