{"markup":"\u003C?xml version=\u00221.0\u0022 encoding=\u0022UTF-8\u0022 ?\u003E\n    \u003Chtml version=\u0022HTML+RDFa+MathML 1.1\u0022\n    xmlns:content=\u0022http:\/\/purl.org\/rss\/1.0\/modules\/content\/\u0022\n    xmlns:dc=\u0022http:\/\/purl.org\/dc\/terms\/\u0022\n    xmlns:foaf=\u0022http:\/\/xmlns.com\/foaf\/0.1\/\u0022\n    xmlns:og=\u0022http:\/\/ogp.me\/ns#\u0022\n    xmlns:rdfs=\u0022http:\/\/www.w3.org\/2000\/01\/rdf-schema#\u0022\n    xmlns:sioc=\u0022http:\/\/rdfs.org\/sioc\/ns#\u0022\n    xmlns:sioct=\u0022http:\/\/rdfs.org\/sioc\/types#\u0022\n    xmlns:skos=\u0022http:\/\/www.w3.org\/2004\/02\/skos\/core#\u0022\n    xmlns:xsd=\u0022http:\/\/www.w3.org\/2001\/XMLSchema#\u0022\n    xmlns:mml=\u0022http:\/\/www.w3.org\/1998\/Math\/MathML\u0022\u003E\n  \u003Chead\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_itu2PgFdrjV-docKmLK8Jn5oXe_05RgvQh73eOhI_mE.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_at_symbol.js?nzm47q\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_article_reference_popup.js?nzm47q\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_I8yX6RYPZb7AtMcDUA3QKDZqVkvEn35ED11_1i7vVpc.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\n(function(i,s,o,g,r,a,m){i[\u0022GoogleAnalyticsObject\u0022]=r;i[r]=i[r]||function(){(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)})(window,document,\u0022script\u0022,\u0022\/\/www.google-analytics.com\/analytics.js\u0022,\u0022ga\u0022);ga(\u0022create\u0022, \u0022UA-15605596-27\u0022, {\u0022cookieDomain\u0022:\u0022auto\u0022});ga(\u0022set\u0022, \u0022page\u0022, location.pathname + location.search + location.hash);ga(\u0022send\u0022, \u0022pageview\u0022);ga(\u0027create\u0027, \u0027UA-189672-26\u0027, \u0027auto\u0027, {\u0027name\u0027: \u0027hwTracker\u0027});\r\nga(\u0027hwTracker.send\u0027, \u0027pageview\u0027);\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\njQuery.extend(Drupal.settings, {\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;5\\\/1\\\/28\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;5\\\/1\\\/28\u0022}],\u0022ac\u0022:{\u0022spmdc;5\\\/1\\\/28\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;5\\\/1\\\/28\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EFive million people in the United States alone suffer with chronic heart failure (HF), producing in excess of 12 million office visits and 6 million hospital days every year. But advances are at hand that hold promise of ameliorating early disease and producing better outcomes in advanced disease. The new ACC\/AHA Guidelines for the Diagnosis and Management of Chronic Heart Failure\u2014the first revision in nearly five years\u2014were released just weeks before the American Heart Association\u0027s 2005 Scientific Sessions convened. In replacing the older term \u201ccongestive heart failure\u201d with simply \u201cheart failure,\u201d the guidelines acknowledge the biological complexity that heart failure encompasses, much of which is not specifically \u201ccongestive\u201d but rather dynamic, structural, and metabolic. Incorporating results of clinical trials as well as technological advances, the guidelines were discussed by ten physicians in two sessions. (See: \u003Ca href=\u0022http:\/\/www.acc.org\/clinical\/guidelines\/failure\/index.pdf\u0022\u003Ehttp:\/\/www.acc.org\/clinical\/guidelines\/failure\/index.pdf\u003C\/a\u003E)\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eguidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eheart failure\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ENew Guidelines for Heart Failure\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EFive million people in the United States alone suffer with chronic heart failure (HF), producing in excess of 12 million office visits and 6 million hospital days every year. But advances are at hand that hold promise of ameliorating early disease and producing better outcomes in advanced disease. The new ACC\/AHA Guidelines for the Diagnosis and Management of Chronic Heart Failure\u2014the first revision in nearly five years\u2014were released just weeks before the American Heart Association\u0027s 2005 Scientific Sessions convened. In replacing the older term \u201ccongestive heart failure\u201d with simply \u201cheart failure,\u201d the guidelines acknowledge the biological complexity that heart failure encompasses, much of which is not specifically \u201ccongestive\u201d but rather dynamic, structural, and metabolic. Incorporating results of clinical trials as well as technological advances, the guidelines were discussed by ten physicians in two sessions. (See: \u003Ca href=\u0022http:\/\/www.acc.org\/clinical\/guidelines\/failure\/index.pdf\u0022\u003Ehttp:\/\/www.acc.org\/clinical\/guidelines\/failure\/index.pdf\u003C\/a\u003E)\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003E2005 guidelines that depart from the earlier recommendations were discussed by two members of the ACC\/AHA guidelines writing committee, Gary S. Francis, MD, Director, Coronary Care Unit, Cleveland Clinic, Cleveland, OH, and committee chair Sharon Ann Hunt, MD, Stanford University School of Medicine, Palo Alto, CA.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003E\n            \u003Cstrong\u003EBeta blockers\u003C\/strong\u003E should be deployed in all stable HF patients with reduced LV ejection fraction, barring other contraindications. The guidelines recommend one of 3 agents that have been shown in randomized clinical trials to reduce the risk of death: bisoprolol (the CIBIS-II trial), carvedilol (the CAPRICORN trial), or sustained-release metoprolol (the MERIT-HF trial).\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003E\n            \u003Cstrong\u003EImplantable condioverter-defibrillators\u003C\/strong\u003E (ICDs) are recommended when LV ejection fractions are less than 31% (barring an end-stage scenario). Ejection fractions \u0026lt; 35% with wide QRS complexes should be considered for cardiac resynchronization therapy (CRT).\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003E\n            \u003Cstrong\u003ESpironalactone and other aldosterone antagonists\u003C\/strong\u003E are appropriate therapy, presuming normal (or relatively normal) renal function and potassium levels. (Dr. Hunt noted that recent studies suggest poorer outcomes associated with aldosterone antagonists in HF patients with demonstrable kidney disease.)\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003E\n            \u003Cstrong\u003EIsosorbide dinitrate and hydralazine\u003C\/strong\u003E should be combined in African American HF patients\u2014or in any patient who cannot tolerate ACEIs.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EOther presenters looked at the implications of HF disease staging.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003E\n            \u003Cstrong\u003EStage A and B\u003C\/strong\u003E HF was reviewed by Donna Mancini, MD, medical director, Cardiac Transplantation Program, NewYork-Presbyterian Hospital\/Columbia University Medical Center, New York, NY, and a member of the ACC\/AHA guidelines writing committee, and Mariell Jessup, MD, director of the heart failure and cardiac transplantation program at the University of Pennsylvania Medical Center in Philadelphia. Patients staged as A or B are not yet in frank HF but are \u201cshowing the signs,\u201d Dr. Mancini said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003E\u201cThese patients have hypertension, or diabetes\u2014and maybe they\u0027re having trouble with lifestyle modification and they tend toward metabolic syndrome\u201d added Dr. Jessup. (Although risk factors are evident in Stage A and B, LV function and dynamics may display either early changes or remain within normal limits.)\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003E\n            \u003Cstrong\u003EStage C\u003C\/strong\u003E HF is the \u201cmost crowded stage in terms of population,\u201d said William Abraham, MD, Director, Division of Cardiovascular Medicine, The Ohio State University Medical Center, Columbus. \u201cThis is where most HF patients fall\u2014either by way of being newly diagnosed, or with established HF but with early symptoms as opposed to acute decompensation.\u201d The use of the beta blockers bisoprolol, carvedilol, or sustained-release metoprolol \u201cis the new thing with the revised guidelines,\u201d Dr. Abraham said. \u201cWhat the trials showed us, and what the guideline writers emphasize, is that all beta blockers are not created equal. The \u2018big three\u2019 all have A-ranked levels of evidence.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EClinicians should go to ARBs in Stage C HF if a patient is ACEI-intolerant. \u201cThe aldosterone antagonists carry an evidence level of B,\u201d Dr. Abraham said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003ECRT can be considered in Stage C patients, Dr. Abraham said, \u201cbut only if optimal medical therapy has been used.\u201d Dr. Abraham offered a four-part algorithm for stage C therapy: \u201cFirst, control volume with diretics. Go with one of the \u2018big three\u2019 beta blockers. Add, as indicated, an ACEI, ARB, and\/or an aldosterone antagonists. If deterioration continues with these therapies in place, consider going to CRT.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003ECRT was subsequently discussed by Maria Costanzo, MD, Medical Director, Midwest Heart Specialists\/Edward Cardiovascular Institute, Naperville, IL. Studies have demonstrated CRT\u0027s capacity to improve exercise capacity and symptoms of patients in Stage C HF. The COMPANION trial (2003) confirmed that CRT \u201ccan reduce the need for hospital stays and improve survival,\u201d according to Dr. Costanzo.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EThe COMPANION trial looked at a group of 1,600 patients with \u201cStage C or D heart failure. These included people who had been hospitalized for HF or had documented conduction delays.\u201d Study participants were randomized to two arms: optimal drug therapy, or optimal drug therapy + CRT. (Dr. Costanzo noted that 50% of the CRT arm received CRT pacing only while 50% received ICDs.)\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EResults from the COMPANION trial demonstrated that patients receiving either CRT alone or ICD saw a 20% reduction in the composite endpoints (total hospitalizations and death from any cause.) Additionally, participants on the ICD arm had a 36% reduction in mortality alone.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EThe benefits demonstrated by COMPANION are \u201cclearly impressive,\u201d said Dr. Costanzo.\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003E\n            \u003Cstrong\u003EStage D\u003C\/strong\u003E HF \u201cmeans we\u0027re talking about the \u2018big stuff\u2019\u2014transplantation and end-of-life issues,\u201d said Marc A. Silver, MD, adjunct professor of medicine at the University of Illinois at Chicago and a guidelines committee member. Dr. Silver urged clinicians to \u201cnot let these issues spring out of the blue in the last days of a patient\u0027s life. Start having conversations with patients and families when Stage D parameters are met. This is a clinical situation in which we must be patient, we must listen, and we must be family champions.\u201d\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2005 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/5\/1\/28.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzm47q\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}