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and LV systolic dysfunction In the second Multicenter Automatic Defibrillator Implantation Trial (MADIT II), 1232 patients with prior myocardial infarction and an EF < 30% were randomized to an ICD or a control group Mortality was 31% lower in the ICD group, which translated into nine lives saved for each 100 patients who received a device and were monitored for 3 years The Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) reinforced and extended these results, showing a 23% relative (72% absolute) reduction in mortality over 5 years with a simple single-lead ICD in a population of patients with symptomatic chronic heart failure and an EF of 35% Patients with class II symptoms appeared to have even larger benefits than patients with class III symptoms These patients were well-managed with contemporary heart failure treatments, including -blockers Based on these results, the United States Centers for Medicare and Medicaid Services have expanded reimbursement coverage to include patients with chronic heart failure and ischemic or nonischemic cardiomyopathy with an EF 35% 2 Biventricular pacing (resynchronization) Many patients with heart failure due to systolic dysfunction have abnormal intraventricular conduction that results in dyssynchronous and hence inefficient contractions Several studies have evaluated the efficacy of multisite pacing, using leads that stimulate the RV from the apex and the LV from the lateral wall via the coronary sinus Patients with wide QRS complexes (generally 120 milliseconds), reduced EFs, and moderate to severe symptoms have been evaluated Results from trials with up to 2 years of follow-up have shown an increase in EF, improvement in symptoms and exercise tolerance, and reduction in death and hospitalization The COMPANION trial included 1520 patients with NYHA class III or IV heart failure, EF of 35%, and QRS duration 120 milliseconds In addition to optimal medical therapy, resynchronization therapy with biventricular pacing with or without implantable defibrillator capability reduced death and hospitalization from any cause by about 20% The CARE-HF trial randomized 813 similar patients, who also required mechanical evidence of dyssynchrony if QRS duration was 120 149 milliseconds, to resynchronization therapy Over a mean follow-up of 29 months, death or hospitalization for cardiac cause was reduced by 37% and mortality was reduced by 36% Thus, resynchronization therapy is indicated for patients with moderate to severe heart failure, EF 35%, and prolonged QRS duration 3 Case management, diet, and exercise training Thirty to 50 percent of CHF patients who are hospitalized will be readmitted within 3 6 months Strategies to prevent clinical deterioration, such as case management, home monitoring of weight and clinical status, and patient adjustment of diuretics, can prevent rehospitalizations and should be part of the treatment regimen of advanced heart failure Patients should routinely practice moderate salt restriction (2 25 g sodium or 5 6 g salt per day) More severe sodium restriction is usually difficult to achieve and unnecessary because of the availability of potent diuretic agents Exercise training improves activity tolerance in significant part by reversing the peripheral abnormalities associated with heart failure and deconditioning In severe heart failure,.

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restriction of activity may facilitate temporary recompensation However, in stable patients, a prudent increase in activity or a regular exercise regimen can be encouraged Indeed, a gradual exercise program is associated with diminished symptoms and substantial increases in exercise capacity 4 Coronary revascularization Since underlying CAD is the cause of heart failure in the majority of patients, coronary revascularization may both improve symptoms and prevent progression However, trials have not been performed in patients with symptomatic heart failure Nonetheless, patients with angina who are candidates for surgery should be evaluated for revascularization, usually by coronary angiography Noninvasive testing for ischemic but viable myocardium may be a more appropriate first step in patients with known coronary disease but no current clinical evidence of ischemia The benefit of evaluating patients with heart failure of new onset without angina or prior myocardial infarction is limited In general, bypass surgery is preferable to PTCA in the setting of heart failure because it provides more complete revascularization 5 Cardiac transplantation Because of the poor prognosis of patients with advanced heart failure, cardiac transplantation has become widely used Since the advent of cyclosporine immunosuppressive therapy and more careful screening of donor hearts, the survival of patients after cardiac transplantation has increased considerably Many centers now have 1-year survival rates exceeding 80 90%, and 5-year survival rates above 70% Infections, hypertension and renal dysfunction caused by cyclosporine, rapidly progressive coronary atherosclerosis, and immunosuppressant-related cancers have been the major complications The high cost and limited number of donor organs require careful patient selection early in the course 6 Other surgical treatment options Several surgical procedures for severe heart failure have received considerable publicity Cardiomyoplasty is a procedure in which the latissimus dorsi muscle is wrapped around the heart and stimulated to contract synchronously with it In ventricular reduction surgery, a large part of the anterolateral wall is resected to make the heart function more efficiently Both approaches are too risky in end-stage patients and have not been shown to improve prognosis or symptoms in controlled studies, and for these reasons they have largely been dropped Externally powered and implantable ventricular assist devices can be used in patients who require ventricular support either to allow the heart to recover or as a bridge to transplantation The latest generation devices are small enough to allow patients unrestricted mobility and even discharge from the hospital However, complications are frequent, including bleeding, thromboembolism, and infection, and the cost is very high, exceeding $200,000 in the initial 1 3 months Although 1-year survival was improved in a recent randomized trial, all patients died by 26 months 7 Palliative care Despite the technologic advances of recent years, including cardiac resynchronization, implantable defibrillators, LV assist devices, and totally implantable artificial hearts, it should be remembered that many patients with chronic heart failure are elderly and have multiple.

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