Pacemaker Better for Certain Heart Patients

New research conducted at Johns Hopkins has found evidence which might bring about a dramatic change in the way heart failure is treated. Follow-up to previous study, the new research found patients with non-systolic heart failure may fare better with pacemakers than beta blocker drugs.

Once installed, pacemakers speed up the heartbeat while beta-blockers slow down the heartbeat and need to be taken over an extended period. An estimated 550,000 Americans are diagnosed with heart failure every year and at least half of them have the non-systolic form.

“Cardiologists are constantly being forced to rethink heart failure because one size does not fit all,” said senior study investigator Dr. David Kass, M.D., a professor at The Johns Hopkins University School of Medicine and its Heart Institute. “We really have to be careful about how we diagnose and approach its treatment,” he said

“We also need to understand all facets and manifestations of the disease because we are seeing ever-increasing numbers of older adults who have heart failure, mostly women over age 50, whose heart pumping appears to be normal. And their cases are clearly different from traditional, systolic heart failure, where pumping function is depressed. However, almost all of the research over the last three decades has applied only to those with systolic heart failure,” Dr. Kass said.

In non-systolic heart failure, the heart’s pumping action, known as ejection fraction, is more or less normal when the patient is at rest. However with the start of daily physical activity, the heart’s action becomes irregular and it is unable to pump enough blood to meet the body’s demands. Even small tasks leave the patient exhausted. So far researchers believed the problem was due to the heart not being able to relax sufficiently.

For some of these patients a combination of drugs and device works best to control to disease, regulating the speed of the heartbeat as required. However in others, it might not work that way. On the other hand, patients with systolic heart failure, the more common form of the disease, have a permanently depressed and weakened heart function, whether relaxed or in activity.

Such patients benefit greatly from beta-blockers as they minimize the stress on their failing heart, especially during physical activity when the body demands the heart pumps out more blood quickly. This Hopkins study is believed to be unique as no previous study has done a head-to-head comparison of patients with non-systolic heart failure and patients with similar medical histories, including high blood pressure, a relatively high ejection fraction and overgrown hearts, but no major symptoms of heart failure.

As part of their study, the research team had its relatively small study group of 17 subjects pedal a stationary bike at increasing speed levels. Heart activity for all subjects was constantly monitored. While the hearts of all subjects filled in a similar manner, a clear difference was seen in the heart function of those with non-systolic heart failure.

Hearts of such patients just failed to keep up, lagging behind by an average 44% in speed than those without heart failure. The blood vessels of the heart patients also failed to dilate sufficiently to meet the higher demand for energy from the body’s muscles. While resistance to blood flow dropped by 28% in the control subjects, it fell by only 19% in the heart-failure group.

Dr. Kass and his team now plan to take their research to the national level through a study of the use of pacemakers in patients with non-systolic heart failure. Dr. Kass believes validation of their current work through the new study could change the practice guidelines for use of beta blockers and pacemakers in this form of heart failure.

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