January 28, 2005

Journal gives national nod to transplant studies

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Javed Butler, M.D.

Journal gives national nod to transplant studies

In the world of cardiovascular medicine, The Journal of American College of Cardiology is one of the premier publications that physicians and researchers alike look to for the latest information and studies. The journal each year highlights a few research studies that it considers are likely to have the highest impact on changing medical care.

In a recent issue of JACC, six such studies were selected in the field of heart failure and transplantation for 2004. Two of these studies were from Vanderbilt University Medical Center and both were authored by Javed Butler, M.D., and his colleagues.

“I did not even know about this until one of the cardiology fellows told me,” said Butler, medical director of the heart transplant program at VUMC. “It is obviously a good feeling to have your work recognized as likely to have a high impact nationally.”

In one of the studies, Butler and his colleagues critically evaluated the criteria used to assess eligibility of patients with heart failure for cardiac transplantation. The current criteria, he noted, are based on studies from the early 1990s and is still in place today despite significant changes in medical care over the last decade.

“With the severe shortage of donor organs for heart transplantation, up to 20 percent of the patients waiting for hearts die due to lack of donor organ availability,” Butler said.

According to existing standards, patients are evaluated and determined to be candidates based on a series of tests.

“Beta-blockers, defibrillators, pacemakers, etc. have not only improved the outcome of patients with advanced heart failure, these treatments may theoretically alter the relationship between transplant eligibility testing and the actual patient outcomes,” he said.

And this is what they proved. Comparing outcomes of patients from a decade ago to a more contemporary cohort, the study suggested that many patients who meet the criteria for transplantation currently have outcomes comparable or even better with medical therapy than with transplantation. Butler suggested that rather than continue with the current guidelines, new ones should be devised based on these results, taking into account the current therapies and transplanting only the highest risk patients.

“A lot of patients currently listed for transplant can be safely managed with medical therapy if the criteria were changed and we only transplanted the sickest of patients. The hope is that by doing so, one may be able to significantly reduce the number of people who die awaiting transplants or require mechanical assist devices.”

Butler admits that changing the current criteria will take years, as this idea will have to be proven in carefully designed prospective studies, but he and his colleagues in the Heart Failure program are working toward proving his theory.

In the other study cited by the JACC, Butler and Marie Griffin, M.D. professor of Medicine, highlighted the problem with outpatient medication use in heart failure patients across acute care hospitals in Tennessee.

Using the data on patients enrolled in TennCare and Medicare, they noted that despite the known benefits with a group of medications called ACE inhibitors in heart failure patients, up to one-third of the patients hospitalized with this condition were not given these medications upon hospital discharge.

Even more important, they showed, was the fact that even if the patients were given prescriptions, at least one-third stopped taking them within six months of discharge. Of the one-third that didn't receive medications upon release from the hospital, less than 15 percent of them were given medications during outpatient visits.

“We have all this strong, scientific data showing the effectiveness of these medications (targeted for heart failure patients) yet the patient's outcomes remain very poor,” Butler said. “It is difficult to explain why people are either not given these medications or they are not taking them. It's not an issue of cost alone. Although some of the drugs can be expensive, we specifically studied a group of patients who had total prescription coverage.

“We have to question poor outcomes when medications are proven to reduce mortality, hospitalization and improve quality of life. If patients were taking the medications, then we could possibly avoid the high costs of health care. This is something we are very interested in finding answers for so that we can improve the overall health care system.”