Download Improving Care for Patients with Heart Failure: What Can Taiwan

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Acta Cardiol Sin 2007;23:211-24
Improving Care for Patients with Heart Failure:
What Can Taiwan Accomplish?
Shyh-Ming Chen,1 Mien-Cheng Chen1 and W. H. Wilson Tang2
Heart failure is a growing public health issue worldwide, due to the improved survival of patients with heart diseases
and the increased complexity of treatment options. If unrecognized and inadequately treated, the disease burden of
heart failure can be devastating and costly. This review will compare the similarities and differences in different
aspects of contemporary care of the patient with heart failure between Taiwan and many Western societies. In
addition, this review will also examine potential treatment modalities and approaches that can be adopted in
Taiwan’s health care system, with the goal of bettering care for patients with heart failure in Taiwan.
Key Words:
Heart failure · Taiwan · Disease management program
sis of heart failure still carries an abysmal prognosis.2 In
a study of over 30,000 patients admitted with new-onset
heart failure, the 30-day and one-year mortality rates
were an 12% and 30%, respectively.3 Several new approaches, including drugs, devices, and surgical approaches, have been explored to combat heart failure. These
treatment approaches have followed the evolution of the
conceptual models created to understand the pathophysiology of heart failure.
The increasing prevalence of heart failure in Taiwan
may parallel with that seen in many Western countries.
The expanding patient population, coupled with rapid
growth in treatment options, demands the recognition of
heart failure as an important subspecialty of cardiology,
and an important target for quality improvement. The
purpose of this paper is to critically evaluate the current
status of heart failure epidemiology and care in Taiwan,
and examine aspects of heart failure care in Western societies that can be applicable to Taiwan.
INTRODUCTION
Heart failure is a growing epidemic worldwide, owing to the aging population and the increasing survival
of patients presenting with acute myocardial infarction
and various other heart diseases. In the USA, heart failure has become one of the most common hospital discharge diagnoses in the elderly population, and has consumed a large proportion of total health care expenditure.1 Patients with heart failure may take on average 5-7
different medications. In many cases, patients with heart
failure have to undergo expensive and risky diagnostic
and therapeutic procedures. They are often restricted to
living their lives in disability, with recurrent hospitalizations for decompensation that are costly to the society.
Despite decades of therapeutic advances, the diagno-
Received: June 28, 2007
Accepted: September 10, 2007
1
Division of Cardiology, Chang Gung Memorial Hospital-Kaohsiung
Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan; 2Department of Cardiovascular Medicine, Cleveland
Clinic, Cleveland, Ohio, USA.
Address correspondence and reprint requests to: Dr. W. H. Wilson
Tang, MD FACC FAHA, Department of Cardiovascular Medicine,
Cleveland Clinic, 9500 Euclid Avenue, Desk F25, Cleveland, Ohio
44195, U.S.A. Tel: +1(216)444-2121; Fax: +1(216)445-6165; E-mail:
[email protected]
Differences between Taiwan and western
countries in heart failure care
Differences in heart failure epidemiology
Although there have been limited data regarding the
epidemiology of heart failure in Taiwan, previous reports have suggested that the annual mortality rate of pa211
Acta Cardiol Sin 2007;23:211-24
Shyh-Ming Chen et al.
are fewer physicians and acute care beds, Taiwan’s existing infrastructure has provided a large volume of ambulatory care services and significant amount inpatient
care10 (Figure 1). Taiwan’s health care system is recognized for its accessibility, low cost, and high degree of
public satisfaction. However, there are several important
challenges with respect to the emerging burden of heart
failure. In particular, the amount of time and attention
spent on each individual heart failure patient with respect to disease management is limited. Most doctors in
Taiwan frequently neglect patients’ understanding of
their disease and adherence to their prescribed medications. Interventions for dietary and lifestyle modification
are not readily available. Since the health literacy and
knowledge of self-care for patients with heart failure in
Taiwan is relatively low, the lack of adequate patientoriented approaches may directly impact the effectiveness of treatment regimens.
Genotype and racial difference
Genetic determinants of the pathophysiology of heart
failure are likely polygenic, and hence the relative contributions to environmental influences are complex.
Though heart failure genomic information has not been
widely utilized in clinical practice, there are many examples of how this information can potentially transform
the way we look at the heart failure phenotype.11 Advances in “pharmacogenetics” rely on observations that involved specific patient populations, with particular genotypes responding differently to the same drug treat-
tients with heart failure could be as high as 40-50% for
New York Heart Association (NYHA) functional class
III to IV patients who are waiting for cardiac transplantation.4,5 Additionally, the in-hospital mortality rate may
be as high as 23.5%.4 These figures appear to be inferior
when directly compared with those in Western societies,
although no direct comparison has been made. Nevertheless, with an aging society and a medical system primarily geared towards reactive salvage as oppose to proactive prevention, the disease burden of heart failure in
Taiwan is only going to increase. More recent data reported a prevalence of heart failure in a communitybased cohort of approximately 5.5%, with the majority
being hypertension as etiology. The 5- and 10-year mortality ranged from 14% and 48.2% in those with impaired LVEF versus 14.1% and 24.4% in those with preserved LVEF, respectively.6
Overall, patients with heart failure in Taiwan have
high prevalences of hypertension and diabetes mellitus
as their comorbid conditions. With the growing influence of the Western diet and the high prevalence of cigarette smoking in Taiwan, myocardial infarction as the
cause of heart failure is becoming increasingly common.
We can witness how the epidemiological trends will go
with a glimpse of heart failure epidemiology in many
Western societies. Even with a strong emphasis in the interdisciplinary management of heart failure in the United
States of America, there are still an estimated 5 million
Americans suffering from heart failure and over 500,000
new cases diagnosed annually.7,8 A larger burden comes
with the costly hospitalizations associated with heart
failure exacerbations: approximately 1 million hospital
admissions per year (a 174% increase from 1979 to
2003),7 and readmission rates as high as 30% at 3 months and 60% at 6 months following discharge.9 In particular, both concomitant atrial fibrillation and diabetes
mellitus commonly occur in the heart failure population,
and both are increasing in prevalence in the Taiwan population as well. This all translates into significant disease burden, large expenditures for heart failure diagnostic testing and treatments, and the desperate need to
improve on existing diagnosis and management strategies.
Health care system differences
Compared to the OECD (Organisation for Economic
Co-operation and Development) countries, Taiwan’s
health care system is relatively efficient. Although there
Acta Cardiol Sin 2007;23:211-24
Figure 1. Ambulatory care service in Taiwan and other OEDC countries in 1999.
212
Heart Failure Care in Taiwan
their Western counterparts. Physicians operate largely on
a paternalistic model without carefully explaining treatment options and providing the necessary counseling for
dietary and lifestyle modifications. With the lack of understanding of the chronicity of the heart failure syndrome, many Taiwanese patients only seek the least
amount of drugs or procedures to relieve symptoms,24
and often fail to understand their responsibilities to alter
their long-term lifestyles or adhere to medical advices.25
They may also have a limited understanding of the gravity of the diagnosis when undertreated. These may
translate into recurrent hospitalizations and unnecessary
morbidity and mortality.
ment. In some cases, the genetic heterogeneity may affect drug metabolism or clearance. For examples, the angiotensinogen gene haplotypes were associated with hypertension in Taiwanese patient, which may interfere
with the treatment in heart failure patient.12,13 In other
cases, the responses to therapy may differ, due to physiologic differences between polymorphisms of enzymes
and metabolic pathways affected. Previous studies also
reported interethnic differences in the frequencies of genotype polymorphisms of the renin-angiotensin system
in Chinese heart failure patients.14-16 How such information in the future can influence our treatment decisions
remains to be investigated.
Racial differences have recently emerged as a “surrogate maker” for underlying genetic heterogeneity. Although clinical evidence has often been extrapolated
from one race to another, clinical presentations and physiologic differences can be observed in different racial
cohorts. For example, in a cohort study of patients admitted with a diagnosis of heart failure, South Asian patients were found to be younger and more often had concomitant diabetes mellitus and acute ischemic heart disease than Caucasian patients.17 The recent African American Heart Failure Trial (A-HeFT) confirmed what was
believed from earlier studies: that fixed-dose hydralazine-isosorbide dinitrate can be beneficial in African
American patients with NYHA class III-IV heart failure.18 However, there is hardly any evidence of direct
causal relationships, and therefore these associations can
be plagued with selection biases (especially when racial
categories are often self-reported). To date, there has been
limited evidence to suggest that Chinese patients would
respond differently to various heart failure medications
when compared to other ethnicities. Therefore current
treatment approaches in Taiwan still follow the general
guidelines generated from professional societies from
Western societies such as the American Heart Association and American College of Cardiology.
Cultural differences
In Taiwan, patients have three characteristics; those
are “quick fix” culture, 19 “doctor-shopping” culture 20
and “herbal-drug preference” culture. 21-23 While these
may be acceptable practices in common ailments, it can
be largely detrimental in the case of heart failure. Regardless of underlying etiologies, the overall health literacy of patients in Taiwan is far lower than that of
Current evidence-based treatment in heart
failure: implications for Taiwan
Medical therapies for heart failure
Our clinical approach to heart failure is a reflection
of the conceptual model applicable to the prevalent understanding of the pathophysiology. It is likely that different models may reflect different aspects of the heart
failure syndrome, and the relative balance can be different with different individuals and in various clinical settings (Figure 2). The cardio-renal model highlights the
importance of congestion as the therapeutic target, and
provids the rational basis for the use of diuretics to control the volume status of patients with heart failure. In
contrast, the cardio-circulatory model emphasizes hemodynamic alterations as the primary target, and provides
the rationale for the use of vasodilators (afterload reduction) or inotropic therapy (augment contractility) to improve cardiac output in order to improve symptoms of
heart failure. These two models have been widely applied as major therapeutic strategies to improve signs
Figure 2. Heart failure models and related treatments.
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Shyh-Ming Chen et al.
tions established from several clinical trial.66 Data from
several clinical trials67,68 trials have also suggested that
chronic right-sided pacing may actually worsen longterm cardiac performance, which has led to improved algorithms of pacing. Other major randomized trials have
demonstrated mechanical dyssynchrony as an important
target of therapy in some patients with heart failure over
standard optimal medical therapy.69,70 However, the biggest limitation of broad adoption of ICD and cardiac
resynchronized therapy (CRT) therapy remains largely
related to the cost. Few communities will be able to afford to treat all patients based on evidence from outcomes trials, and the experience of broad adoption of device therapies has led to significant numbers of patients
who were CRT “non-responders,” and effective defibrillation occurring only in less than 20% of implanted
ICDs. Furthermore, an integrated and interdisciplinary
approach facilitating optimal patient selection, device optimization and careful titration of the medical therapy in
the post-implantation period is critical for maximizing the
response of device therapies,71 although the exact protocols for optimization remain to be prospectively validated.
Surgical therapies for heart failure
There has been great promise in specialized heart
failure surgical interventions, but heart transplantation
remains the most effective long-term treatment for patients with refractory heart failure symptoms to date. In
large transplant centers, the 1-, 5-, and 10-year survival
rates averaged 85%, 70%, and 60%, respectively.72,73 Assessment of patient prognosis without transplantation
can be reasonably determined by objective measurement
of cardiac geometry and performance, hemodynamic abnormalities, degree of neurohormonal activation, and impairment in exercise tolerance.74
Mechanical assist devices have established clear roles as bridges to heart transplant and in the management
of postcardiotomy shock. The first prospective randomized trial of long-term left ventricular assist device
(LVAD) support for end-stage heart failure, the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart failure (REMATCH) Trial,
showed a 48% reduction in the risk of death in the LVAD
cohort. 75 Progressive LV remodeling may contribute
independently to the future deterioration of LV function.76-79 Further work is needed in improving the durability of the devices and limiting complications.
and symptoms of heart failure over the past three decades. However, these therapeutic strategies have yet to
prevent progression of heart failure, nor have they led to
prolonged life for patients with moderate to severe heart
failure 26-29 except vasodilator therapy in selected patients.30
The “serendipitous” discovery of the importance of
antagonizing the renin-angiotensin-aldosterone system
has broadened our understanding of the so-called “neurohormonal model,” whereby over-expression of biologically active molecules that are capable of exerting
toxic effects on the heart and circulation can be antagonized.31,32 Serum norepinephrine, angiotensin-II, vasopressin, and endothelin all have vasoconstrictive properties that are operative in the setting of heart failure.
Overactive neurohormonal pathways, via aldosterone
and vasopressin (anti-diuretic hormone), can directly result in volume retention.33 Several approaches have successfully administered adequate neurohormonal antagonism to alleviate such adverse effects without compromising the patients’ well-being (side effects of drug
therapy, such as hypotension or azotemia). 34-38 These
medications included: b-adrenergic blockers, angiotensin-converting enzyme (ACE) inhibitors, and aldosterone receptor antagonist. 39-41 These drugs can halt or
even reverse the progressive cardiac dilatation that occurs as heart failure progresses, and many are affordable
for broad adoption. Major societies have published extensive guidelines for the treatment of heart failure.42-45
These include extensive guidelines from the American
College of Cardiology/American Heart Association. 42
European Society of Cardiology,43 Canadian Cardiovascular Society,44 and Heart Failure Society of America.45
These guidelines all emphasize the importance of timely
and adequacy of treatment with neurohormonal antagonist, with careful monitoring and maintenance of the
euvolemic state. Their recommendations are based on an
impressive collection of clinical trials that establish the
“evidence” for medical therapy (Table 1), and can be
readily applicable in Taiwan.
Device therapies for heart failure
The past decade also witnessed an important shift
from predominantly pharmacologic management to the
broadened use of medical devices. The availability of reliable and compact implantable converter defibrillators
(ICDs) has led to enormous advances through the indicaActa Cardiol Sin 2007;23:211-24
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Heart Failure Care in Taiwan
Table 1.
Drugs
Major guideline
Major trials
Comments
46-48
Digoxin
Class IIa
DIG trials
1.maintaining serum digoxin level 0.5~0.8 ng/mL in men,
0.5~0.9 ng/ml in women.
2.systolic dysfunction with atrial fibrillation.
3.Start digoxin despite appropriate therapy, including an
ACE inhibitor, and/or beta blocker.
Diuretics
Class I
Cochrane review49
1.furosemide, bumetanide and torsemide.
2.A continuous infusion of a loop diuretic may improve
diuresis and reduce toxicity when compared to
intermittent bolus injections.49
ACEI
Class I
CONSENSUS,50
SOLVD36
1.asymptomatic or symptomatic left ventricular dysfunction.
2.Begin therapy with low doses (e.g., 2.5 mg of enalapril
twice daily, 6.25 mg of captopril three times daily, or 5
mg of lisinopril once daily).
Angiotensin receptor
blockade (ARB)
Class IIa (Class I
if ACEIs
intolerant)
ELITE II,51 ValHeFT,52 CHARMAdded,53 CHARMAlternative,54
VALIANT,55 ARCH-J56
1.addition of an ARB, if tolerated, to HF therapy in patients
who are still symptomatic on ACE inhibitors and beta
blockers.
2.an ARB should not be added to an ACE inhibitor in the
immediate post-MI setting.
b-blocker
Class I
MERIT-HF,57,58
COPERNICUS, U.S.
Carvedilol Heart Failure
Study,38 CIBIS II,59,60
COMET61
1.carvedilol, metoprolol, and bisoprolol.
2.equivalent survival benefit in patients with stable class IV
compared with those with class II and III.38,58,60
3.improvement in survival is additive to that induced by
ACE inhibitors.62
Aldosterone
antagonist
Class IIa (cre <
2.5 mg/dL in
men, < 2.0 in
women, K < 5.0
meq/L)
RALES,40 EPHESUS63
1.spironolactone and eplerenone.
2.The role of aldosterone blockade in mild-to-moderate HF
has not been defined, and its use is not recommended in
such patients.
3.spirolactone 30% reduction in mortality, eplerenone 15%
reduction in mortality in post-MI patients.
Hydralazine/Isodil
(ISDN-HYD)
Class IIa (who
are already
taking an ACEIs
and b-blocker for
symptomatic HF)
VAC,30 V-HeFT,34,64
1.Hydralazine (25 mg tid to 100 mg tid) and isosorbide
dinitrate (40 mg tid or qid) or mononitrate (40 to 120 mg
QD) produce modest benefit in patients with HF
compared to placebo,30 and are less effective than ACE
inhibitors.34
2.benefit of fixed-dose ISDN-HYD in addition to standard
therapy, especially in AA.18,65
65
A-HeFT
cording to the post-hoc analyses.80,81 Judicious use of diuretics is beneficial when done with careful consideration of optimal volume status. Recent attention has
also focused on the contributions of unexplained anemia
(or “anemia of heart failure”) in morbidity and mortality
and as a potential therapeutic target.82 Indeed, administration of erythropoesis stimulating agents (such as
darbepoetin-alfa) in anemic patients with heart failure
has been associated with improved quality of life and
Managing co-morbidities
While many doctors have focused on the treatment
of the heart failure syndrome, there has been more and
more recognition that co-morbidities have greatly affected the clinical outcomes of patients with acute and
chronic heart failure. Several important co-morbidities
are worth special attention. For example, renal preservation is important both prognostically and therapeutically.
Chronic diuretic therapy may be potentially harmful, ac215
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Shyh-Ming Chen et al.
functional capacity,83 but larger studies are ongoing to
provide conclusive evidence.
Another important co-morbid condition commonly
found in Taiwan is diabetes mellitus. While the primary
focus of many studies has been on the impact of diabetes
mellitus on coronary ischemia, it has been well established that the diabetic myocardium is prone to a wide
spectrum of abnormalities, and the use of several anti-diabetic medications (such as metformin, thiazolidinedione,84-86 and even insulin) in patients with underlying
heart failure has been challenging. The side-effects of
fluid retention, edema and congestive heart failure have
been reported in the literature with regard to the use of
PPARg agonists (or thiazolidinediones). There is also
relatively good documentation in the literature that thiazolidinediones do not produce adverse haemodynamic
consequences. Thiazolidinediones-induced fluid retention is often sub-acute in nature, developed over weeks
to months following initiation. Current approval of thiazolidinedione use in patients with mild (NYHA class
I-II) and stable heart failure is supported by existing literature and clinical experience.86 To date, the appropriate
goals and ranges of glycemic control in patients with advanced heart failure are still not established,87 but it is reassuring that all evidence-based medications have been
shown to be equally effective in the diabetic population.
Medical therapies for decompensated heart
failure
For most patients presenting with acute decompensated heart failure, adequate tissue perfusion and relief
of congestion are still the mainstay therapeutic goals.
According to the cardio-circulatory model, there are two
strategies: an early and sustained reduction in filling
pressures by vasodilator therapy, and in some cases an
overdrive of existing contractile apparatus by inotropic
therapy. These strategies were designed decades ago,
and had not been rigorously tested in modern-day clinical trials. Over the past years, it is becoming clearer and
clearer that vasodilators may offer a generally effective
and more benign form of parenteral support for acute
decompensated heart failure than inotropic therapy, as a
large proportion of patients present with vascular alterations and/or diastolic dysfunction rather than worsening
contractile impairment. In contrast, the weight of current
evidence88,89 supports the hypothesis that drugs acting to
increase intracellular cyclic adenosine monophosphate in
Acta Cardiol Sin 2007;23:211-24
the myocardium are associated with adverse long-term
outcomes, most prominently increased mortality. Even
overzealous use of intravenous diuretics in this setting
may promote rather than suppress the neurohormonal
response to heart failure.90
Vasodilators have fallen out of favor with many physicians, but their beneficial effects have been well established. Nitroglycerin acts by increasing intracellular levels of cyclic guanosine monophosphate (GMP), resulting in venous and, for higher doses, arterial vasodilation. 89 The advantages of nitroglycerin include low
cost, patient comfort, and a proven safety profile. Suboptimal dosing aside, there are two primary obstacles to
the effective use of nitroglycerin, the phenomenon of
tolerance and its effect on neurohormonal pathways. 91
Sodium nitroprusside has been proven to effectively and
rapidly reduce filling pressures and increase stroke volume through venous and arterial dilation. However, the
use of sodium nitroprusside requires frequent titration,
and careful monitoring of hemodynamic alterations have
to be achieved via a pulmonary artery catheter. The risk
of thiocyanate toxicity has been widely quoted, 92 although clinically, patients appear to tolerate sodium
nitroprusside infusions well. Synthetic analogues of natriuretic peptides such as nesiritide in the United States
and carperitide in Japan have also been used as vasodilators with ancillary properties in the setting of acute
decompensated heart failure.93 Short-term infusion of
nesiritide has been shown to substantially improve hemodynamics and heart failure symptoms in a randomized,
controlled comparison with nitroglycerin in patients with
decompensated advanced heart failure.91,94 However, recent post-hoc meta-analyses linking nesiritide use and adverse effects, specifically, worsening renal function95 and
death,96 has prompted concerns about long-term safety.
The challenges to identify effective drug therapies
highlight the difficulties facing clinical drug development, regulatory approval, and clinical applications, particularly in the setting of acute decompensated heart failure. The Acute Decompensated Heart Failure National
Registry (ADHERE) shows that most hospitalizations
for acute decompensated heart failure are due to congestion in patients refractory to oral diuretics.97 Approximately 25% to 30% of patients may develop diuretic resistance, defined as reduced diuresis and natriuresis (serum creatinine [sCr] ³ 1.5 mg/dl, high daily oral diuretic
216
Heart Failure Care in Taiwan
itor patients’ volume status and titrate various heart failure medications, as well as triage and sometimes avert
admissions. In Taiwan, the nursing specialists have helped make a 41.8% total cost reduction in an organized
heart failure management in one University hospital.108
Second, efforts should be made to educate patients and
their caregivers about the self-management of heart failure, precipitating factors, and the need for compliance
with medication and dietary advice (particularly because
most heart failure re-admissions are caused by factors
that patients can be taught to recognize and avoid).109 Finally, there must be ready access to clinicians with an interest and expertise in treating patients with heart failure,
especially in complex levels of care when faced with
end-stage strategies of transplant, end-of-life issues, or
mechanical support.
Evidence-based practice implementation in hospital setting
Despite the compelling clinical trial evidence and
guideline endorsements regarding the use of ACE inhibitors and b-blockers in chronic heart failure, these agents
continue to be largely underused.110 Recent trends have
identified the hospital as an ideal setting for initiating
these therapies, and systematic improvement in the process of care may be more effective than identifying novel therapies. For example, the Initiation Management
Pre-discharge Process for Assessment of Carvedilol Therapy for Heart Failure (IMPACT-heart failure) trial demonstrated that in-hospital initiation of b-blockade resulted in a significantly greater use of b-blockers at 60
days after randomization compared with post-discharge
initiation at the physician’s discretion.111 This is in contrast with clinical practice a decade ago, when b-bloc-
doses [furosemide > 80 mg, torsemide > 40 mg, or bumetamide > 2 mg], or both).98 Therapies for diuretic resistance have had limited success. Ultrafiltration is an alternative treatment that has been shown to reduce right
atrial and pulmonary artery wedge pressures and increase cardiac output, diuresis, and natriuresis without
changes in heart rate, systolic blood pressure (SBP), renal function, electrolytes, or intravascular volume.99 Early ultrafiltration in patients with fluid overload and diuretic resistance have bee shown to favorably decrease
length of stay and re-hospitalizations in high-risk heart
failure patients.100 An optimal strategy utilizing continuous renal replacement therapy can dramatically improve
the patient’s clinical condition, mitigate the neurohumoral stimulation, increase urinary output and promote
absorption of excessive extravascular fluid.101
Improving the focus and organization of care
(Figure 3)
Heart failure disease management clinics
Although numerous studies have shown that medications and lifestyle modifications may reduce mortality in
chronic heart failure, adherence to these interventions is
often below optimal levels. Granger and colleagues assessed the association between adherence and clinical
outcome in the CHARM (Candesartan in Heart failure:
Assessment of Reduction in Mortality and morbidity)
programme. They found that good adherence to medication (> 80% of their prescribed drugs) was associated
with a lower risk of death than poor adherence in patients with chronic heart failure irrespective of treatment
or placebo groups.102 This is a very important observation to illustrate that discovering an effective drug can
only be effective if the drug is being utilized, and compliance itself (in other words, closer attention to selfmanagement) is associated with improvement in outcomes.
When studied in the context of multidisciplinary
teams, often led by cardiologists, nurse specialists have
been shown to contribute significantly to improving outcomes.103-105 Three elements are crucial to the success of
these programs. First, specially trained nurses should be
key components of any heart failure intervention.106-108
In the United States, nurses often assume the role as
“specialists” who are trained to manage patients with
heart failure as physician extenders, and are able to mon-
Figure 3. Heart failure care algorithm.
217
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Shyh-Ming Chen et al.
kers were contraindicated in the setting of acute decompensation and physicians often waited until patients
became “stable” in the ambulatory care setting – in many
cases without restarting. Several studies have demonstrated that in-hospital initiation of evidence-based,
guideline-recommended lifesaving therapies has markedly improved treatment use, long-term patient compliance, and clinical outcomes in patients with cardiovascular disease.112,113 The benefits of in-hospital drug initiation has been confirmed by the Organized Program to
Initiate Lifesaving Treatment in Hospitalized Patients
with Heart Failure (OPTIMIZE-HF) program, which
contains a hospital tool kit with evidence-based best
practices algorithms, critical pathways, standardized orders, discharge checklists, pocket cards, chart stickers,
and a variety of other elements to assist hospitals in improving heart failure management.114 Using these toolkits, increased rate of carvedilol use at discharge has
been associated with an early survival benefit.115
Cardiopulmonary exercise testing (CPET) and
rehabilitation
CPET is a well-established tool applied in several
clinical entities, and significant overlap exists in the exercise responses of patients with different respiratory
and cardiac diseases.116 Peak oxygen consumption (VO2)
measured during maximal exercise testing provides an
objective assessment of functional capacity in patients
with heart failure and an indirect assessment of cardiovascular reserve. A significant deterioration of maximal
exercise performance frequently precedes clinical decompensation. Gas exchange measurements during exercise provide an accurate assessment of severity of heart
failure and, by performing repeated studies, progression
of disease and response to therapy. Beaver et al. developed this method, termed the V-slope method, to detect
the anaerobic threshold (AT), using computerized regression analysis of the slopes of the CO2 uptake (VCO2) vs.
VO2 plot, which detects the beginning of the excess CO2
output generated from the buffering of [H+].117 These parameters have been used extensively to objectively determine the need to consider for cardiac transplantation,
and a value of 14 ml/min/kg has been a standard that has
stood the test of time (although recently it has been challenged with the recognition that women have relatively
lower VO2 for the same mortality risks).118 Recently, the
VE/VCO2 slope to peak exercise was also proposed as the
Acta Cardiol Sin 2007;23:211-24
one of the best predictors of mortality in patients with
heart failure.119
Benefits of exercise training have been reported in
skeletal muscles, respiratory and cardiovascular systems,
and in their physiological responses to exercise. 120 A
systematic review of 81 published studies, including
2387 exercising heart failure patients, 121 and a metaanalysis of nine randomized, parallel-controlled trials,
including 801 patients, has recently concluded that properly supervised training programs are safe and associated
with clear evidence of an overall reduction in mortality.122 In this setting, symptom-limited CPET has the following uses: (1) definition of exercise tolerance; (2) selection of exercise training intensity; (3) assessment of
improvement in functional capacity; and (4) prognostic
evaluation.123
Current challenges for Taiwan
Despite increasing heart failure disease burden in
Taiwan, several factors may account for a wide treatment
gap between clinical practice guideline recommendations and actual clinical practice in the care of patients
with heart failure. Efforts should be made for doctors in
centers as well as of primary care to be aware of and familiar with the existing clinical practice guideline recommendations. In addition, the overall health literacy issue in Taiwan society may require the setting up of a nationwide registration and education program to improve
the awareness of heart failure self-management. This extensive patient educational program may require the involvement of non-physician healthcare providers with
direct care responsibilities in the format of disease management programs, as seen in Western societies. However, the global budget payment system challenges the
resources needed to further care and education for patients with heart failure.
Taiwan’s National Health Insurance (NHI) program,
which was implemented in 1995, is planning a hospital
case payment system to avoid unnecessary utilization.
The vast discrepancies in the quality of care provided by
different medical institutions have prompted the proposal of “pay for performance,” whereby reimbursements for medical services rendered is rewarded by a
graded pay scale. The experience of heart failure center
in National Taiwan University Hospital has demonstrated a decrease in hospital expenditure, ambulatory cli218
Heart Failure Care in Taiwan
nic visiting rate, and days of hospital’s stay. The 5-year
survival rate has also increased from 50% to 66%.108
The NHI in Taiwan is going to apply the concept of
Diagnosis Related Groups (DRGs) throughout the health
care system in 2008. Quality control will be a rising issue in the new payment system. It is suggested that the
NHI should design and execute the clinical pathway
along with the new DRG system to monitor and control
the quality of heart failure care. The disease management program with patient education should be a necessary element in the heart failure treatment, which has
been proven to be cost-effective in various literature.108
4.
5.
6.
7.
CONCLUSION
Heart failure is a costly disease with an increasing
prevalence, and will likely pose a significant burden in
the coming decades in Taiwan. Although there have been
great strides in the development and application of evidence-based treatment strategies, the prognosis for patients with heart failure is still poor, in some cases worse
than many of the cancer diagnoses. Changes in the concept of the heart failure syndrome have transformed this
once-believed terminal illness into a manageable chronic
condition, readily responsive to special therapies and
counseling. However, the treatment of heart failure (as
well as the organization of heart failure care) has received far lesser attention and recognition in Taiwan, in
part because there is no single procedure or therapy that
has been embraced by physicians specialized in taking
care of patients with heart failure. The multidisciplinary
approach with coordinated care is novel in Taiwan, and
the training of heart failure nurse specialists and establishment of rehabilitation programs are urgently needed.
8.
9.
10.
11.
12.
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Review
Acta Cardiol Sin 2007;23:211−24
改善心臟衰竭病人的治療  臺灣可以更進步
陳世明 1 陳勉成 1 W. H. Wilson Tang2
高雄縣 高雄長庚紀念醫院 心臟內科 長庚大學醫學院1
美國俄亥俄州克里夫蘭醫院 心臟內科2
心臟衰竭是一個成長中的全世界性問題，由於心臟疾病治療的改善以及心臟衰竭治療的日
趨複雜，我們必須正視此問題的重要性，若不妥善處理，無論病人數及其花費將節節攀升，
此篇綜論主要討論西方國家與台灣在心臟衰竭治療之異同，在不同的面向上討論我們有那
些地方可以改善並進而增進病人的福祉。
關鍵詞：心臟衰竭、臺灣、整合治療。
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