T. Montague et al., ASSESSING APPROPRIATENESS OF TREATMENT - A CASE-STUDY OF TRANSPLANTATION IN OLDER PATIENTS WITH CONGESTIVE-HEART-FAILURE, Canadian journal of cardiology, 12(1), 1996, pp. 47-52
OBJECTIVE: To evaluate the appropriateness of transplantation therapy
for older patients with congestive heart failure (CHF). DATA SOURCES:
Comparative review of contemporary survival life data of CHF patients
treated medically versus by transplantation. DATA SYNTHESIS: Approxima
tely 300,000 Canadians have CHF and the incidence is increasing as the
population ages; suitable donor allografts are found for about 300 CH
F patients each year. Overall survival among cardiac allograft recipie
nts, with a mean age of 48 years is approximately 80% at two years, Ho
wever, risk from all causes appears higher, and survival lower (range
40 to 78%), for transplant patients 55 years of age and older. Among m
edically treated patients, with mean age over 60 years, survival is in
versely related to level of functional disability averaging more than
90% at two years for patients with mild limitation and decreasing to 7
5% and 40% for patients with moderate and severe symptoms respectively
. Perceived quality of life is low in all CHF patients, but is signifi
cantly improved by intense out-patient care and education, irrespectiv
e of medical or transplant allocation. CONCLUSIONS: Among adults with
with CHF, the greatest benefit of transplantation enhanced survival in
younger severely disabled patients. However, noncardiac risks are sub
stantial, particularly for older recipients. The great discrepancy bet
ween donor and candidate availability prohibits transplantation from b
eing a life expanding therapy for the whole CHF population. When physi
cians are, simultaneously, patients' and society's advocates a utilita
rian decision model using the totality of efficacy data, including deg
ree of efficacy and population effectiveness, may assist determination
of the most appropriate therapy.