Heart-lung transplantation for patients with cystic fibrosis: a test of clinical wisdom

Article Abstract:

Developments in medical technology often bring with them new challenges for clinicians, who must make ethical decisions regarding their use; such is the case for heart-lung transplantation (HLT) to treat severe cystic fibrosis (CF, an inherited, progressive disorder affecting the respiratory and other systems). The availability of HLT for CF patients raises ethical problems concerning selection of the most appropriate patients to receive this treatment (transplanted lungs do not develop disease). Some of these issues are discussed in this editorial. A case history is presented of a CF patient who did not meet transplantation criteria but who was referred to a CF treatment center from another state, largely because of the insistence of the family and referring physicians. The patient died soon after transfer to the hospital, away from his home environment, made ill in part by the stress of the trip. Should the availability of HLT, a treatment associated with considerable complications and mortality, change the way seriously ill CF patients are treated? Criteria for HLT recipients, as developed by the Cystic Fibrosis Foundation's Heart-Lung Transplant Advisory Group, state that recipients should be very sick but not terminally ill, and have life expectancies of between one and two years. Presently, HLT is not an alternative for most CF patients, because it is still experimental, donor organs are scarce, and patient management after transplantation is difficult. Only 50 HLT procedures at most, and 20 to 30 double-lung transplantations, are performed in the US each year for all conditions; CF patients could only hope to receive a maximum of 10 such procedures, while approximately 500 CF patients die each year. HLT is expensive (more than $200,000), and medication costs additional thousands per year; in most cases, families must bear these burdens themselves. The ethical dilemmas surrounding the selection of the ''best'' CF patients for this extremely scarce resource are part of the broader current debate about resource allocation: should money be spent on complex procedures that benefit a few, or to promote treatments with more universal applicability? (Consumer Summary produced by Reliance Medical Information, Inc.)

Prognosis, Social policy, Transplantation of organs, tissues, etc., Organ transplantation, Tissue transplantation, Transplantation, Cystic fibrosis, editorial

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Angiotensin-converting enzyme inhibitors in congestive heart failure

Article Abstract:

Congestive heart failure (CHF) is the inability of the heart to pump blood effectively, and is characterized by symptoms of weakness, shortness of breath, abdominal discomfort, and edema (fluid retention). This heart disease has been treated with angiotensin-converting enzyme (ACE) inhibitors, which prevent the formation of angiotensin, a factor that constricts blood vessels. Angiotensin also activates the production and release of the adrenal hormone aldosterone, which regulates sodium, chloride, and potassium metabolism. ACE inhibitors were shown to improve circulatory and clinical characteristics of severe CHF, and are also used to treat mild to moderate CHF. These agents also improve the function of the heart ventricles and the quality of life in patients with CHF. Combined therapy with the ACE inhibitor captopril and diuretics, which increase the excretion of water, is an effective alternative treatment to digoxin, which increases heart contraction, in patients with mild to moderate CHF. Other ACE inhibitors, specifically enalapril maleate and lisinopril, are combined with digoxin and diuretics to treat moderate to severe CHF. Captopril and enalapril were shown to improve survival in some patients. All ACE inhibitors have a similar mechanism of action, but differ in their absorption, distribution, metabolism, and excretion from the body. ACE inhibitors with a long duration of action may cause prolonged hypotension (low blood pressure), which may adversely affect organ function and the blood supply to tissues. Agents with a short duration of action produce only transient hypotension that rarely affects organ function. (Consumer Summary produced by Reliance Medical Information, Inc.)

Health aspects, Drug therapy, ACE inhibitors, Angiotensin converting enzyme inhibitors, Congestive heart failure agents, Enalapril, Captopril

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Trends in hospitalization rates for heart failure in the United States, 1973-1986

Article Abstract:

Congestive heart failure (CHF) is the condition resulting from the inability of the heart to pump blood effectively, and is characterized by the accumulation of fluid within the lungs. In 1983 the incidence of CHF was estimated at 400,000 cases. The trends in the prevalence of CHF from 1973 through 1986 were assessed by examining the discharge records from a sample of short-stay hospitals. It was found that the number of discharges related to CHF more than doubled, and CHF discharge rates increased from 53 to 88 percent among black and white men and women. The annual hospitalization rates were 33 percent higher in nonwhite men, compared with white men, and 50 percent higher in nonwhite women, compared with white women. Hospitalization rates over the 14-year period remained the same for those under the age of 55 years, but increased markedly among the elderly. However, the death rate due to CHF declined; this may be due to the increasing age of the population or longer survival of patients with chronic heart disease. It is not clear whether improved medical therapy contributed to the changing trends in the prevalence of CHF. New approaches are needed to treat and prevent the underlying disorders which result in CHF and to decrease the need for hospitalizing patients with this common disease. (Consumer Summary produced by Reliance Medical Information, Inc.)

Reports, Demographic aspects, Hospital utilization

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