The Managed Ventricular Pacing? Versus VVI 40 Pacing (MVP) Trial: Clinical Background, Rationale, Design, and Implementation

Management of heart failure in elderly people

AIMS

To review currently available knowledge on presentation, clinical features and management of heart failure (HF) in elderly people.

METHODS

To review currently available evidence, we performed a thorough search of several evidence-based sources of information, including Cochrane Database of Systematic Reviews, Clinical Evidence, Evidence-based guidelines from National Guidelines Clearinghouse and a comprehensive MEDLINE search with the MeSH terms: 'heart failure', 'elderly' and 'management'.

RESULTS

A number of features of ageing may predispose elderly people to HF, and may impair the ability to respond to injuries. Another hallmark of elderly patients is the increasing prevalence of multiple coexisting chronic conditions and geriatric syndromes that may complicate the clinical presentation and evolution of HF. Although diagnosis may be challenging, because atypical symptoms and presentations are common, and comorbid conditions may mimic or complicate the clinical picture, diagnostic criteria do not change in elderly people. Drug treatment is not significantly different from that recommended in younger patients, and largely remains empiric, because clinical trials have generally excluded elderly people and patients with comorbid conditions. Disease management programmes may have the potential to reduce morbidity and mortality for patients with HF.

CONCLUSIONS

Heart failure is the commonest reason for hospitalisation and readmission among older adults. HF shows peculiar features in elderly people, and is usually complicated by comorbidities, presenting a significant financial burden worldwide, nevertheless elderly people have been generally excluded from clinical trials, and thus management largely remains empiric and based on evidence from younger age groups.

Eliminating right ventricular pacing may not be best for patients requiring implantable cardioverter-defibrillators

BACKGROUND

Excessive right ventricular (RV) pacing has been associated with adverse clinical outcomes in patients receiving pacemakers or implantable cardioverter-defibrillators (ICDs). It remains uncertain how much RV pacing is clinically deleterious.

OBJECTIVE

This retrospective analysis assessed the relationship between the amount of RV pacing and the composite of all-cause mortality and heart failure hospitalization in all patients programmed DDDR in the Inhibition of Unnecessary RV Pacing with AV Search Hysteresis in ICDs (INTRINSIC RV) study.

METHODS

Seven hundred fifteen patients consistently programmed to DDDR mode throughout follow-up (mean 11.6 months) were examined. The relationship between RV pacing tier and death and heart failure hospitalization was determined and compared with patient characteristics.

RESULTS

Across the six RV pacing tiers, patients differed significantly with respect to age, clinical history of ventricular tachycardia, atrial fibrillation, and atrial flutter, and amiodarone use. When controlling for these baseline differences, the best outcome was seen in the group with RV pacing between 10% and 19% (2.8% event rate; n = 106). Increasing levels of RV pacing were generally predictive of higher event rates (death or heart failure hospitalization; P = 0.003), except for the group (n = 344) with the least amount of RV pacing (0-9%). This group exhibited poorer outcomes than otherwise expected (P = 0.016), with 8.1% of these patients experiencing an event.

CONCLUSIONS

High levels of RV pacing are associated with heart failure hospitalization and mortality in a large ICD population. However, ICD patients with some RV pacing (10%-19%) exhibit lower event rates compared with those with very low levels (0-9%), possibly due to the physiologically appropriate nature of that RV pacing.