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- December 1, 2008 |
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"Progress in Heart Failure: Outcomes Trials Resulting in Evidence-Based Interventions"Dr. James Young (biography)
English - 2006-11-11 - 35 minutes
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Summary :
Progress in our understanding of heart failure can be defined by increasing insight into the enormous morbidity and mortality associated with this syndrome, as well as elucidation of its pathophysiology. Arguably, the “modern” day of heart failure awareness and therapy began in the mid-1960s when the syndrome was characterized more as a systemic cardiovascular disease than simply a problem related to cardiac pump dysfunction. Indeed, up until that point in time, “dropsy” conditions were related to, most generally, valvular heart disease and hypertension. Our understanding that pathological cardiac remodeling and peripheral circulatory perturbation lead to the clinical hallmarks of heart failure was an important advancement, and led to the clinical trials that studied, more precisely, intervention effects. In the early 1970s, based on laboratory experiments demonstrating seemingly propitious hemodynamic alterations with a variety of vasodilating and, subsequently, neurohormonal modulating compounds, treatments for congestive heart failure were developed that had been previously thought counterintuitive. Clinical trials that began in earnest in the mid-1980s that demonstrated not only beneficial effects of a variety of agents but also many antiarrhythmic compounds, adrenergic nervous system-modulating drugs, certain vasodilators, and other innovative interventions could be harmful. Indeed, perhaps the best examples of this are the clinical trials that focused on routine use of antiarrhythmic agents in the postmyocardial infarction heart failure setting. In the end, results from the compendium of clinical trials dealing with heart failure patients have driven so-called evidence-based medical practice, which, today, means the clinician attempts to follow guidelines for diagnosis and treatment of heart failure that are based on the results of clinical trials. Very generally, heart failure clinical trials have demonstrated convincingly that angiotensinconverting enzyme inhibitors, angiotensin-receptor blockers, beta-adrenergic blockers, and aldosterone antagonists are the pharmacotherapeutic underpinnings of treatment when added to, in select cases, more established treatments such as loop diuretics and digoxin. More recently, clinical trials have indicated that device intervention has actually produced profound reductions in heart failure morbidity and mortality. Specifically, the use of cardiac resynchronization pacing devices, and implantable cardioverter defibrillators, have had an extraordinary impact on the management of heart failure. Again, as with medications, clinical trials have paved the way for knowledge in this arena and have clarified best medical practices. Of course, clinical trials are not the perfect tool to define most precisely our clinical practices and the “art” of medicine. They are cumbersome, expensive, inflexible programs and cannot address all important questions. Still, patients with heart failure have benefited tremendously from the use of these tools, but much more needs to be done to prevent and ameliorate the morbidity and mortality associated with heart failure.
Learning objectives :
After viewing this presentation the participant will be able to discuss:
- The facets of heart failure
- Historical perspectives on heart failure
- The emergence of clinical trials in heart failure
- Modern evolution of heart failure therapies
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