ASSESSING APPROPRIATENESS OF TREATMENT - A CASE-STUDY OF TRANSPLANTATION IN OLDER PATIENTS WITH CONGESTIVE-HEART-FAILURE

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.