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)

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.

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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)

10.22541/au.161347884.43686236/v1 ◽

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.

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

EP Europace ◽

10.1093/europace/euab116.106 ◽

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

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

European Heart Journal ◽

10.1093/eurheartj/ehab724.0935 ◽

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) <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.

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P5680One-year outcomes of heart failure patients undergoing cardiac resynchronization therapy using adaptivCRT algorithm

European Heart Journal ◽

10.1093/eurheartj/ehz746.0622 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

S Briongos Figuero ◽

A Estevez ◽

M L Perez ◽

J B Martinez-Ferrer ◽

L Alvarez-Costa ◽

...

Keyword(s):

Heart Failure ◽

Cardiac Resynchronization Therapy ◽

Real Life ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Ventricular Pacing ◽

Class Iii ◽

Resynchronization Therapy ◽

Risk Of Death

Abstract Background Adaptive cardiac resynchronization therapy (aCRT) algorithm provides synchronized left ventricular (LV) only pacing and ambulatory optimization of the intrinsic atrioventricular and interventricular conduction intervals. Studies reporting morbidity and mortality outcomes of aCRT carriers in daily clinical practice are lacking. Purpose To determine in a real-life setting, whether 1-year outcomes were different among CRT carriers undergoing aCRT pacing and those under conventional biventricular (biV) pacing. Methods Symptomatic heart failure (HF) patients with sinus rhythm undergoing first CRT-defibrillator implant were selected from the UMBRELLA nationwide registry (2012–2017). The primary endpoint was the composite of all-cause mortality or HF hospitalization at 12-month follow-up. HF admission was defined as hospitalization due to symptoms requiring intravenous diuretic treatment. Primary healthcare records were used to prospectively collect all data. Results Two hundred and six patients were collected (66.1±8.7 years; 73.3% male). Eighty-seven out of 206 patients were implanted with an aCRT capable device, but this algorithm was activated at implant and remained enabled at 1-year in 59 patients (aCRT group). The other 147 patients composed the non-aCRT group. At implant left bundle branch block was present in 93% of patients, 69.6% of population was in functional class III or IV and mean left ventricle ejection fraction was of 26.5±5.6%. Non-ischemic cardiomyopathy was present in 63.1% of patients and optimal medical treatment was achieved in majority of population (92% of patients with beta-blockers; angiotensin-converting enzyme inhibitorsor angiotensin II receptor blockersin 89%). The percentage of ventricular pacing through 12 months was 96.1±9.4% in non-aCRT patients and 97.5±2.7% in aCRT patients (p=0.261). In aCRT patients, LV-only pacing accounted for a mean of 53.3±37.6% of all ventricular pacing. After 12-month follow-up period, 25 patients (12.1%) met the primary composite endpoint of death or HF hospitalization. Nine patients died and nineteen patients were admitted due to worsening HF. There was no difference in the risk of all-cause death or HF hospitalization between aCRT and non-aCRT patients (10.2% vs. 12.9% respectively; OR=0.76, CI: 0.29–2.01, p=0.585) Conclusions In this contemporary cohort of HF patients undergoing CRT with high percentages of ventricular pacing, clinical performance of aCRT algorithm was adequate. The risk of death or HF hospitalization was low and no differences were observed at one-year follow-up. Future randomized studies will clarify the role of this algorithm in CRT carriers. Acknowledgement/Funding None

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P1174Impact of sex-differences in long-term outcomes with cardiac resynchronization therapy: are women different?

EP Europace ◽

10.1093/europace/euaa162.365 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

Z L Moreno Weidmann ◽

C Alonso-Martin ◽

F Mendez-Zurita ◽

E Rodriguez-Font ◽

J Guerra-Ramos ◽

...

Keyword(s):

Heart Failure ◽

Cardiac Resynchronization Therapy ◽

Ischemic Cardiomyopathy ◽

Nyha Class ◽

Real Life ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Left Ventricular Ejection ◽

Resynchronization Therapy ◽

The Moment

Abstract Introduction Women are frequently underrepresented in clinical trials for heart failure. Differences on cardiovascular background may imply differences on indications, device election and outcomes in patients receiving cardiac devices (CRT and ICD). We sought to compare sex-related differences in a real-life cohort. Methods We analyzed all subjects who underwent a cardiac resynchronization therapy (CRT) implantation (with or without ICD) between 2016 and 2019 in a single center, all of them followed by remote monitoring. Baseline characteristics and outcomes were compared according to gender. Response to resynchronization was defined as clinical improvement in NYHA class or an increase of > =10% in LVEF. Results A total of 430 devices (ICD or CRT) were implanted. 149 (35%) of them were CRTs: 116 (88%) CRT-D and 33 (22%) CRT-P. Of the whole cohort, 43 (29%) were women and the mean age was similar in both sex (70+/-9 years). Women had more likely non-ischemic cardiomyopathy (86% vs 49%, p < 0.01), higher proportion of NYHA class III-IV (26% vs 40%, p 0.04) and worse renal function (mean glomerular filtration 61ml/min vs 75ml/min, p 0.04), but tend to be less affected by atrial fibrillation (21% vs 40%, p 0.05). Left ventricular ejection fraction was similar at the moment of implantation among both sex (30+/-7%, p > 0.05) and no difference on optimal medical treatment was observed. Women trend to receive more frequently CRT-P than men (33% vs 18%, p 0.054). After a mean follow-up of 3 years, a four-fold higher response to CRT was observed in women (OR 4.0, 95% CI 2.0-10.7, p 0.002), after adjustment by the etiology of the myocardiopathy. No differences on all-cause mortality (6% in men vs 1% in women, p 0.2) or ventricular arrhythmias (10% in men vs 2% in women, p 0.3) were observed. Conclusions in a real-life cohort, CRT implantation showed a sex-disparity: the proportion of women receiving a CRT was lower than in men, but a CRT without defibrillation was more frequently implanted in women, reflecting a higher prevalence of ischemic cardiomyopathy in men. The underlying myocardial substrate in women and a lower prevalence of AF may explain a more favorable response to CRT, despite more pronounced symptoms of heart failure at the moment of implantation.

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Cardiac resynchronization therapy outcomes in patients with chronic heart failure and comorbidity

In a good rythm ◽

10.5604/01.3001.0013.7380 ◽

2019 ◽

Vol 3 (52) ◽

pp. 7-11

Author(s):

Jędrzej Michalik ◽

Marek Szołkiewicz

Keyword(s):

Quality Of Life ◽

Heart Failure ◽

Chronic Heart Failure ◽

Cardiac Resynchronization ◽

Resynchronization Therapy ◽

Therapy Outcomes ◽

Current Opinion ◽

Clinical Cardiology ◽

Overall Mortality

Chronic heart failure (CHF) is currently the most biggest problem of clinical cardiology. It occurs in isolation rather rarely; it is usually accompanied by multiple comorbidities that affect the treatment outcomes. Some methods of cardiac electrotherapy are used in the treatment of patients with CHF, especially resynchronization therapy (CRT), because they efficiently improve a quality of life and reduce overall mortality. However, there are doubts if the cardiac electrotherapy methods are equally effective in patients with the widespread multiple comorbidity. In this review, we present current opinion on the legitimacy for CRT use in patients with CHF and multimorbidity burden.

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