scholarly journals Impact of Guideline-Based Medical Therapy on Malignant Arrhythmias and Mortality among Heart Failure Patients Implanted with Cardioverter Defibrillator (ICD) or Cardiac Resynchronization-Defibrillator device (CRTD)

2021 ◽  
Author(s):  
Tal Hasin ◽  
Ilya Davarashvili ◽  
Yoav Michowitz ◽  
Rivka Farkash ◽  
Haya Presman ◽  
...  
Keyword(s):  
Heart Failure ◽  
Medical Treatment ◽  
Beta Blockers ◽  
Real Life ◽  
Cardiac Resynchronization ◽  
Multivariable Model ◽  
Target Dose ◽  
Cardioverter Defibrillator ◽  
Treatment Medication ◽  
Overall Mortality

Aim: To evaluate prevalence of heart failure (HF) medical treatment and its impact on ventricular arrhythmia (VA) and survival among patients implanted with primary prevention ICD/CRTD. Methods and results: The association of treatment and dose (% guideline recommended target) of beta-blockers (BB), Angiotensin-antagonists (AngA), Mineralocorticoid-antagonsits (MRA), and Anti-Arrhythmic Drugs (AAD) after ICD/CRTD implant with VA episodes and mortality was analyzed. We included 186 patients, meanSD age 66.412 years, 15.1% female, 79(42.5%) implanted with an ICD and 107(57.5%) with CRTD. During 3.8 [2.1;6.7] (median[IQR]) years; 52(28%) had VA and 77(41.4%) died. Treatment (medication, % of patients) included: BB (83%), AngA (87%), MRA (59%), and AAD (43.5%). Median doses were 25[12.5;50]% of target for BB or AngA and 25[0;50]% of target for MRA. Treatment with >25% target dose of BB was associated with reduced incident VA. In a multivariable model including age, gender, diabetes, heart rate, and medication doses, increased BB dose was significantly and independently associated with reduced VA (HR 0.443 95%CI 0.222-0.885; p=0.021). On multivariable model for overall mortality including age, gender, renal disease, VA, and medical treatment; VA was associated with increased mortality (HR 2.672; 95% CI 1.429-4.999; p=0.002) and AngA treatment was significantly and independently associated with reduced mortality (HR 0.515; 95% CI 0.285-0.929; p=0.028). Conclusions: In this cohort of real-life HF patients discharged after ICD/CRTD implant, most of the patients were prescribed with guideline-based HF medications albeit with low doses. Higher BB dose was associated with reduced VA, while treatment with AngA was associated with improved survival.

scholarly journals Impact of guideline-based medical therapy on malignant arrhythmias and mortality among heart failure patients implanted with a primary prevention ICD/CRTD

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
M Rav Acha ◽  
R Farkash ◽  
I Davarashvili ◽  
M Glikson ◽  
T Hasin
Keyword(s):  
Heart Failure ◽  
Primary Prevention ◽  
Medical Treatment ◽  
Beta Blockers ◽  
Real Life ◽  
Multivariable Model ◽  
Target Dose ◽  
Funding Sources ◽  
Treatment Medication ◽  
Overall Mortality

Abstract Funding Acknowledgements Type of funding sources: None. Background In contrast with the well-established impact of heart failure (HF) medical treatment reducing HF hospitalizations and improving survival, its impact on ventricular arrhythmia (VA) is based mainly on circumstantial evidence. Aim To evaluate prevalence of HF medical treatment and its impact on VA and overall survival among HF patients implanted with primary prevention ICD/CRTD. Methods Single center retrospective analysis of all HF patients implanted with ICD/CRTD as primary prevention. Patients" indication for implant according to guidelines was confirmed by a senior EP physician. Thereafter, the association of HF medications and dose (% guideline recommended target dose) of beta-blockers (BB), Angiotensin-antagonists (AgA), Mineralocorticoid-antagonsits (MRA), and Anti-Arrhythmic Drugs (AAD) with VA episodes and overall mortality was analyzed, based on patients" medical records and device clinic regular interrogations. Results 186 HF patients qualifying for primary prevention ICD/CRTD implant according to HF and device guidelines, were included. Their mean ± SD age 66.4 ± 12 years, 15.1% female, 79 (42.5%) implanted with an ICD and 107 (57.5%) with CRTD. During 3.8 [2.1;6.7] (median[IQR]) years; 52 (28%) had VA and 77 (41.4%) died. Treatment (medication, % of patients) included: BB (83%), AgA (87%), MRA (59%), and AAD (43.5%). Doses were 25[12.5;50]% of target for BB or AgA and 25[0;50]% of target for MRA. Treatment with >25% target dose of BB was associated with significantly reduced VA incidence. In a multivariable model including age, gender, diabetes, heart rate, and medication doses, increased BB dose was significantly and independently associated with reduced VA (HR 0.443 95%CI 0.222-0.885; p = 0.021). Kapkan-Myer analysis for survival without VA according to each medication group dose, supported reduced VA among patients receiving > median dose of BB (Figure 1). Multivariable model for overall mortality including age, gender, renal disease, VA, and medical treatment; VA was associated with increased mortality (HR 2.672; 95% CI 1.429-4.999; p = 0.002) while AgA treatment was significantly and independently associated with reduced mortality (HR 0.515; 95% CI 0.285-0.929; p = 0.028). Conclusions In this cohort of real-life HF patients discharged after primary prevention ICD/CRTD implant, most of the patients were prescribed with guideline-based HF medications albeit with low doses. Higher BB dose was associated with reduced VA, while treatment with AgA was associated with improved survival. Abstract Figure. Survival without VA according to HF medi

scholarly journals Association of Guideline-Based Medical Therapy with Malignant Arrhythmias and Mortality among Heart Failure Patients Implanted with Cardioverter Defibrillator (ICD) or Cardiac Resynchronization-Defibrillator Device (CRTD)

2021 ◽  
Vol 10 (8) ◽  
pp. 1753
Author(s):  
Tal Hasin ◽  
Ilia Davarashvili ◽  
Yoav Michowitz ◽  
Rivka Farkash ◽  
Haya Presman ◽  
...  
Keyword(s):  
Heart Failure ◽  
Adrenergic Receptor ◽  
Real Life ◽  
Cardiac Resynchronization ◽  
Implantable Cardiac Defibrillator ◽  
Multivariable Model ◽  
Resynchronization Therapy ◽  
Target Dose ◽  
Mineralocorticoid Antagonists ◽  
Overall Mortality

Aim: Evaluate prevalence of heart failure (HF) medications and their association with ventricular arrhythmia (VA) and survival among patients implanted with primary prevention implantable cardiac defibrillator (ICD)/cardiac resynchronization therapy + defibrillator (CRTD) devices. Methods: Association of treatment and dose (% guideline recommended target) of beta-adrenergic receptor antagonist (BB), angiotensin-antagonists (AngA), and mineralocorticoid-antagonists (MRA), after ICD/CRTD implant with VA and mortality was retrospectively analyzed. Results: Study included 186 HF patients; 42.5% and 57.5% implanted with ICD and CRTD, respectively. During 3.8 (2.1;6.7) years; 52 (28%) had VA and 77 (41.4%) died. Treatment (% of patients) included: BB (83%), AngA (87%), and MRA (59%). Median doses were 25(12.5;50)% of target for all medications. BB treatment >25% target dose was associated with reduced VA incidence. In the multivariable model including age, gender, diabetes, heart rate, and medication doses, increased BB dose was associated with reduced VA (hazard ratio (HR) 0.443 95% CI 0.222–0.885; p = 0.021). In the multivariable model for overall mortality including age, gender, renal disease, VA, and medical treatment, VA was associated with increased mortality (HR 2.672; 95% CI 1.429–4.999; p = 0.002) and AngA treatment was associated with reduced mortality (HR 0.515; 95% CI 0.285–0.929; p = 0.028). Conclusions: In this cohort of real-life HF patients discharged after ICD/CRTD implant, prevalence of guideline-based HF medications was high, albeit with low doses. Higher BB dose was associated with reduced VA, while AngA was associated with improved survival.

scholarly journals Remote heart failure management using a multiparameter implantable cardioverter-defibrillator alert: the multicentric RE-HEART registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
J De Juan Baguda ◽  
J.J Gavira Gomez ◽  
M Pachon Iglesias ◽  
L Pena Conde ◽  
J.M Rubin Lopez ◽  
...  
Keyword(s):  
Heart Failure ◽  
Implantable Cardioverter Defibrillator ◽  
Median Duration ◽  
Office Visit ◽  
Active Phase ◽  
Cardiac Resynchronization ◽  
Office Visits ◽  
Icd Implantation ◽  
Cardioverter Defibrillator ◽  
Clinical Events

Abstract Background The HeartLogic algorithm combines multiple implantable cardioverter-defibrillator (ICD)-based sensors into an index for prediction of impending heart failure (HF) decompensation. In patients with ICD and cardiac resynchronization therapy ICD remotely monitored at 13 Spanish centers, we analyzed the association between clinical events and HeartLogic alerts and we described the use of the algorithm for the remote management of HF. Methods The association between clinical events and HeartLogic alerts was studied in the blinded phase (from ICD implantation to alert activation – no clinical actions taken in response to alerts) and in the following active phase (after alert activation – clinicians automatically notified in case of alert). Results We enrolled a total of 215 patients (67±13 years old, 77% male, 53% with ischemic cardiomyopathy) with ICD (19%) or CRT-D (81%). The median duration of the blinded phase was 8 [3–12] months. In this phase, the HeartLogic index crossed the threshold value (set by default to 16) 34 times in 20 patients. HeartLogic alerts were associated with 6 HF hospitalizations and 5 unplanned in-office visits for HF. Five additional HeartLogic threshold crossings were not associated with overt HF events, but occurred at the time of changes in drug therapy or of other clinical events. The rate of unexplained alerts was 0.25 alert-patient/year. The median time spent in alert was longer in the case of HF hospitalizations than of in-office visits (75 [min-max: 30–155] days versus 39 [min-max: 5–105] days). The maximum HeartLogic index value was 38±15 in the case of hospitalizations and 24±7 in that of minor HF events. The median duration of the following active phase was 5 [2–10] months. After HeartLogic activation, 40 alerts were reported in 26 patients. Twenty-seven (68%) alerts were associated with multiple HF- or non-HF related conditions or changes in prescribed HF therapy. Multiple actions were triggered by these alerts: HF hospitalization (4), unscheduled in-office visits (8), diuretics increase (8), change in other cardiovascular drugs (5), device reprogramming (2), atrial fibrillation ablation (1), patient education on therapy adherence (2). The rate of unexplained alerts not followed by any clinical action was 0.13 alert-patient/year. These alerts were managed remotely (device data review and phone contact), except for one alert that generated an unscheduled in-office visit. Conclusions HeartLogic index was frequently associated with HF-related clinical events. The activation of the associated alert allowed to remotely detect relevant clinical conditions and to implement clinical actions. The rate of unexplained alerts was low, and the work required in order to exclude any impending decompensation did not constitute a significant burden for the centers. Funding Acknowledgement Type of funding source: None

P3517Failure to achieve adequate heart rate control in women during therapy optimization

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
V Kutyifa ◽  
J W Erath ◽  
A Burch ◽  
B Assmus ◽  
D Bondermann ◽  
...  
Keyword(s):  
Heart Failure ◽  
Heart Rate ◽  
Beta Blocker ◽  
Rate Control ◽  
Beta Blockers ◽  
Heart Rate Control ◽  
Blocker Therapy ◽  
Cardioverter Defibrillator ◽  
Beta Blocker Therapy ◽  
The Mean

Abstract Background Previous studies highlighted the importance of adequate heart rate control in heart failure patients, and suggested under-treatment with beta-blockers especially in women. However, data on women achieving effective heart rate control during beta-blocker therapy optimization are lacking. Methods The wearable cardioverter defibrillator (WCD) allows continuous monitoring of heart rate (HR) trends during WCD use. In the current study, we assessed resting HR trends (nighttime: midnight-7am) in women, both at the beginning of WCD use and at the end of WCD use to assess the adequacy of beta-blockade following a typical 3 months of therapy optimization with beta-blockers. An adequate heart rate control was defined as having a nighttime HR <70 bpm at the end of the 3 months. Results There were a total of 21,453 women with at least 30 days of WCD use (>140 hours WCD use on the first and last week). The mean age was 67 years (IQR 58–75). The mean nighttime heart rate was 72 bpm (IQR 65–81) at the beginning of WCD use, that decreased to 68 bpm (IQR 61–76) at the end of WCD use with therapy optimization. Women had an insufficient heart rate control with resting heart rate ≥70 bpm in 59% at the beginning of WCD use that decreased to 44% at the end of WCD use, but still remained surprisingly high. Interestingly, there were 21% of the women starting with HR ≥70 bpm at the beginning of use (BOU) who achieved adequate heart rate control by the end of use (EOU). Interestingly, 6% of women with adequate heart rate control at the start of therapy optimization ended up having higher heart rates >70 bpm at the end of the therapy optimization time period (Figure). Figure 1 Conclusions A significant proportion of women with heart failure and low ejection fraction do not reach an adequate heart rate control during the time of beta blocker initiation/titration. The wearble cardioverter defibrillator is a monitoring device that has been demonstrated in this study to appropriately identify patients with inadequate heart rate control at the end of the therapy optimization period. The WCD could be utilized to improve management of beta-blocker therapy in women and improve the achievement of adequate heart rate control in women.

scholarly journals Outcomes of Cardiac Resynchronization Therapy in Patients with Hypothyroidism and Heart Failure

2020 ◽  
Author(s):  
MEI YANG ◽  
Xuping Li ◽  
John C. Morris III ◽  
Jinjun Liang ◽  
Abhishek J. Deshmukh ◽  
...  
Keyword(s):  
Heart Failure ◽  
Cardiac Resynchronization Therapy ◽  
Implantable Cardioverter Defibrillator ◽  
Hazard Ratio ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Therapy Outcomes ◽  
Implantable Cardioverter Defibrillator Therapy ◽  
Cardioverter Defibrillator ◽  
All Cause Mortality

Abstract Background Hypothyroidism is known to be associated with adverse clinical outcomes in heart failure. The association between hypothyroidism and cardiac resynchronization therapy outcomes in patients with severe heart failure is not clear. Methods The study included 1,316 patients who received cardiac resynchronization therapy between 2002 and 2015. Baseline demographics and cardiac resynchronization therapy outcomes, including left ventricular ejection fraction, New York Heart Association class, appropriate implantable cardioverter-defibrillator therapy, and all-cause mortality, were collected from the electronic health record. Results Of the study cohort, 350 patients (26.6%) were classified as the hypothyroidism group. The median duration of follow-up was 3.6 years (interquartile range, 1.7-6.2). Hypothyroidism was not associated with a higher risk of all-cause mortality in patients receiving CRT for heart failure. The risk of appropriate implantable cardioverter-defibrillator therapy significantly increased in association with increased baseline thyroid -stimulating hormone level in the entire cohort (hazard ratio, 1.23 per 5mIU/L increase; 95% CI, 1.01-1.5; P=0.04) as well as in the hypothyroid group (hazard ratio, 1.44 per 5mIU/L increase; 95% CI, 1.13-1.84; P=0.004). Conclusions CRT improves cardiac function in hypothyroid patients. The ventricular arrhythmic events requiring ICD therapies are associated with baseline TSH level, which might be considered as an important biomarker to stratify the risk of sudden death for patients with heart failure and hypothyroidism.

scholarly journals Underlying causes of under-utilization of cardiac resynchronization therapy in real-world heart failure settings

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
E Choha ◽  
J Henrysson ◽  
E Thunstrom ◽  
M Fu ◽  
C Basic
Keyword(s):  
Heart Failure ◽  
Heart Disease ◽  
Cardiac Resynchronization Therapy ◽  
Real World ◽  
Angiotensin Receptor Blockers ◽  
Real Life ◽  
University Hospital ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Underlying Causes

Abstract Background Despite well-established effectiveness of cardiac resynchronization therapy (CRT) in patients with heart failure (HF), it remained significantly under-utilized. The underlying causes are still not well described. Aim To investigate how many patients with HF were eligible for CRT and determine underlying causes why CRT was abstained for these patients in real life settings. Methods Retrospective review of medical data was carried out in all patients hospitalized for newly diagnosed HF from January 1, 2016 to December 31, 2019. Patients were identified from the local university hospital register with three afiliations by use of international classification of disease (ICD)-10 codes I50.0-I50.9. Medical journals, including electrocardiograms and echocardiograms, were reviewed. The indication for CRT was evaluated three months after mineralocorticoid receptor antagonists (MRA) were initiated as addition to angiotensin converting enzyme inhibitor /angiotensin-receptor blockers and beta-blocker treatment according to European guidelines for heart failure from 2016. Follow-up was minimum one year and up to two years after HF diagnosis. Results In 3456 patients with HF, 642 (18.6%) were patients hospitalized for new onset of HF with ejection fraction (EF) &lt;40%. Out of those, 104 (16.2%) patients were excluded because of incomplete medical record as a result of referral to primary care. Finally, 538 were included in this study. Overall, 163 patients (30.3%) met CRT criteria with 22.5%, 2.6%, 1.9% complying with recommendation IA, IIA, IIB respectively, and 3.9% had more than 50% right ventricular pacing. Only 52 (9.7%) of patients received CRT with mean age 69.3±11.5 years, and 69.2% men and EF 31.9% ± 7.6. In all these patients with HF eligible for CRT, no difference was found in baseline data including hypertension, ischemic heart disease, atrial fibrillation, valvular heart disease, diabetes mellitus, stroke, cancer and renal failure nor medical treatment between those received CRT and those without CRT. Among underlying causes of under-utilization of CRT, 24.3% were due to multiple concomitant comorbidities, 4.5% due to patient's own wish, 12.5% due to other reasons such as socioeconomic problems and 58.6% with unknown reasons. Mortality rates were 20.7% in patients without treatment with CRT compared with 7.7% in those who received CRT (p=0.037). Conclusion In this real world HF cohort, 1/3 patients were eligible for CRT treatment. However only 1/3 received CRT and 58.6% had no contraindication but did not receive CRT, which emphasize urgent need for structured implementation methods for device treatment in patients with HF. FUNDunding Acknowledgement Type of funding sources: None.

Abstract 17488: What Are the Gaps? A Qualitative Study on Patient and Family Decision Making Regarding Implantable Cardioverter Defibrillator and Cardiac Resynchronization Therapy

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Qi Zheng ◽  
Sarah Goodlin
Keyword(s):  
Heart Failure ◽  
Decision Making ◽  
Qualitative Study ◽  
Cardiac Resynchronization Therapy ◽  
Functional Status ◽  
Implantable Cardioverter Defibrillator ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Cardioverter Defibrillator ◽  
Life Style Changes

Background: Implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT-D) reduce mortality and improve functional status in selected patients with heart failure (HF). However, there are potential procedural risks and psychosocial concerns associated with device implant. This qualitative study aims to explore patients’ and families’ understanding of ICD/CRT-D, heart failure and arrhythmia in the process of decision making regarding device implant. Methods: We conducted 14 focus groups or interviews in Salt Lake City UT and Silver Spring MD. This study included 23 patients, who had either an ICD or CRT-D implant for primary prevention, and 14 family members. Grounded theory analysis was performed to reach a conceptual understanding of patients’ and families’ perceptions and needs. Results: Patients and families largely made decision of ICD/CRT implant based on physicians’ recommendations, e.g. “I really try to do what they tell me to do” (icdpt 1). Patients perceived ICD as lifesaving and CRT being helpful to improve functional status. Many patients described ICD as lifesaving by “restarting a heart if it stops”, while did not understand HF or ventricular arrhythmia. Patients perceived an urgency to consider ICD implant from their physicians, but no such urgency was perceived when they discussed about CRT-D implant. Few participants were concerned with costs, or had knowledge of potential lead malfunction, device removal and associated risks. Many emphasized the importance of information about life expectancies, what HF is, options of different devices, complications and precautions, and what to expect regarding lifestyle changes. Conclusion: Patients and families largely relied on the information provided by physicians and followed physicians’ guidance. They had limited understanding of their prognosis, HF and arrhythmia, and they were motivated to learn. Discussion about devices should include prognosis and healthy life style changes.

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