Assessing automated external defibrillators in preventing deaths from sudden cardiac arrest: An economic evaluation

2007 ◽  
Vol 23 (3) ◽  
pp. 362-367 ◽  
Author(s):  
Waseem Sharieff ◽  
Kellee Kaulback
Keyword(s):  
Cardiac Arrest ◽  
Cost Effectiveness ◽  
High Risk ◽  
Effective Means ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Automated External Defibrillators ◽  
High Risk Patients ◽  
Risk Patients

Objectives:The aim of this study was to evaluate the cost-effectiveness of on-site automated external defibrillators (AEDs) in the initial management of cardiac arrest in Ontario.Methods:This was a cost-effectiveness analysis based on published literature and data from the Canadian Institute of Health Information. The participants were fictitious male and female cardiac arrest patients who were initially managed with on-site AEDs, compared with similar patients managed without on-site AEDs. This group included a subgroup of high-risk patients (i.e., heart failure and left ventricular ejection fraction <35 percent). The analysis was conducted in a variety of settings including hospitals and homes in Ontario, Canada. The main outcome evaluated was cost per quality-adjusted life-year (QALY) gained from a payer's perspective.Results:Cost per QALY (all costs reported in Canadian dollars) was $12,768 when AEDs were deployed in hospitals, $511,766 when deployed in office buildings, $2,360,023 when deployed in apartment buildings, $87,569 when deployed in homes of high-risk patients, and $1,529,371 when deployed in homes of people older than 55 years of age.Conclusions:Indiscriminate deployment of AEDs is not a cost-effective means of improving health outcomes of cardiac arrest. Their use should be restricted to emergency response programs, high-risk sites (such as hospitals), and high-risk patients.

scholarly journals CMR feature tracking remote myocardial strain analyses for optimized risk prediction following acute myocardial infarction

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
T Lange ◽  
T Stiermaier ◽  
SJ Backhaus ◽  
P Boom ◽  
JT Kowallick ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
High Risk ◽  
Feature Tracking ◽  
Circumferential Strain ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
High Risk Patients ◽  
Risk Patients

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiac magnetic resonance myocardial feature tracking (CMR-FT) derived global strain assessments provide incremental prognostic information in patients following acute myocardial infarction (AMI). Functional analyses of the remote myocardium (RM) are scarce and whether they provide an additional prognostic value in these patients is unknown. Methods 1052 patients following acute myocardial infarction were included. CMR imaging and strain analyses as well as scar size quantification were performed after reperfusion by primary percutaneous coronary intervention. The occurrence of major adverse cardiac events (MACE) within 12 months after the index event was defined as primary clinical endpoint. Results Patients with MACE had significantly lower RM circumferential strain (CS) compared to those without MACE. A cut-off value for RM CS of -25.8% best identified high-risk patients (p &lt; 0.001 on log-rank testing) and impaired RM CS was a strong predictor of MACE (HR 1.05, 95% CI 1.07-1.14, p = 0.003). RM CS provided further risk stratification amongst patients considered at risk according to established CMR parameters for 1.) patients with reduced left ventricular ejection fraction (LVEF) ≤ 35 % (p = 0.002 on log-rank testing), 2.) patients with reduced global circumferential strain (GCS) &gt; -18,3 % (p = 0.015 on log-rank testing), and 3.) patients with large microvascular obstruction ≥ 1.46 % (p = 0.038 on log-rank testing). Conclusion CMR-FT derived RM CS is a useful parameter to characterize the response of RM and allows improved stratification following AMI beyond commonly used parameters, especially of high-risk patients.

scholarly journals Functional and prognostic implications of cardiac magnetic resonance feature tracking-derived remote myocardial strain analyses in patients following acute myocardial infarction

2020 ◽  
Author(s):  
Torben Lange ◽  
Thomas Stiermaier ◽  
Sören J. Backhaus ◽  
Patricia C. Boom ◽  
Johannes T. Kowallick ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
High Risk ◽  
Circumferential Strain ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Cardiac Events ◽  
Ventricular Ejection Fraction ◽  
High Risk Patients ◽  
Risk Patients

Abstract Background Cardiac magnetic resonance myocardial feature tracking (CMR-FT)-derived global strain assessments provide incremental prognostic information in patients following acute myocardial infarction (AMI). Functional analyses of the remote myocardium (RM) are scarce and whether they provide an additional prognostic value in these patients is unknown. Methods 1034 patients following acute myocardial infarction were included. CMR imaging and strain analyses as well as infarct size quantification were performed after reperfusion by primary percutaneous coronary intervention. The occurrence of major adverse cardiac events (MACE) within 12 months after the index event was defined as primary clinical endpoint. Results Patients with MACE had significantly lower RM circumferential strain (CS) compared to those without MACE. A cutoff value for RM CS of − 25.8% best identified high-risk patients (p < 0.001 on log-rank testing) and impaired RM CS was a strong predictor of MACE (HR 1.05, 95% CI 1.07–1.14, p = 0.003). RM CS provided further risk stratification among patients considered at risk according to established CMR parameters for (1) patients with reduced left ventricular ejection fraction (LVEF) ≤ 35% (p = 0.038 on log-rank testing), (2) patients with reduced global circumferential strain (GCS) > −  18.3% (p = 0.015 on log-rank testing), and (3) patients with large microvascular obstruction ≥ 1.46% (p = 0.002 on log-rank testing). Conclusion CMR-FT-derived RM CS is a useful parameter to characterize the response of the remote myocardium and allows improved stratification following AMI beyond commonly used parameters, especially of high-risk patients. Trial registration ClinicalTrials.gov, NCT00712101 and NCT01612312 Graphic abstract Defining remote segments (R) in the presence of infarct areas (I) for the analysis of remote circumferential strain (CS). Remote CS was significantly lower in patients who suffered major adverse cardiac events (MACE) and a cutoff value for remote CS of − 25.8% best identified high-risk patients. In addition, impaired remote CS ≥ − 25.8 % (Remote −) and preserved remote CS < − 25.8 % (Remote +) enabled further risk stratification when added to established parameters like left ventricular ejection fraction (LVEF), global circumferential strain (GCS) or microvascular obstruction (MVO).

scholarly journals Echocardiography and EuroSCORE II for the stratification of low-gradient severe aortic stenosis and preserved left ventricular ejection fraction

2021 ◽  
Author(s):  
Yan Fan ◽  
Hong Shen ◽  
Brandon Stacey ◽  
David Zhao ◽  
Robert J. Applegate ◽  
...  
Keyword(s):  
High Risk ◽  
Left Ventricular Ejection Fraction ◽  
Risk Group ◽  
Severe Aortic Stenosis ◽  
Left Ventricular ◽  
High Risk Group ◽  
Low Risk ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Risk Patients

AbstractThe purpose of this study was to explore the utility of echocardiography and the EuroSCORE II in stratifying patients with low-gradient severe aortic stenosis (LG SAS) and preserved left ventricular ejection fraction (LVEF ≥ 50%) with or without aortic valve intervention (AVI). The study included 323 patients with LG SAS (aortic valve area ≤ 1.0 cm2 and mean pressure gradient < 40 mmHg). Patients were divided into two groups: a high-risk group (EuroSCORE II ≥ 4%, n = 115) and a low-risk group (EuroSCORE II < 4%, n = 208). Echocardiographic and clinical characteristics were analyzed. All-cause mortality was used as a clinical outcome during mean follow-up of 2 ± 1.3 years. Two-year cumulative survival was significantly lower in the high-risk group than the low-risk patients (62.3% vs. 81.7%, p = 0.001). AVI tended to reduce mortality in the high-risk patients (70% vs. 59%; p = 0.065). It did not significantly reduce mortality in the low-risk patients (82.8% with AVI vs. 81.2%, p = 0.68). Multivariable analysis identified heart failure, renal dysfunction and stroke volume index (SVi) as independent predictors for mortality. The study suggested that individualization of AVI based on risk stratification could be considered in a patient with LG SAS and preserved LVEF.

Anthracycline cardiotoxicity: an update on mechanisms, monitoring and prevention

Heart ◽  
2017 ◽  
Vol 104 (12) ◽  
pp. 971-977 ◽  
Author(s):  
Peter A Henriksen
Keyword(s):  
Heart Failure ◽  
High Risk ◽  
Left Ventricular Dysfunction ◽  
Ventricular Dysfunction ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Anthracycline Cardiotoxicity ◽  
High Risk Patients ◽  
Risk Patients ◽  
Clinical Heart Failure

Anthracycline chemotherapy causes dose-related cardiomyocyte injury and death leading to left ventricular dysfunction. Clinical heart failure may ensue in up to 5% of high-risk patients. Improved cancer survival together with better awareness of the late effects of cardiotoxicity has led to growing recognition of the need for surveillance of anthracycline-treated cancer survivors with early intervention to treat or prevent heart failure. The main mechanism of anthracycline cardiotoxicity is now thought to be through inhibition of topoisomerase 2β resulting in activation of cell death pathways and inhibition of mitochondrial biogenesis. In addition to cumulative anthracycline dose, age and pre-existing cardiac disease are risk markers for cardiotoxicity. Genetic susceptibility factors will help identify susceptible patients in the future. Cardiac imaging with echocardiographic measurement of global longitudinal strain and cardiac troponin detect early myocardial injury prior to the development of left ventricular dysfunction. There is no consensus on how best to monitor anthracycline cardiotoxicity although guidelines advocate quantification of left ventricular ejection fraction before and after chemotherapy with additional scanning being justified in high-risk patients. Patients developing significant left ventricular dysfunction with or without clinical heart failure should be treated according to established guidelines. Liposomal encapsulation reduces anthracycline cardiotoxicity. Dexrazoxane administration with anthracycline interferes with binding to topoisomerase 2β and reduces both cardiotoxicity and subsequent heart failure in high-risk patients. Angiotensin inhibition and β-blockade are also protective and appear to prevent the development of left ventricular dysfunction when given prior or during chemotherapy in patients exhibiting early signs of cardiotoxicity.

MitraClip for High-Risk Patients with Significant Mitral Insufficiency: Shall We Unreservedly Recommend It?

2017 ◽  
Vol 66 (07) ◽  
pp. 537-544 ◽  
Author(s):  
Thomas Claus ◽  
Martin Hartrumpf ◽  
Ralf Kuehnel ◽  
Christian Braun ◽  
Christian Butter ◽  
...  
Keyword(s):  
High Risk ◽  
Mitral Valve ◽  
Left Ventricular ◽  
Wilcoxon Test ◽  
Left Ventricular Ejection ◽  
Matched Pair ◽  
Mitral Insufficiency ◽  
Technical Failure ◽  
High Risk Patients ◽  
Risk Patients

Background MitraClip (Abbott Inc.) is propagated as a palliative option for high-risk patients with mitral insufficiency considered not qualifying for surgical repair. A proportion of patients requires consecutive surgery because of technical failure or inappropriate clinical improvement. Furthermore, surgical reconstruction is impossible in almost all patients after MitraClip implantation. Consequently, these patients receive replacement although primary repair may have been possible. The outcome of those patients compared with patients receiving primary mitral valve replacement (MVR) or mitral valve repair (MVP) was analyzed. Methods A total of 23 patients were retrospectively analyzed after MVR following MitraClip. Overall, 46 patients with corresponding demographic data and risk profile receiving primary MVR (23 patients) or MVP (23 patients) were retrieved for matched pair analysis. Results Mean age was 70 years in all groups, log European system for cardiac operative risk evaluation (EuroSCORE) was 22.47% ± 16.30 in MVR after MitraClip (MC), 22.34% ± 16.23 in MVP, and 22.33% ± 16.14 in MVR group. Preoperative left ventricular ejection fraction (LVEF) was 44%, and postoperative LVEF was 48% in all groups. The 30-day mortality was 21.7% in the MitraClip group whereas it was 4.3% in the MVR and 13.0% in the MVP group. The 1-year survival was 56.5% in the MitraClip group while it was 95.6% in the MVR group and 82.6% in the MVP group (Wilcoxon test: p = 0.007; chi-square test: p = 0.001 MitraClip vs. MVR; p = 0.054 MitraClip vs. MVP). Conclusions Patients requiring surgical MVR after the previous MitraClip fared worse than matched cohorts receiving primary MVR or MVP. Indication for MitraClip should, therefore, be made very cautiously given the excellent results gained with primary surgery.

Long term survival in high-risk patients after percutaneous mitral leaflet repair in a single centre: comparable mortality regardless of aetiology

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
L Connolly ◽  
P Rajani ◽  
B M-Labbe ◽  
A Davies ◽  
A Duncan ◽  
...  
Keyword(s):  
High Risk ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Mitral Leaflet ◽  
Single Centre ◽  
High Risk Patients ◽  
Risk Patients ◽  
Baseline Characteristics

Abstract Background Percutaneous mitral leaflet repair (PMVR) is a safe and effective alternative to conventional surgery in high-risk patients with both degenerative (DMR) and functional (FMR) mitral regurgitation. We present an analysis of a large cohort of consecutive patients treated with PMVR at a high-volume UK centre. Purpose We sought to analyse the outcomes of a group of patients undergoing PMVR over a 7-year period at a single centre, where surgery had been excluded. We hypothesised that the long-term mortality in this group would be high and would differ depending on the aetiology of MR. Methods We identified 246 consecutive patients over the duration of the PMVR programme, where follow up and pre-procedural data were available. We collected baseline characteristics including age at procedure, left ventricular ejection fraction (LVEF), left ventricular indexed diastolic volumes (LVEDVi) and aetiology of MR. Post procedural data included MR at end of procedure, all-cause mortality and duration of follow up. Results Baseline characteristics for the group, as a whole, were as follows: mean age 76±11 years, 170 (69%) male, DMR 136 (55%) vs. FMR 110 (45%), LVEF 49±15%. Baseline data by aetiology subgroup: mean age DMR 80±9 vs. FMR 71±11 (p&lt;0.001), LVEF DMR 58±10 vs. FMR 40±14 (p&lt;0.001), LVEDVi DMR 71±25 FMR 85±25 (p&lt;0.001). 99% of patients were treated with the MitraClip® device (Abbott, US), 1% received the Pascal device (Edwards, US). Post-procedural MR grade was similar for both groups (DMR 1.5±0.8 vs. 1.4±0.8, p=NS). Overall procedural mortality was 0.4% and at a mean follow up of 1097 days (median 1021, IQR 289–1555) was 30.8%. Mortality was identical regardless of aetiology (DMR 30.9% vs. FMR 30.8%, p=NS). Conclusions This analysis of consecutive “real world” patients demonstrates encouraging survival outcome at a mean of 3 years after PMVR, regardless of MR aetiology. DMR patients tended to be older but with lower LVEDVi and significantly higher LVEF. These data compare favourably with the published literature, where mortality for mixed and similarly high-risk populations at 12 months averages approximately 20–25%. Mortality in our FMR group at 3 years was also similar to that seen in the recently published COAPT study at 2 years. We have demonstrated that PMVR is a safe option for our cohort of unselected high-risk patients presenting with either degenerative or functional MR. We hypothesise that the absence of survival difference could relate to the younger age of FMR patients despite the significantly lower baseline LVEF and higher ventricular volumes. This analysis encourages the more routine use of PMVR for FMR in the UK, where currently only DMR is commissioned. Funding Acknowledgement Type of funding source: None

scholarly journals Updating the Risk Stratification for Sudden Cardiac Death in Cardiomyopathies: The Evolving Role of Cardiac Magnetic Resonance Imaging. An Approach for the Electrophysiologist

Diagnostics ◽  
2020 ◽  
Vol 10 (8) ◽  
pp. 541 ◽  
Author(s):  
Ourania Kariki ◽  
Christos-Konstantinos Antoniou ◽  
Sophie Mavrogeni ◽  
Konstantinos A. Gatzoulis
Keyword(s):  
Cardiac Magnetic Resonance ◽  
High Risk ◽  
Sudden Cardiac Death ◽  
Magnetic Resonance ◽  
Cardiac Death ◽  
Ventricular Arrhythmias ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
High Risk Patients ◽  
Risk Patients

The prevention of sudden cardiac death (SCD) in cardiomyopathies (CM) remains a challenge. The current guidelines still favor the implantation of devices for the primary prevention of SCD only in patients with severely reduced left ventricular ejection fraction (LVEF) and heart failure (HF) symptoms. The implantation of an implantable cardioverter-defibrillator (ICD) is a protective barrier against arrhythmic events in CMs, but the benefit does not outweigh the cost in low risk patients. The identification of high risk patients is the key to an individualized prevention strategy. Cardiac magnetic resonance (CMR) provides reliable and reproducible information about biventricular function and tissue characterization. Furthermore, late gadolinium enhancement (LGE) quantification and pattern of distribution, as well as abnormal T1 mapping and extracellular volume (ECV), representing indices of diffuse fibrosis, can enhance our ability to detect high risk patients. CMR can also complement electro-anatomical mapping (EAM), a technique already applied in the risk evaluation and in the ventricular arrhythmias ablation therapy of CM patients, providing a more accurate assessment of fibrosis and arrhythmic corridors. As a result, CMR provides a new insight into the pathological substrate of CM. CMR may help identify high risk CM patients and, combined with EAM, can provide an integrated evaluation of scar and arrhythmic corridors in the ablative therapy of ventricular arrhythmias.

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