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CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 9, October 2012
AFRICA
Ivabradine reduces total hospital burden in heart failure Heart rate reduction using ivabradine in patients with chronic heart failure who were in sinus rhythm and with heart rates of at least 70 beats/min resulted in substantially reduced clinical deterioration in total hospitalisations for worsening heart failure and in an increase in time to first and subsequent hospitalisations.1 This was despite patients being treated with guideline-based background therapy, including maximally treated betablockade. Presenting the results of the posthoc analysis of the SHIfT study, which focused on recurrent hospitalisation, Prof Jeffrey Borer, New York, stressed that ivabradine therapy did not unmask any other problems that would lead to hospitalisation. ‘In the Total Time Analysis,
the time to occurrence of hospitalisation for heart failure was reduced for first events by 25%, for second events by 34%, and for a third event by 29%. All of these reductions were highly statistically significant’, Prof Borer pointed out. Another way of evaluating the hospitalisation data focused on the causes of hospitalisation. In this review, hospitalisation for worsening heart failure was reduced by 25%, hospitalisation for any cause by 15%, and hospitalisation for cardiovascular-related events by 16%. Overall hospitalisations other than for worsening heart failure were reduced by 8%, which did not, however, reach statistical significance. Acknowledging some of the normal limits of a post-hoc study and the fact
that the treatment effect is dependent on previous hospitalisations (the cumulative effect of the first, second and third event) and differences in hospitalisation burden in different countries, Prof Borer nonetheless concluded that ivabradine reduces the total burden on the patient and the healthcare system. ‘The financial burden can be expected to be substantially reduced when ivabradine is added to guideline-based heart-failure therapies’, he concluded. J Aalbers 1.
Borer JS, Böhm M, Ford I, Komajda M, et al. Effect of ivabradine on recurrent hospitalization for worsening heart failure in patients with chronic systolic heart failure: the SHIFT study. Eur Heart J. 12 Sept 2012 [Epub ahead of print]. doi:10.1093/ eurheartj/ehs259.
GARFIELD: a window on the real-life treatment of atrial fibrillation South Africa joins the GARFIELD registry The results of the evaluation of the first cohort of 10 000 newly diagnosed atrial fibrillation (AF) patients in the GARFIELD registry, which reflects contemporary global real-life treatment of AF, has shown that fewer than half of the eligible patients received anticoagulant therapy with vitamin K antagonists. In addition, those patients at significantly increased risk of experiencing stroke or systemic emboli with a CHADS2 risk score greater than 2 were poorly treated. Patients who were not really at risk (those with a CHADS2 score of zero) and who did not generally require anticoagulation treatment were frequently given anticoagulant therapy in some 80% of cases. The GARFIELD (Global Anticoagulant Registry in the FIELD) seeks better understanding of these contradictions in an academically driven project, led by the UK-based Thrombosis Research Institute and funded with an unrestricted grant from Bayer Healthcare. Prof Barry Jacobson, haematologist, Witwatersrand University, will lead the South African arm of the registry which
has now begun to document and track non-valvular AF patients with at least one additional cardiovascular risk factor. Patients will be recruited at both primary and specialist-care levels in the country. Speaking at a special symposium at the 2012 ESC congress, Prof Lord Ajay Kakkar, University College Hospital, London, noted that the registry aims to describe treatment patterns that reflect the real world beyond so-called centres of excellence. ‘It includes the many diverse places where doctors are working, including those placed in less well-resourced settings. We need to be sensitive to the extent of the strokeprevention challenges the world will face over the next 30 years, as the number of stroke cases are set to double in both middle- and low-income countries. This registry will help us to develop valuebased healthcare approaches which can be applied in a wide variety of clinical settings’, he concluded. Patients in the registry will be followed for at least two years. Importantly, the registry includes a patient-satisfaction questionnaire and seeks to explore the
in-practice bridging of anticoagulation when vitamin K antagonist therapy is interrupted. Prof Alex Turpie, McMaster University, Canada pointed out that experience within GARFIELD will also allow evaluation of combination therapies in patients with AF and other cardiovascular co-morbidities. ‘All of the new anticoagulant agents have been Q-tested in phase II trials in ACS and appear to have potential. However, rivaroxiban is the only drug to date that has been shown in phase III trials to be beneficial in this setting’, he pointed out.
Expert comment Prof Barry Jacobson’s views on the new SA-based initiative ‘I feel that this study will help us understand not only how patients who have access to First-world medicine are treated but also how indigent patients are managed in a Third-world setting’, says Prof Jacobson. J Aalbers