McCullough and colleagues1 offer an important analysis of the Interagency Registry for Mechanically Assisted Circulatory Support data, suggesting that those patients treated with comprehensive neurohormonal blockade after left ventricular assist device (LVAD) placement for advanced heart failure have an observed survival advantage at 4 years and better quality of life vs those not receiving any neurohormonal blockade. These findings address an important question. By convention, many patients after LVAD continue receiving heart failure guideline-directed medical therapy, in part as treatment for hypertension but also to address the residual pathophysiology of ventricular dysfunction from activated neurohormonal schema. Yet, we have few mechanistic data to support the use of neurohormonal blockade after LVAD, and to our knowledge, there are no randomized data to inform this question. Thus, the analyses as presented by McCullough and colleagues1 are informative, less so because they define a new algorithm of care, but more so because these findings highlight the need for randomized data. The observed benefits, despite credible efforts using propensity analyses, sensitivity analyses, and negative controls, may still reflect a healthy user bias. It remains likely that unmeasured variables and the health of the cohort taking/able to tolerate neurohormonal blockade contribute substantially to the associated benefits observed.
Yancy CW, Fonarow GC, Hernandez AF. Does Guideline-Directed Medical Therapy for Heart Failure Offer Benefits After LVAD Placement?—A Call for a Randomized Clinical Trial. JAMA Cardiol. Published online November 18, 2019. doi:https://doi.org/10.1001/jamacardio.2019.5019
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