Optimal medical therapy is superior to transplantation for the treatment of class I, II, and III heart failure: a decision analytic approach.
BACKGROUND
The survival benefit of heart transplantation (HT) compared with optimal medical therapy (OMT) has never been tested.


RESULTS
We created a decision analytic model that simulates a randomized clinical trial of OMT versus HT for each New York Heart Association (NYHA) class. The simulation calculates average life expectancy. The following assumptions were made for OMT annual mortality: class I no excess mortality from HF; class II and III based on MERIT-HF are 5.3% and 8.1%. Class IV is 12.8%, based on COPERNICUS. HT mortality rates were based on survival curves for HT 1982 to 2001. For classes I, II, and III, OMT demonstrated a life expectancy gain of 113 months (232+/-2.2 versus 119+/-2.1), 38 months (152+/-2.1 versus 114+/-2.1), and 6 months (117+/-1.8 versus 111+/-2.2), respectively, over HT. Class IV favored HT with a life expectancy gain of 26 months (107+/-2.1 versus 81+/-1.4) over OMT. Sensitivity analysis revealed if improvement in OMT decreased mortality by 38% for class IV patients, OMT and HT would have equivalent life expectancies. If improvement in HT resulted in a 7% increase in post-HT survival, OMT and HT would be equivalent for class III patients. If improvement in HT resulted in a 30% increase in post-HT survival, OMT and HT would be equivalent for class II patients.


CONCLUSIONS
Our model predicts that currently, OMT is superior to HT for classes I, II, and III, but HT is superior for class IV. However, future advances in OMT or HT may change the relative benefits of these treatment modalities.
Freudenberger
R S
RS
University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ, USA. freuders@umdnj.edu
Kim
J
J
Tawfik
I
I
Sonnenberg
F A
FA
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D015331:Cohort Studies; D015897:Comorbidity; D003198:Computer Simulation; D003645:Death, Sudden / Q000453:epidemiology; D016757:Death, Sudden, Cardiac / Q000453:epidemiology; D003661:Decision Support Techniques; D003663:Decision Trees; D006333:Heart Failure / Q000145:classification / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D016027:Heart Transplantation; D006801:Humans; D008017:Life Expectancy; D008390:Markov Chains; D008962:Models, Theoretical; D009369:Neoplasms / Q000401:mortality; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data*; D051437:Renal Insufficiency / Q000401:mortality; D012306:Risk; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome
D000319:Adrenergic beta-Antagonists