Cardio Debate talks to Prof Francisco Leyva from Aston University, Birmingham and The Queen Elizabeth Hospital, London, UK, about his presentation in the Heart Failure section during the Cardiology Update 2016 meeting, organised by St George’s, University of London on the 2nd December 2016 at the RSA in London, UK.
What were the key messages in your speech today?
I concentrated on the incidence of sudden cardiac death in patients with heart failure, and the role of device therapy in patients with heart failure.
The recent Defibrillator Implantation in Patients with Nonischaemic Systolic Heart failure (DANISH) study , which concentrated on patients with nonischaemic cardiomyopathy has shown that there is no benefit from adding defibrillator therapy in patients with heart failure and nonischaemic cardiomyopathy.
Now this has led to a lot of questions because the current indications are there, both in terms of UK guidelines, NICE guidelines and European guidelines. But it’s important really to appreciate that the DANISH trial may have been underpowered to answer that question.
It dealt with just under 1100 patients, and we know that with a meta-analysis we need about 14,000 patients to demonstrate a beneficial role of ICDs in patients with noniscaemic cardiomyopathy.
There are other aspects, of course, in that nonischaeimic cardiomyopathies can be very varied – can be valvular, can be hypertensive, can have scar or no scar, and they have different rates of sudden cardiac death. So one noniscaemic cardiomyopathy can be very different from another.
So I have gone through some various data sets in order to show that, and I think that further studies will be needed, because it is likely that the guideline groups will take notice of the excellent DANISH study, but it is not the definitive answer.
I also reviewed some of the evidence for remote monitoring in heart failure. These are monitors within cardiac devices, defibrillators and CRT devices, and largely they’ve not shown to be of benefit in terms of hard end points – mortality and morbidity. However I think they are of definite benefit to patients.
I do wonder whether the heard end points are the right way to measure the effect, because effectively a remote monitor is a diagnostic adjunct and it’s always difficult to demonstrate a mortality benefit from a diagnostic tool.
I also touch upon some of the studies on device therapy using quadripolar leads, which are now a standard of care in most centres, and really have been shown to be of benefit to most patients, and to virtually eliminate the need to bring patients back for the repositioning of left ventricular leads.