Syllabus & General Information. Intended Audience. Instructor Information. Website (Login Required) Description

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1 Advanced Pharmacy Practice Experience Advanced Heart Failure Syllabus & General Information Intended Audience Final-Year Student Pharmacists (PY4) Pharmacy Practice Residents (PGY1) Non-Cardiology Pharmacy Specialty Residents (PGY2) Instructor Information Brent N. Reed, PharmD, BCPS, FAHA Assistant Professor, Cardiology Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Office: (410) Pager: (410) Mobile: (423) Website (Login Required) [To be determined] Description Despite considerable advances over the last decade, cardiovascular disease remains the cause of 1 out of every 3 deaths in the United States more than all types of cancer combined. 1 An estimated 5.1 million American adults have heart failure, a number expected to increase by nearly 25% by the year Given a lifetime risk for developing heart failure of 1 in 5, all health care professionals should anticipate managing patients with this condition. Although more clinical practice guidelines exist to support the management of cardiovascular disease than any other therapeutic area, only 1 in 10 recommendations is based on evidence from multiple randomized controlled trials. 2 Adding further complexity to the management of this patient population are new and emerging frontiers in advanced cardiovascular therapies, including mechanical circulatory support and cardiac transplantation. Finally, patients with heart failure are at exceedingly high risk for rehospitalization, 3 adding significant cost to the health care system and making heart failure the subject of several national quality measures. Taken altogether, these features make the unique expertise of a pharmacist paramount to the management of this patient population. This advanced pharmacy practice experience focuses on the foundational knowledge and skills expected of a clinical pharmacy specialist in the area of advanced heart failure. Trainees should begin to develop strategies for providing patient-centered care with the goal of optimizing medication therapy and improving patient outcomes across a diverse array of cardiovascular diseases and comorbid conditions. Emphasis will also be placed on the development of professional attitudes and behaviors, including personal accountability, service to patients and caregivers, ethically sound decision-making, and clinical leadership. Trainees are expected to develop in their role as a valued member of the multidisciplinary health care team by collaborating with physicians, nurses, allied health providers, students of other health professions, and other qualified support personnel. 1

2 Location & Schedule The practice site for this experience is the University of Maryland Medical Center (UMMC) in Baltimore, MD. Patients admitted to the Advanced Heart Failure Service (AHFS) are located in the Coronary Care Unit (CCU, Gudelsky 3W), Progressive Care Unit (PCU, Gudelsky 3E), and general cardiology ward (3DS). The schedule for this experience is Monday through Friday, from approximately 7:30 AM to 5:00 PM. A calendar detailing the locations and times of specific activities will be determined during the first week of the experience. Course Prerequisites Prior to enrolling in this experience, student pharmacists should have: Completed all coursework required of the first three professional years of pharmacy school Demonstrated basic knowledge of cardiovascular diseases as presented in prior courses, e.g., normal cardiovascular physiology, etiology and pathophysiology, risk factor identification and management, classifications and staging systems, signs and symptoms, laboratories and other diagnostic tests, and general approaches to medication therapy management Demonstrated proficiency in the practical use of pharmacokinetic equations (e.g., vancomycin, aminoglycosides) and other strategies for individualizing drug therapy (e.g., renal function) Obtained access to patient information systems at UMMC Residents are encouraged to review the etiology, pathophysiology, diagnosis, assessment, and management of common cardiovascular disorders. Required Materials White coat with identification badge Scientific calculator (i.e., capable of performing natural log) Patient monitoring form/system (paper or electronic is acceptable) Required Readings Lange RA, Hillis LD. Cardiovascular Testing. In: Dipro J, Talbert RL, Posey LM, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 9th ed. New York, NY: McGraw-Hill; Rodgers JE, Reed BN. Acute Decompensated Heart Failure. In: Dipro J, Talbert RL, Posey LM, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 9th ed. New York, NY: McGraw-Hill; Recommended Readings Yancy CW, Jessup M, Wilkoff BL, et al ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation Oct 15;128(16): Available online at: Section 12: Evaluation and Management of Patients with Acute Decompensated Heart Failure. In: Lindenfeld, J, Albert NM, Walsh MN, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010;16:e1-e194. Available online at: McMurray JJ. Systolic Heart Failure. N Engl J Med 2010;362: Aurigemma GP, Gaasch WH. Diastolic Heart Failure. N Engl J Med 2004;351:

3 Learning Outcomes By the completion of this experience, students should be able to: 1. When assigned a patient presenting with an acute cardiovascular disorder, design an evidence-based medication therapy management plan, that: For a given disease state, incorporates: an understanding of etiology, pathophysiology, and therapeutic goals; pertinent laboratory and diagnostic findings that impact clinical decision-making; and medication therapies indicated for the condition, including their dosing, precautions and contraindications, monitoring parameters, adverse effects, mechanism of action, and clinical pharmacokinetics. For a given patient, incorporates: relevant information obtained from the history of present illness, past medical history, social and family history, medication history, acute hospital course, and patient/caregiver interview (adapted for cultural competency and health-literacy); identification, assessment, and prioritization of the conditions present, including medication-related problems for each; medication therapy recommendations that incorporate evidence from clinical practice guidelines, primary literature, and/or established standards of care; adjustments that account for patient-specific characteristics (e.g., age, weight, renal and hepatic function, cost); a monitoring plan for safety and efficacy; and patient-centered medication education, with information on indication, directions for use (including administration technique when relevant), and self-monitoring of efficacy and adverse effects. For a given case, is presented in an organized, problem-focused fashion. Lists of the cardiovascular disease states and pharmacotherapies emphasized in this pharmacy practice experience are provided in Appendix When assigned to an interdisciplinary patient care team, exemplify the attitudes and behaviors expected of a health care professional, specifically: Effective interpersonal communication skills. A willingness to collaborate with members of the multidisciplinary health care team. Empathy and genuine concern for the well-being of patients. A commitment to learn and develop practice knowledge and skills. Personal accountability for performance. Professional attire appropriate for the practice site and in accordance with dress code policies. 3. When given a selection from the peer-reviewed literature, critically analyze the information and apply it to clinical practice, by: As it relates to medical literature, demonstrating: efficient and effective strategies for literature search and retrieval; an evaluation of the credibility of a source of medical information; and an ability to articulate evidence-based responses to drug information requests. As it relates to a specific clinical trial or other publication, describing: its purpose and context within existing standards of care, the appropriateness of its basic design (e.g., randomization, blinding, inclusion and exclusion criteria, interventions, endpoints, statistical analysis); its results in terms of number needed-to-treat and number needed-to-harm; how characteristics of the trial limit its application to clinical practice; and how benefits compare with harm and/or costs of therapy. 3

4 In addition to the above learning outcomes, residents should be able to: 1. Assume independent responsibility for the aforementioned practice activities on their assigned patients, with support from the preceptor when necessary (R2.6, 2.9, 2.10). 2. Develop strategies for prioritizing patient care in relation to other required residency activities (R2.2). 3. Provide information to the multidisciplinary health care team that integrates critical analysis of the peerreviewed literature, with specific emphasis on clinical applicability and limitations (R1.5). 4. Document practice activities in accordance with the requirements of the practice site (R2.12, 5.1). 5. Serve as a co-preceptor, mentor, and role model for student pharmacists, especially as it relates to the professional attitudes, knowledge, and skills expected of a practicing pharmacist (R3.1, 3.3, 5.1). 6. Demonstrate ongoing development of skills and attributes expected of a practice leader (R3.1, 3.3). 7. Participate in the management of medical emergencies (E5.1). Overview of Activities & Assignments Over the course of this practice experience, trainees will complete the following activities and assignments: Pre-Examination A pre-examination consisting of multiple-choice, true-false, and short answer questions will be administered to assess the trainee s baseline knowledge of cardiovascular pharmacotherapy. Pharmacy Practice Activities Trainees should be prepared to discuss assigned patients an hour prior to rounds, attend and actively participate on rounds when appropriate, and perform any follow-up activities after rounds have been completed. Trainees are also responsible for reconciling medications for assigned patients (and others as needed), including resolution of any discrepancies in the official medication record. Finally, trainees are responsible for providing discharge counseling (i.e., patient-specific treatment and monitoring plans, expected benefits and risks, administration techniques, and/or adherence strategies) for selected high-risk medications (e.g., anticoagulants, select antiarrhythmics). Patient Presentation & Discussion Trainees will be asked to periodically present assigned patients. Formal presentations may be required on the day of admission, including relevant details of the patient s presenting complaint, past medical history, and home medication regimen as well as a problem-focused assessment and plan. Thereafter, trainees may provide abbreviated presentations, highlighting significant changes made during the course of care. The focus of patient discussion will be the identification, assessment, and resolution of patient-specific medication-related problems. Topic Discussion Topic discussions will be held once weekly (see Appendix 2 for topics and assigned readings). To prepare for each topic discussion, trainees will be assigned videos and/or selections from the primary cardiovascular literature. The purpose of the videos is to provide an overview of fundamental concepts, whereas literature selections are meant to expose trainees to the evidence supporting clinical practice guidelines and current standards of care. Both are designed to facilitate a more indepth exploration of content during topic discussions. Approximately 5-10 minutes of video and 5-6 selections will be assigned per week. To ensure trainees are prepared for topic discussions, a short assessment (2-3 questions based on the videos and/or readings) will be performed. 4

5 Clinical Trial Analysis Trainees will be asked to select a recent publication from the primary cardiovascular literature to critically analyze and informally present at a journal club (i.e., a slide deck or handout is not required). A guide for evaluating clinical trials will be provided. Approximately minutes will be allocated for presentation of the trial (summary and analysis) and the remaining minutes for discussion. Patient Cases A set of written patient cases will be assigned to trainees at the beginning of the practice experience. Given substantial variability in the acuity and diversity of patients encountered over the course of a month, these cases are designed to ensure trainees are exposed to the fundamental concepts of advanced heart failure. Cases are due by the last week of the practice experience. Learning Log Trainees will be asked to maintain a learning log over the course of the month. Each entry in the log should consist of a short paragraph (i.e., 2-3 sentences) describing something learned each day, and at least one supporting citation from the primary literature. Final Examination A final examination consisting of multiple-choice, true-false, and short answer questions will be administered to assess knowledge and skills obtained during the pharmacy practice experience. Assessment & Grading Trainees will receive a formal midpoint and final evaluation of their performance, and informal feedback will be provided periodically. Final grades will be determined according to the following: Pre-Examination 5% Pharmacy Practice Skills & Behaviors 50% Topic & Patient Discussion 10% Patient Cases 10% Clinical Trial Analysis 5% Learning Log 5% Final Examination 10% Pharmacy practice skills and professional behaviors will be evaluated using the Performance Outcome Rubric for acute care pharmacy practice experiences developed by the University of Maryland School of Pharmacy. Mobile Technology Policy Mobile phones may be used for researching information prior to or after rounds but may not be used during rounds (unless specifically asked), as other team members may perceive this as disinterest. Downtime during rounds is common, so mobile phones may be used at that time. Use of an electronic tablet, ipad, or similar device is acceptable at all times during rounds. Honor Code & Other Relevant Policies Student pharmacists are expected to adhere to the Honor Code and other relevant policies. 5

6 References 1. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics update: a report from the American Heart Association. Circulation Jan 1;127(1):e6 e Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC Jr. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA J Am Med Assoc Feb 25;301(8): Krumholz HM, Merrill AR, Schone EM, Schreiner GC, Chen J, Bradley EH, et al. Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circ Cardiovasc Qual Outcomes Sep;2(5):

7 Appendix 1 Cardiovascular Diseases States & Pharmacotherapy Covered Cardiovascular Disease States & Conditions By the end of the pharmacy practice experience, trainees should demonstrate a fundamental understanding of the etiology, pathophysiology, and therapeutic goals; pertinent laboratory and diagnostic findings that impact clinical decision-making; and medication therapies for the following conditions: Acute Coronary Syndromes Acute Decompensated Heart Failure Atrial Fibrillation Cardiac Transplantation Cardiogenic Shock Chronic Heart Failure Diabetes Mellitus Dyslipidemia Hypertension Mechanical Circulatory Support Ventricular Arrhythmias Cardiovascular Pharmacotherapy By the end of this pharmacy practice experience, trainees should be proficient in the general management (i.e., initiation, titration, monitoring for safety and efficacy, common adverse effects, and education for patients/caregivers) of the following cardiovascular medications or therapeutic classes: Aldosterone Receptor Antagonists Angiotensin-Converting Enzyme Inhibitors Angiotensin II Receptor Blockers Antidyslipidemic Agents Anticoagulants Antiplatelet Agents Beta Blockers Calcium Channel Blockers Class III Antiarrhythmics Cardiac Glycosides Diuretics Immunosuppressants Intravenous Inotropes Vasodilators Vasopressors 7

8 Appendix 2 Topic Discussions & Assigned Readings Week 1 Cardiovascular Hemodynamics & Vasoactive Therapies Required Readings Abraham WT, Adams KF, Fonarow GC, et al; ADHERE Scientific Advisory Committee and Investigators; ADHERE Study Group. In-hospital mortality in patients with acute decompensated heart failure requiring intravenous vasoactive medications: an analysis from the Acute Decompensated Heart Failure National Registry (ADHERE). J Am Coll Cardiol Jul 5;46(1): Cuffe MS, Califf RM, Adams KF Jr, et al; Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) Investigators. Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. JAMA Mar 27;287(12): Mullens W, Abrahams Z, Francis GS, et al. Sodium nitroprusside for advanced low-output heart failure. J Am Coll Cardiol Jul 15;52(3): O'Connor CM, Starling RC, Hernandez AF, et al. Effect of nesiritide in patients with acute decompensated heart failure. N Engl J Med Jul 7;365(1): Fonarow GC, Abraham WT, Albert NM, et al; OPTIMIZE-HF Investigators and Coordinators. Influence of betablocker continuation or withdrawal on outcomes in patients hospitalized with heart failure: findings from the OPTIMIZE-HF program. J Am Coll Cardiol Jul 15;52(3): Supplemental Readings Publication Committee for the VMAC Investigators (Vasodilatation in the Management of Acute CHF). Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial. JAMA Mar 27;287(12): Aaronson KD, Sackner-Bernstein J. Risk of death associated with nesiritide in patients with acutely decompensated heart failure. JAMA Sep 27;296(12): Sackner-Bernstein JD, Skopicki HA, Aaronson KD. Risk of worsening renal function with nesiritide in patients with acutely decompensated heart failure. Circulation Mar 29;111(12): Jondeau G, Neuder Y, Eicher JC, et al; B-CONVINCED Investigators. B-CONVINCED: Beta-blocker CONtinuation Vs. INterruption in patients with Congestive heart failure hospitalized for a decompensation episode. Eur Heart J Sep;30(18): Metra M, Nodari S, D'Aloia A, et al. Beta-blocker therapy influences the hemodynamic response to inotropic agents in patients with heart failure: a randomized comparison of dobutamine and enoximone before and after chronic treatment with metoprolol or carvedilol. J Am Coll Cardiol Oct 2;40(7): Teerlink JR, Cotter G, Davison BA, et al; RELAXin in Acute Heart Failure (RELAX-AHF) Investigators. Serelaxin, recombinant human relaxin-2, for treatment of acute heart failure (RELAX-AHF): a randomised, placebocontrolled trial. Lancet Jan 5;381(9860):

9 Week 2 Acute Management of Volume Overload Required Readings Felker GM, Lee KL, Bull DA, et al; NHLBI Heart Failure Clinical Research Network. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med Mar 3;364(9): Jentzer JC, DeWald TA, Hernandez AF. Combination of loop diuretics with thiazide-type diuretics in heart failure. J Am Coll Cardiol Nov 2;56(19): Chen HH, Anstrom KJ, Givertz MM, et al; NHLBI Heart Failure Clinical Research Network. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction: the ROSE acute heart failure randomized trial. JAMA Dec 18;310(23): Konstam MA, Gheorghiade M, Burnett JC Jr, et al; Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) Investigators. Effects of oral tolvaptan in patients hospitalized for worsening heart failure: the EVEREST Outcome Trial. JAMA Mar 28;297(12): Bart BA, Goldsmith SR, Lee KL, et al; Heart Failure Clinical Research Network. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med Dec 13;367(24): Supplemental Readings Allen LA, Turer AT, Dewald T, Stough WG, Cotter G, O'Connor CM. Continuous versus bolus dosing of Furosemide for patients hospitalized for heart failure. Am J Cardiol Jun 15;105(12): Thomson MR, Nappi JM, Dunn SP, Hollis IB, Rodgers JE, Van Bakel AB. Continuous versus intermittent infusion of furosemide in acute decompensated heart failure. J Card Fail Mar;16(3): Triposkiadis FK, Butler J, Karayannis G, et al. Efficacy and safety of high dose versus low dose furosemide with or without dopamine infusion: The Dopamine in Acute Decompensated Heart Failure II (DAD-HF II) Trial. Int J Cardiol Mar 1;172(1): Gheorghiade M, Gattis WA, O'Connor CM, et al; Acute and Chronic Therapeutic Impact of a Vasopressin Antagonist in Congestive Heart Failure (ACTIV in CHF) Investigators. Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. JAMA Apr 28;291(16): Costanzo MR, Guglin ME, Saltzberg MT, et al; UNLOAD Trial Investigators. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol Feb 13;49(6):

10 Week 3 Neurohormonal Inhibition Required Readings The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med Jun 4;316(23): Granger CB, McMurray JJ, Yusuf S, et al; CHARM Investigators and Committees. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensinconverting-enzyme inhibitors: the CHARM-Alternative trial. Lancet Sep 6;362(9386): ATLAS Study Group. Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. Circulation Dec 7;100(23): Packer M, Poole-Wilson PA, Armstrong PW, et al. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet Jun 12;353(9169): Poole-Wilson PA, Swedberg K, Cleland JG, et al; Carvedilol Or Metoprolol European Trial Investigators. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial. Lancet Jul 5;362(9377):7-13. Bristow MR, Gilbert EM, Abraham WT, et al. Carvedilol produces dose-related improvements in left ventricular function and survival in subjects with chronic heart failure. MOCHA Investigators. Circulation Dec 1;94(11): Zannad F, McMurray JJ, Krum H, et al; EMPHASIS-HF Study Group. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med Jan 6;364(1): Yusuf S, Pfeffer MA, Swedberg K, et al; CHARM Investigators and Committees. Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. Lancet Sep 6;362(9386): Supplemental Readings The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med Aug 1;325(5): Pfeffer MA, Swedberg K, Granger CB, et al; CHARM Investigators and Committees. Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme. Lancet Sep 6;362(9386): Konstam MA, Neaton JD, Dickstein K, et al; HEAAL Investigators. Effects of high-dose versus low-dose losartan on clinical outcomes in patients with heart failure (HEAAL study): a randomised, double-blind trial. Lancet Nov 28;374(9704): Packer M, Coats AJ, Fowler MB, et al; Carvedilol Prospective Randomized Cumulative Survival Study Group. Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med May 31;344(22):

11 Gattis WA, O'Connor CM, Gallup DS, Hasselblad V, Gheorghiade M; IMPACT-HF Investigators and Coordinators. Predischarge initiation of carvedilol in patients hospitalized for decompensated heart failure: results of the Initiation Management Predischarge: Process for Assessment of Carvedilol Therapy in Heart Failure (IMPACT-HF) trial. J Am Coll Cardiol May 5;43(9): Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med Sep 2;341(10): Juurlink DN, Mamdani MM, Lee DS, et al. Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. N Engl J Med Aug 5;351(6): Cleland JG, Tendera M, Adamus J, Freemantle N, Polonski L, Taylor J; PEP-CHF Investigators. The perindopril in elderly people with chronic heart failure (PEP-CHF) study. Eur Heart J Oct;27(19):

12 Week 4 Adjunct Therapies & Special Populations Required Readings Cohn JN, Archibald DG, Ziesche S, et al. Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. N Engl J Med Jun 12;314(24): Taylor AL, Ziesche S, Yancy C, et al; African-American Heart Failure Trial Investigators. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. Engl J Med Nov 11;351(20): Rathore SS, Curtis JP, Wang Y, Bristow MR, Krumholz HM. Association of serum digoxin concentration and outcomes in patients with heart failure. JAMA Feb 19;289(7): Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. RADIANCE Study. N Engl J Med Jul 1;329(1):1-7. Bardy GH, Lee KL, Mark DB, et al; Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med Jan 20;352(3): Cleland JG, Daubert JC, Erdmann E, et al; Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med Apr 14;352(15): Supplemental Readings Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F, et al. A comparison of enalapril with hydralazineisosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med Aug 1;325(5): Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med Feb 20;336(8): Ahmed A, Gambassi G, Weaver MT, Young JB, Wehrmacher WH, Rich MW. Effects of discontinuation of digoxin versus continuation at low serum digoxin concentrations in chronic heart failure. Am J Cardiol Jul 15;100(2): Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med Dec 26;335(26): Moss AJ, Zareba W, Hall WJ, et al; Multicenter Automatic Defibrillator Implantation Trial II Investigators. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med Mar 21;346(12): Bristow MR, Saxon LA, Boehmer J, et al; Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med May 20;350(21): Moss AJ, Hall WJ, Cannom DS, et al; MADIT-CRT Trial Investigators. Cardiac-resynchronization therapy for the prevention of heart-failure events. N Engl J Med Oct 1;361(14):

13 Week 5 Mechanical Circulatory Support & Cardiac Transplantation To be determined 13