RESUMEN
BACKGROUND: Data on the benefits of cardiac resynchronization therapy (CRT) in patients with severe heart failure symptoms are limited. We investigated the relative effects of CRT in patients with ambulatory New York Heart Association (NYHA) IV versus III functional class at the time of device implantation. METHODS AND RESULTS: In this meta-analysis, we pooled patient-level data from the MIRACLE (Multicenter InSync Randomized Clinical Evaluation), MIRACLE-ICD (Multicenter InSync Implantable Cardioversion Defibrillation Randomized Clinical Evaluation), and COMPANION (Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure) trials. Outcomes evaluated were time to the composite end point of the first heart failure hospitalization or all-cause mortality, and time to all-cause mortality alone. The association between CRT and outcomes was evaluated using a Bayesian hierarchical Weibull survival regression model. We assessed if this association differed between NYHA III and IV groups by adding an interaction term between CRT and NYHA class as a random effect. A sensitivity analysis was performed by including data from RAFT (Resynchronization-Defibrillation for Ambulatory Heart Failure). Our pooled analysis included 2309 patients. Overall, CRT was associated with a longer time to heart failure hospitalization or all-cause mortality (adjusted hazard ratio [aHR], 0.79 [95% credible interval [CI], 0.64-0.99]; posterior probability or P=0.044), with a similar association with time to all-cause mortality (aHR, 0.78 [95% CI, 0.59-1.03]; P=0.083). Associations of CRT with outcomes were not significantly different for those in NYHA III and IV classes (ratio of aHR, 0.72 [95% CI, 0.30-1.27]; P=0.23 for heart failure hospitalization/mortality; ratio of aHR, 0.70 [95% CI, 0.35-1.34]; P=0.27 for all-cause mortality alone). The sensitivity analysis, including RAFT data, did not show a significant relative CRT benefit between NYHA III and IV classes. CONCLUSIONS: Overall, there was no significant difference in the association of CRT with either outcome for patients in NYHA functional class III compared with functional class IV.
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Terapia de Resincronización Cardíaca , Insuficiencia Cardíaca , Humanos , Terapia de Resincronización Cardíaca/mortalidad , Insuficiencia Cardíaca/terapia , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/diagnóstico , Resultado del Tratamiento , Hospitalización/estadística & datos numéricos , Ensayos Clínicos Controlados Aleatorios como Asunto , Femenino , Anciano , Factores de Riesgo , Factores de Tiempo , Masculino , Cardioversión Eléctrica/mortalidad , Cardioversión Eléctrica/instrumentación , Cardioversión Eléctrica/efectos adversos , Índice de Severidad de la Enfermedad , Persona de Mediana Edad , Teorema de BayesRESUMEN
BACKGROUND: Shock-reduction implantable cardioverter-defibrillator programming (SRP) was associated with fewer therapies and improved survival in randomized controlled trials, but real-world studies investigating SRP and associated outcomes are limited. METHODS AND RESULTS: The BIOTRONIK CERTITUDE registry was linked with the Medicare database. We included all patients with an implantable cardioverter-defibrillator implanted between August 22, 2012 and September 30, 2021 in the United States. SRP was defined as programming to either a therapy rate cutoff ≥188 beats per minute or number of intervals to detection ≥30/40 for treatment. Among 6781 patients (mean 74±9 years; 27% women), 3393 (50%) had SRP. Older age, secondary prevention indication, and device implantation in the southern or western United States were associated with lower use of SRP. The cumulative incidence rate of implantable cardioverter-defibrillator shocks was lower in the SRP group (5.1% shocks/patient year) compared with the non-SRP group (7.2% shocks/patient year) (adjusted hazard ratio [HR], 0.83 [95% CI, 0.73-0.96]; P=0.005). Over a median follow-up of 2.9 years, 739 deaths occurred in the SRP group and 822 deaths occurred in the non-SRP group (adjusted HR, 0.97 [95% CI, 0.88-1.07]; P=0.569). SRP was associated with a lower all-cause mortality among patients without ischemic heart disease compared with patients with ischemic heart disease (adjusted HR, 0.64 [95% CI, 0.48-0.87] versus adjusted HR, 1.02 [95% CI, 0.92-1.14]; Pinteraction=0.004). CONCLUSIONS: Adoption of SRP is low in real-world clinical practice. Age, clinical variables, and geographic factors are associated with use of SRP. In this study, SRP-associated decrease in mortality was limited to patients without ischemic heart disease.
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Muerte Súbita Cardíaca , Desfibriladores Implantables , Cardioversión Eléctrica , Sistema de Registros , Humanos , Femenino , Anciano , Masculino , Estados Unidos/epidemiología , Cardioversión Eléctrica/instrumentación , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/mortalidad , Anciano de 80 o más Años , Muerte Súbita Cardíaca/prevención & control , Muerte Súbita Cardíaca/epidemiología , Prevención Secundaria/métodos , Factores de Riesgo , Resultado del Tratamiento , Medicare , Factores de Tiempo , Medición de RiesgoRESUMEN
AIMS: Previous studies have indicated a poorer survival among women following out-of-hospital cardiac arrest (OHCA), but the mechanisms explaining this difference remain largely uncertain.This study aimed to assess the survival after OHCA among women and men and explore the role of potential mediators, such as resuscitation characteristics, prior comorbidity, and socioeconomic factors. METHODS AND RESULTS: This was a population-based cohort study including emergency medical service-treated OHCA reported to the Swedish Registry for Cardiopulmonary Resuscitation in 2010-2020, linked to nationwide Swedish healthcare registries. The relative risks (RR) of 30-day survival were compared among women and men, and a mediation analysis was performed to investigate the importance of potential mediators. Total of 43 226 OHCAs were included, of which 14 249 (33.0%) were women. Women were older and had a lower proportion of shockable initial rhythm. The crude 30-day survival among women was 6.2% compared to 10.7% for men [RR 0.58, 95% confidence interval (CI) = 0.54-0.62]. Stepwise adjustment for shockable initial rhythm attenuated the association to RR 0.85 (95% CI = 0.79-0.91). Further adjustments for age and resuscitation factors attenuated the survival difference to null (RR 0.98; 95% CI = 0.92-1.05). Mediation analysis showed that shockable initial rhythm explained â¼50% of the negative association of female sex on survival. Older age and lower disposable income were the second and third most important variables, respectively. CONCLUSION: Women have a lower crude 30-day survival following OHCA compared to men. The poor prognosis is largely explained by a lower proportion of shockable initial rhythm, older age at presentation, and lower income.
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Reanimación Cardiopulmonar , Análisis de Mediación , Paro Cardíaco Extrahospitalario , Sistema de Registros , Humanos , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Femenino , Masculino , Suecia/epidemiología , Anciano , Factores Sexuales , Persona de Mediana Edad , Reanimación Cardiopulmonar/estadística & datos numéricos , Anciano de 80 o más Años , Tasa de Supervivencia , Factores de Riesgo , Servicios Médicos de Urgencia/estadística & datos numéricos , Factores Socioeconómicos , Cardioversión Eléctrica/instrumentación , Cardioversión Eléctrica/mortalidadRESUMEN
BACKGROUND: This study aimed to investigate the association between the temporal transitions in heart rhythms during cardiopulmonary resuscitation (CPR) and outcomes after out-of-hospital cardiac arrest. METHODS: This was an analysis of the prospectively collected databases in 3 academic hospitals in northern and central Taiwan. Adult patients with out-of-hospital cardiac arrest transported by emergency medical service between 2015 and 2022 were included. Favorable neurological recovery and survival to hospital discharge were the primary and secondary outcomes, respectively. Time-specific heart rhythm shockability was defined as the probability of shockable rhythms at a particular time point during CPR. The temporal changes in the time-specific heart rhythm shockability were calculated by group-based trajectory modeling. Multivariable logistic regression analyses were performed to examine the association between the trajectory group and outcomes. Subgroup analyses examined the effects of extracorporeal CPR in different trajectories. RESULTS: The study comprised 2118 patients. The median patient age was 69.1 years, and 1376 (65.0%) patients were male. Three distinct trajectories were identified: high-shockability (52 patients; 2.5%), intermediate-shockability (262 patients; 12.4%), and low-shockability (1804 patients; 85.2%) trajectories. The median proportion of shockable rhythms over the course of CPR for the 3 trajectories was 81.7% (interquartile range, 73.2%-100.0%), 26.7% (interquartile range, 16.7%-37.5%), and 0% (interquartile range, 0%-0%), respectively. The multivariable analysis indicated both intermediate- and high-shockability trajectories were associated with favorable neurological recovery (intermediate-shockability: adjusted odds ratio [aOR], 4.98 [95% CI, 2.34-10.59]; high-shockability: aOR, 5.40 [95% CI, 2.03-14.32]) and survival (intermediate-shockability: aOR, 2.46 [95% CI, 1.44-4.18]; high-shockability: aOR, 2.76 [95% CI, 1.20-6.38]). The subgroup analysis further indicated extracorporeal CPR was significantly associated with favorable neurological outcomes (aOR, 4.06 [95% CI, 1.11-14.81]) only in the intermediate-shockability trajectory. CONCLUSIONS: Heart rhythm shockability trajectories were associated with out-of-hospital cardiac arrest outcomes, which may be a supplementary factor in guiding the allocation of medical resources, such as extracorporeal CPR.
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Reanimación Cardiopulmonar , Bases de Datos Factuales , Cardioversión Eléctrica , Paro Cardíaco Extrahospitalario , Recuperación de la Función , Humanos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/diagnóstico , Paro Cardíaco Extrahospitalario/fisiopatología , Masculino , Anciano , Femenino , Reanimación Cardiopulmonar/mortalidad , Estudios Retrospectivos , Persona de Mediana Edad , Cardioversión Eléctrica/instrumentación , Cardioversión Eléctrica/mortalidad , Cardioversión Eléctrica/efectos adversos , Resultado del Tratamiento , Factores de Tiempo , Taiwán/epidemiología , Factores de Riesgo , Anciano de 80 o más Años , Frecuencia Cardíaca , Medición de Riesgo , Oxigenación por Membrana Extracorpórea/mortalidad , Oxigenación por Membrana Extracorpórea/efectos adversosRESUMEN
INTRODUCTION: Heart failure patients with a history of atrial fibrillation (AF) and ventricular tachycardia/ventricular fibrillation (VT/VF) are known to have worse outcomes. However, there are limited data on the temporal relationship between development of these arrhythmias and the risk of subsequent congestive heart failure (CHF) exacerbation and death. METHODS: The study cohort comprised 5511 patients implanted with an implantable cardioverter-defibrillator (ICD) in landmark clinical trials (MADIT-II, MADIT-RISK, MADIT-CRT, MADIT-RIT, and RAID) who were in sinus rhythm at enrollment. Multivariate cox analysis was performed to evaluate the time-dependent association between development of in-trial device detected AF and VT/VF with subsequent CHF exacerbation and death. RESULTS: Multivariate analysis showed that AF occurrence and VT/VF occurrence were both associated with a similar magnitude of risk for subsequent CHF exacerbation (HR = 1.73 and 1.87 respectively, p < .001 for both). In contrast, only in-trial VT/VF was associated with a significant > two-fold increase in the risk of subsequent mortality (HR = 2.13, p < .001) whereas AF occurrence was not associated with a significant mortality increase after adjustment for in-trial VT/VF (HR = 1.36, p = .096). CONCLUSION: Our findings from a large cohort of ICD recipients enrolled in landmark clinical trials show that device detected AF and VT/VF can be used to identify patients with increased risk for CHF exacerbation and mortality. These findings suggest a need for early intervention in CHF patients who develop device-detected atrial and ventricular tachyarrhythmias.
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Fibrilación Atrial , Desfibriladores Implantables , Insuficiencia Cardíaca , Taquicardia Ventricular , Humanos , Masculino , Femenino , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatología , Taquicardia Ventricular/mortalidad , Taquicardia Ventricular/terapia , Taquicardia Ventricular/etiología , Anciano , Persona de Mediana Edad , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/terapia , Fibrilación Atrial/mortalidad , Factores de Riesgo , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/terapia , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Fibrilación Ventricular/diagnóstico , Fibrilación Ventricular/mortalidad , Fibrilación Ventricular/fisiopatología , Fibrilación Ventricular/terapia , Fibrilación Ventricular/etiología , Factores de Tiempo , Medición de Riesgo , Cardioversión Eléctrica/instrumentación , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/mortalidad , Resultado del TratamientoRESUMEN
AIMS: Primary prevention patients with ischaemic cardiomyopathy and chronic total occlusion of an infarct-related coronary artery (CTO) are at a particularly high risk of implantable cardioverter-defibrillator (ICD) therapy occurrence. The trial was designed to evaluate the efficacy of preventive CTO-related substrate ablation strategy in ischaemic cardiomyopathy patients undergoing primary prevention ICD implantation. METHODS AND RESULTS: The PREVENTIVE VT study was a prospective, multicentre, randomized trial including ischaemic patients with ejection fraction ≤40%, no documented ventricular arrhythmias (VAs), and evidence of scar related to the coronary CTO. Patients were randomly assigned 1:1 to a preventive substrate ablation before ICD implantation or standard therapy with ICD implantation only. The primary outcome was a composite of appropriate ICD therapy or unplanned hospitalization for VAs. Secondary outcomes included the primary outcome's components, the incidence of appropriate ICD therapies, cardiac hospitalization, electrical storm, and cardiovascular (CV) mortality. Sixty patients were included in the study. During the mean follow-up of 44.7 ± 20.7 months, the primary outcome occurred in 5 (16.7%) patients undergoing preventive substrate ablation and in 13 (43.3%) patients receiving only ICD [hazard ratio (HR): 0.33; 95% confidence interval (CI): 0.12-0.94; P = 0.037]. Patients in the preventive ablation group also had fewer appropriate ICD therapies (P = 0.039) and the electrical storms (Log-rank: P = 0.01). While preventive ablation also reduced cardiac hospitalizations (P = 0.006), it had no significant impact on CV mortality (P = 0.151). CONCLUSION: Preventive ablation of the coronary CTO-related substrate in patients undergoing primary ICD implantation is associated with the reduced risk of appropriate ICD therapy or unplanned hospitalization due to VAs.
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Ablación por Catéter , Oclusión Coronaria , Desfibriladores Implantables , Isquemia Miocárdica , Prevención Primaria , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Oclusión Coronaria/mortalidad , Oclusión Coronaria/terapia , Oclusión Coronaria/prevención & control , Oclusión Coronaria/complicaciones , Resultado del Tratamiento , Estudios Prospectivos , Isquemia Miocárdica/complicaciones , Isquemia Miocárdica/mortalidad , Taquicardia Ventricular/prevención & control , Taquicardia Ventricular/terapia , Taquicardia Ventricular/mortalidad , Cardiomiopatías/mortalidad , Cardiomiopatías/complicaciones , Cardiomiopatías/terapia , Muerte Súbita Cardíaca/prevención & control , Muerte Súbita Cardíaca/etiología , Factores de Riesgo , Cardioversión Eléctrica/instrumentación , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/mortalidad , Infarto del Miocardio/mortalidad , Infarto del Miocardio/prevención & control , Infarto del Miocardio/complicaciones , Enfermedad Crónica , Factores de TiempoAsunto(s)
Arritmias Cardíacas/terapia , Desfibriladores Implantables , Cardioversión Eléctrica/instrumentación , Ensayo de Materiales , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidad , Arritmias Cardíacas/fisiopatología , Estudios de Casos y Controles , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/mortalidad , Seguridad de Equipos , Femenino , Humanos , Italia , Masculino , Seguridad del Paciente , Puntaje de Propensión , Diseño de Prótesis , Falla de Prótesis , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Insuficiencia del TratamientoRESUMEN
OBJECTIVE: To determine the use of epinephrine (adrenaline) before defibrillation for treatment of in-hospital cardiac arrest due to a ventricular arrhythmia and examine its association with patient survival. DESIGN: Propensity matched analysis. SETTING: 2000-18 data from 497 hospitals participating in the American Heart Association's Get With The Guidelines-Resuscitation registry. PARTICIPANTS: Adults aged 18 and older with an index in-hospital cardiac arrest due to an initial shockable rhythm treated with defibrillation. INTERVENTIONS: Administration of epinephrine before first defibrillation. MAIN OUTCOME MEASURES: Survival to discharge; favorable neurological survival, defined as survival to discharge with none, mild, or moderate neurological disability measured using cerebral performance category scores; and survival after acute resuscitation (that is, return of spontaneous circulation for >20 minutes). A time dependent, propensity matched analysis was performed to adjust for confounding due to indication and evaluate the independent association of epinephrine before defibrillation with study outcomes. RESULTS: Among 34 820 patients with an initial shockable rhythm, 7054 (20.3%) were treated with epinephrine before defibrillation, contrary to current guidelines. In comparison with participants treated with defibrillation first, participants receiving epinephrine first were less likely to have a history of myocardial infarction or heart failure, but more likely to have renal failure, sepsis, respiratory insufficiency, and receive mechanical ventilation before in-hospital cardiac arrest (standardized differences >10% for all). Treatment with epinephrine before defibrillation was strongly associated with delayed defibrillation (median 4 minutes v 0 minutes). In propensity matched analysis (6569 matched pairs), epinephrine before defibrillation was associated with lower odds of survival to discharge (22.4% v 29.7%; adjusted odds ratio 0.69; 95% confidence interval 0.64 to 0.74; P<0.001), favorable neurological survival (15.8% v 21.6%; 0.68; 0.61 to 0.76; P<0.001) and survival after acute resuscitation (61.7% v 69.5%; 0.73; 0.67 to 0.79; P<0.001). The above findings were consistent in a range of sensitivity analyses, including matching according to defibrillation time. CONCLUSIONS: Contrary to current guidelines that prioritize immediate defibrillation for in-hospital cardiac arrest due to a shockable rhythm, one in five patients are treated with epinephrine before defibrillation. Use of epinephrine before defibrillation was associated with worse survival outcomes.
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Cardioversión Eléctrica/mortalidad , Epinefrina/administración & dosificación , Paro Cardíaco/terapia , Adulto , Arritmias Cardíacas/complicaciones , Arritmias Cardíacas/mortalidad , Cardioversión Eléctrica/métodos , Femenino , Paro Cardíaco/etiología , Paro Cardíaco/mortalidad , Humanos , Masculino , Alta del Paciente/estadística & datos numéricos , Puntaje de Propensión , Sistema de Registros , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: To investigate the clinical outcomes of patients who underwent cardioversion compared with those who did not have cardioverson in a large dataset of patients with recent onset non-valvular atrial fibrillation. DESIGN: Observational study using prospectively collected registry data (Global Anticoagulant Registry in the FIELD-AF-GARFIELD-AF). SETTING: 1317 participating sites in 35 countries. PARTICIPANTS: 52 057 patients aged 18 years and older with newly diagnosed atrial fibrillation (up to six weeks' duration) and at least one investigator determined stroke risk factor. MAIN OUTCOME MEASURES: Comparisons were made between patients who received cardioversion and those who had no cardioversion at baseline, and between patients who received direct current cardioversion and those who had pharmacological cardioversion. Overlap propensity weighting with Cox proportional hazards models was used to evaluate the effect of cardioversion on clinical endpoints (all cause mortality, non-haemorrhagic stroke or systemic embolism, and major bleeding), adjusting for baseline risk and patient selection. RESULTS: 44 201 patients were included in the analysis comparing cardioversion and no cardioversion, and of these, 6595 (14.9%) underwent cardioversion at baseline. The propensity score weighted hazard ratio for all cause mortality in the cardioversion group was 0.74 (95% confidence interval 0.63 to 0.86) from baseline to one year follow-up and 0.77 (0.64 to 0.93) from one year to two year follow-up. Of the 6595 patients who had cardioversion at baseline, 299 had a follow-up cardioversion more than 48 days after enrolment. 7175 patients were assessed in the analysis comparing type of cardioversion: 2427 (33.8%) received pharmacological cardioversion and 4748 (66.2%) had direct current cardioversion. During one year follow-up, event rates (per 100 patient years) for all cause mortality in patients who received direct current and pharmacological cardioversion were 1.36 (1.13 to 1.64) and 1.70 (1.35 to 2.14), respectively. CONCLUSION: In this large dataset of patients with recent onset non-valvular atrial fibrillation, a small proportion were treated with cardioversion. Direct current cardioversion was performed twice as often as pharmacological cardioversion, and there appeared to be no major difference in outcome events for these two cardioversion modalities. For the overall cardioversion group, after adjustments for confounders, a significantly lower risk of mortality was found in patients who received early cardioversion compared with those who did not receive early cardioversion. STUDY REGISTRATION: ClinicalTrials.gov NCT01090362.
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Fibrilación Atrial/terapia , Cardioversión Eléctrica/mortalidad , Anciano , Fibrilación Atrial/mortalidad , Fibrilación Atrial/patología , Causas de Muerte , Cardioversión Eléctrica/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Sistema de Registros , TerapéuticaRESUMEN
Background Optimal management of asymptomatic Brugada syndrome (BrS) with spontaneous type I electrocardiographic pattern is uncertain. Methods and Results We developed an individual-level simulation comprising 2 000 000 average-risk individuals with asymptomatic BrS and spontaneous type I electrocardiographic pattern. We compared (1) observation, (2) electrophysiologic study (EPS)-guided implantable cardioverter-defibrillator (ICD), and (3) upfront ICD, each using either subcutaneous or transvenous ICD, resulting in 6 strategies tested. The primary outcome was quality-adjusted life years (QALYs), with cardiac deaths (arrest or procedural-related) as a secondary outcome. We varied BrS diagnosis age and underlying arrest rate. We assessed cost-effectiveness at $100 000/QALY. Compared with observation, EPS-guided subcutaneous ICD resulted in 0.35 QALY gain/individual and 4130 cardiac deaths avoided/100 000 individuals, and EPS-guided transvenous ICD resulted in 0.26 QALY gain and 3390 cardiac deaths avoided. Compared with observation, upfront ICD reduced cardiac deaths by a greater margin (subcutaneous ICD, 8950; transvenous ICD, 6050), but only subcutaneous ICD improved QALYs (subcutaneous ICD, 0.25 QALY gain; transvenous ICD, 0.01 QALY loss), and complications were higher. ICD-based strategies were more effective at younger ages and higher arrest rates (eg, using subcutaneous devices, upfront ICD was the most effective strategy at ages 20-39.4 years and arrest rates >1.37%/year; EPS-guided ICD was the most effective strategy at ages 39.5-51.3 years and arrest rates 0.47%-1.37%/year, and observation was the most effective strategy at ages >51.3 years and arrest rates <0.47%/year). EPS-guided subcutaneous ICD was cost-effective ($80 508/QALY). Conclusions Device-based approaches (with or without EPS risk stratification) can be more effective than observation among selected patients with asymptomatic BrS. BrS management should be tailored to patient characteristics.
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Síndrome de Brugada/terapia , Técnicas de Apoyo para la Decisión , Desfibriladores Implantables , Cardioversión Eléctrica/instrumentación , Adulto , Enfermedades Asintomáticas , Síndrome de Brugada/diagnóstico , Síndrome de Brugada/economía , Síndrome de Brugada/mortalidad , Investigación sobre la Eficacia Comparativa , Análisis Costo-Beneficio , Desfibriladores Implantables/economía , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/economía , Cardioversión Eléctrica/mortalidad , Electrocardiografía , Costos de la Atención en Salud , Humanos , Persona de Mediana Edad , Modelos Económicos , Años de Vida Ajustados por Calidad de Vida , Recuperación de la Función , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Temporal trends in clinical composition and outcome in dilated cardiomyopathy (DCM) are largely unknown, despite considerable advances in heart failure management. We set out to study clinical characteristics and prognosis over time in DCM in Sweden during 2003-2015. METHODS: DCM patients (n = 7873) from the Swedish Heart Failure Registry were divided into three calendar periods of inclusion, 2003-2007 (Period 1, n = 2029), 2008-2011 (Period 2, n = 3363), 2012-2015 (Period 3, n = 2481). The primary outcome was the composite of all-cause death, transplantation and hospitalization during 1 year after inclusion into the registry. RESULTS: Over the three calendar periods patients were older (p = 0.022), the proportion of females increased (mean 22.5%, 26.4%, 27.6%, p = 0.0001), left ventricular ejection fraction was higher (p = 0.0014), and symptoms by New York Heart Association less severe (p < 0.0001). Device (implantable cardioverter defibrillator and/or cardiac resynchronization) therapy increased by 30% over time (mean 11.6%, 12.3%, 15.1%, p < 0.0001). The event rates for mortality, and hospitalization were consistently decreasing over calendar periods (p < 0.0001 for all), whereas transplantation rate was stable. More advanced physical symptoms correlated with an increased risk of a composite outcome over time (p = 0.0043). CONCLUSIONS: From 2003 until 2015, we observed declining mortality and hospitalizations in DCM, paralleled by a continuous change in both demographic profile and therapy in the DCM population in Sweden, towards a less affected phenotype.
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Terapia de Resincronización Cardíaca/tendencias , Cardiomiopatía Dilatada/terapia , Fármacos Cardiovasculares/uso terapéutico , Cardioversión Eléctrica/tendencias , Trasplante de Corazón/tendencias , Hospitalización/tendencias , Anciano , Terapia de Resincronización Cardíaca/efectos adversos , Terapia de Resincronización Cardíaca/mortalidad , Cardiomiopatía Dilatada/diagnóstico , Cardiomiopatía Dilatada/mortalidad , Cardiomiopatía Dilatada/fisiopatología , Fármacos Cardiovasculares/efectos adversos , Causas de Muerte/tendencias , Progresión de la Enfermedad , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/mortalidad , Femenino , Trasplante de Corazón/efectos adversos , Trasplante de Corazón/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Fenotipo , Pronóstico , Sistema de Registros , Factores de Riesgo , Suecia , Factores de TiempoRESUMEN
BACKGROUND: Data regarding recurrences of ventricular tachyarrhythmias in implantable cardioverter defibrillator (ICD) recipients according to atrial fibrillation is limited. OBJECTIVE: To assess the prognostic impact of atrial fibrillation on recurrences of ventricular tachyarrhythmias in implantable cardioverter defibrillator recipients. METHODS: A large retrospective registry was used, including all ICD recipients with episodes of ventricular tachycardia or fibrillation from 2002 to 2016. Patients with atrial fibrillation were compared to those without atrial fibrillation. The primary endpoint was first recurrence of ventricular tachyarrhythmias at 5 years. Secondary endpoints comprised recurrences of ICD-related therapies, first cardiac rehospitalization and all-cause mortality at 5 years. Cox regression, Kaplan-Meier and propensity score-matching analyses were applied. RESULTS: A total of 592 consecutive ICD recipients were included (33% with atrial fibrillation). Atrial fibrillation was associated with reduced freedom from recurrent ventricular tachyarrhythmias (42% vs. 50%, log-rank P=0.004; hazard ratio 1.445, 95% confidence interval 1.124-1.858), mainly attributable to recurrent ventricular fibrillation in secondary-preventive ICD recipients. Accordingly, atrial fibrillation was associated with reduced freedom from first appropriate ICD therapies (31% vs. 42%, log-rank P=0.001; hazard ratio 1.598, 95% confidence interval 1.206-2.118). Notably, the primary endpoint of freedom from first episode of recurrent ventricular tachyarrhythmias was still reduced in those with atrial fibrillation compared to those without atrial fibrillation after propensity score matching. Regarding secondary endpoints, patients with atrial fibrillation still showed a trend towards reduced freedom from appropriate ICD therapies. CONCLUSIONS: Atrial fibrillation was associated with increased rates of recurrent ventricular tachyarrhythmias and appropriate device therapies in ICD recipients with ventricular tachyarrhythmias.
Asunto(s)
Fibrilación Atrial/fisiopatología , Desfibriladores Implantables , Cardioversión Eléctrica/instrumentación , Taquicardia Ventricular/terapia , Fibrilación Ventricular/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/mortalidad , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/mortalidad , Femenino , Alemania/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/mortalidad , Taquicardia Ventricular/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Fibrilación Ventricular/diagnóstico , Fibrilación Ventricular/mortalidad , Fibrilación Ventricular/fisiopatología , Adulto JovenRESUMEN
BACKGROUND: Patients with tricuspid valve (TV) disease and indication for TV surgery frequently have permanent pacemaker (PM) or defibrillator (AICD) leads, placed in the right ventricle (RV). The aim of this study was to analyze postoperative results and mid-term outcomes after isolated TV surgery (with no further concomitant cardiac procedures) in the presence of permanent RV leads. METHODS: From January 2005 to January 2019 a total of 80 patients (mean age: 67.7±10.3 yrs; 56.3% male) with isolated TV disease and presence of at least one permanent RV lead in place were referred to our institution for isolated TV repair/replacement; patients with concomitant procedures were excluded for this analysis. All data were retrospectively analyzed. The follow-up was 98% complete. RESULTS: Mean follow-up time was 4.3±3.9 years. Mean preoperative clinical NYHA status was 3.0±0.8, left ventricular ejection fraction 50.7±12.9%, mean pulmonary artery pressure 23.8±9.3mmHg, creatinine 125.7±57.5µmol/L, mean MELD-XI Score (Model of End-stage-Liver Disease excluding INR) was 14.6±5.0 µmol/L. Thirty-day mortality was 6.3% with a 5-years survival of 58.2±6.0%. Cox regression analysis revealed the MELD-XI-Score as the only highly significant predictor for postoperative mortality (P=0.002). CONCLUSIONS: Hepatorenal dysfunction - possibly indicating long lasting TV failure - could be a factor for limited postoperative survival in our patient cohort. This finding could underline our hypothesis, that early TV surgery may achieve better postoperative survival, even in patients with TV disease caused by RV leads. Therefore, further investigations are needed.
Asunto(s)
Estimulación Cardíaca Artificial , Desfibriladores Implantables , Cardioversión Eléctrica/instrumentación , Marcapaso Artificial , Insuficiencia de la Válvula Tricúspide/cirugía , Válvula Tricúspide/cirugía , Anciano , Estimulación Cardíaca Artificial/efectos adversos , Estimulación Cardíaca Artificial/mortalidad , Desfibriladores Implantables/efectos adversos , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Marcapaso Artificial/efectos adversos , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/fisiopatología , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/mortalidad , Insuficiencia de la Válvula Tricúspide/fisiopatologíaRESUMEN
BACKGROUND: Management of young adults with hypertrophic cardiomyopathy (HCM) is challenging. AIMS: To evaluate the profile of young adults (16-25 years) with HCM included in the French prospective HCM registry. METHODS: Patients were compared according to occurrence of major adverse cardiac events (MACE), comprising sudden cardiac death (SCD) events (implantable cardioverter defibrillator [ICD] discharge, SCD, sustained ventricular tachycardia), atrial fibrillation/embolic stroke, heart failure hospitalisation and unexplained syncope, at a mean follow-up of 4.4±2.2 years. RESULTS: At baseline, among 61 patients (20.5±3.0 years; 16 women, 26.2%), 13 (21.3%) had a prophylactic ICD, 24.6% a family history of SCD, 29.5% obstruction, 86.0% magnetic resonance imaging myocardial fibrosis, 11.8% abnormal exercise blood pressure and 52.8% a European Society of Cardiology (ESC) 5-year SCD score<4% (24.5%≥6%). At follow-up, 15 patients (24.6%; seven women; all with fibrosis) presented 17 MACE, comprising: SCD events (n=7, 41.2%; including three patients with an ICD, five with at least one SCD major classical risk factor and an ESC score≥5% and two with no risk factors and an ESC score<4%); atrial fibrillation/stroke (n=6, 35.3%); heart failure (n=1, 5.9%); syncope (n=3, 17.6%). An ICD was implanted in 11 patients (four for secondary prevention), but in only 61.5% of patients with a score≥6%. Only obstruction significantly increased MACE risk (odds ratio 3.96; P=0.035), with a non-significant trend towards a lower risk in men (OR 0.29; P=0.065). CONCLUSIONS: In young adults with HCM, MACE are common in the short term, especially in obstructive HCM and women, mostly arrhythmic in origin. Prophylactic ICD implantation is frequent and does not strictly follow the guidelines, while the use of European/USA guidelines is helpful but imperfect in identifying SCD risk.
Asunto(s)
Anticoagulantes/uso terapéutico , Arritmias Cardíacas/terapia , Cardiomiopatía Hipertrófica/terapia , Muerte Súbita Cardíaca/prevención & control , Cardioversión Eléctrica , Adolescente , Adulto , Factores de Edad , Anticoagulantes/efectos adversos , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidad , Arritmias Cardíacas/fisiopatología , Cardiomiopatía Hipertrófica/diagnóstico por imagen , Cardiomiopatía Hipertrófica/mortalidad , Cardiomiopatía Hipertrófica/fisiopatología , Desfibriladores Implantables , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/instrumentación , Cardioversión Eléctrica/mortalidad , Femenino , Francia , Hospitalización , Humanos , Masculino , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
Orthotropic heart transplantation remains the most effective therapy for patients with end-stage heart failure, with a median survival of ≈13 years. Yet, a number of complications are observed after orthotropic heart transplantation, including atrial and ventricular arrhythmias. Several factors contribute to arrhythmias, such as autonomic denervation, effect of the surgical technique, acute and chronic rejection, and transplant vasculopathy among others. To minimize risk of future arrhythmias, the bicaval technique and minimizing ischemic time are current surgical standards. Sinus node dysfunction is the most common indication for early (within 30 days) pacemaker implantation, whereas atrioventricular block incidence increases as time from transplant increases. Atrial fibrillation can occur in the first few weeks following transplantation but is uncommon in the long term unless secondary to a precipitant such as acute rejection. The most common atrial arrhythmias are atrial flutters, which are mainly typical, but atypical circuits can be observed such as those that involve the remnant donor atrium in regions immediately adjacent to the atrioatrial anastomosis suture line. Choosing the appropriate pharmacological therapy requires careful consideration due to the potential interaction with immunosuppressive agents. Despite historical concerns, adenosine is effective and safe at reduced doses if administered under cardiac monitoring. Catheter ablation has emerged as an effective treatment strategy for symptomatic supraventricular tachycardias, including ablation of atypical flutter circuits. Cardiac allograft vasculopathy is an important risk factor for sudden cardiac death, yet the role of prophylactic implantable cardioverter-defibrillator implant for sudden death prevention is unclear. Current indications for implantable cardioverter-defibrillator implantation are as in the nontransplant population. A number of questions for future research are posed.
Asunto(s)
Antiarrítmicos/uso terapéutico , Arritmias Cardíacas/terapia , Ablación por Catéter , Cardioversión Eléctrica , Frecuencia Cardíaca/efectos de los fármacos , Trasplante de Corazón/efectos adversos , Potenciales de Acción , Animales , Antiarrítmicos/efectos adversos , Arritmias Cardíacas/etiología , Arritmias Cardíacas/mortalidad , Arritmias Cardíacas/fisiopatología , Ablación por Catéter/efectos adversos , Ablación por Catéter/mortalidad , Desfibriladores Implantables , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/instrumentación , Cardioversión Eléctrica/mortalidad , Trasplante de Corazón/mortalidad , Humanos , Factores de Riesgo , Resultado del TratamientoRESUMEN
[Figure: see text].
Asunto(s)
Arritmias Cardíacas/terapia , Muerte Súbita Cardíaca/prevención & control , Remoción de Dispositivos , Cardioversión Eléctrica/instrumentación , Potenciales de Acción , Anciano , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidad , Arritmias Cardíacas/fisiopatología , Desfibriladores Implantables , Remoción de Dispositivos/efectos adversos , Remoción de Dispositivos/mortalidad , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/mortalidad , Femenino , Frecuencia Cardíaca , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Medición de Riesgo , Factores de Riesgo , Volumen Sistólico , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
The wearable cardioverter-defibrillator (WCD) was first approved for clinical use in 2002, and is routinely used in select populations at high risk for sudden cardiac death. WCDs are frequently considered as a bridge to definitive therapy or in circumstances where insertion of conventional implantable cardioverter-defibrillators (ICD) is temporarily contraindicated. In this review, we summarize the literature on WCDs. From prospective trials to the first randomized controlled trial with WCD, there is a growing body of evidence that suggests that the WCD is safe and effective. In the first randomized controlled trial of the WCD (VEST Trial), there was no reduction in arrhythmia death but there was a reduction in all-cause mortality. We discuss the mortality impact, rate of inappropriate shocks, compliance, and potential quality of life implications with the WCD. Finally, we present the evidence for WCD use in select populations (e.g., post-myocardial infarction, device extraction), and the current guideline recommendations for WCD use.
Asunto(s)
Arritmias Cardíacas/terapia , Muerte Súbita Cardíaca/prevención & control , Desfibriladores , Cardioversión Eléctrica/instrumentación , Dispositivos Electrónicos Vestibles , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidad , Arritmias Cardíacas/fisiopatología , Toma de Decisiones Clínicas , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/mortalidad , Diseño de Equipo , Humanos , Selección de Paciente , Medición de Riesgo , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: In this study we aimed to assess long-term outcomes in subcutaneous implantable cardioverter-defibrillator (S-ICD) recipients with structural heart disease by focussing especially on shock incidence, predictors, and associated prognoses. METHODS: In this multicenter registryâbased study, we retrospectively included all patients who underwent S-ICD implantation at 3 tertiary centers. The prognostic impact of S-ICD shock was assessed with a composite outcome that included all-cause death and hospitalisation for heart failure. RESULTS: A total of 351 patients with underlying cardiomyopathy were included in the investigation. Using multivariable Fine and Gray regression models, secondary prevention, left ventricular ejection fraction (LVEF), conditional shock threshold, and QRS duration appeared to be independent predictors of appropriate S-ICD shock occurrence. In the multivariate Cox regression model adjusted for age, baseline LVEF, underlying cardiomyopathy subtype, New York Heart Association class, and appropriate shocks were significantly associated with increased composite prognostic outcome risk (hazard ratio [HR], 2.61; 95% confidence interval [CI], 1.21-5.65; P = 0.014), whereas inappropriate shocks were not (HR, 1.35; 95% CI, 0.75-4.48; P = 0.18). The analysis of each component of the composite prognostic outcome highlighted that the occurrence of appropriate shocks was associated with an increased risk of hospitalisation for heart failure (HR, 3.10; 95% CI, 1.26-7.58; P = 0.013) and a trend for mortality (HR, 2.19; 95% CI, 0.78-6.16; P = 0.14). CONCLUSIONS: Appropriate S-ICD shocks were associated with a 3-fold increase in acute heart failure admission, whereas inappropriate shocks were not. Conditional shock threshold programming is an independent predictor of S-ICD shock, and its prognostic impact should be investigated further in patients with structural heart disease.
Asunto(s)
Cardiomiopatías , Muerte Súbita Cardíaca/prevención & control , Desfibriladores Implantables , Cardioversión Eléctrica , Insuficiencia Cardíaca , Adulto , Cardiomiopatías/clasificación , Cardiomiopatías/fisiopatología , Cardiomiopatías/terapia , Muerte Súbita Cardíaca/etiología , Desfibriladores Implantables/efectos adversos , Desfibriladores Implantables/normas , Desfibriladores Implantables/estadística & datos numéricos , Cardioversión Eléctrica/instrumentación , Cardioversión Eléctrica/métodos , Cardioversión Eléctrica/mortalidad , Cardioversión Eléctrica/estadística & datos numéricos , Femenino , Francia/epidemiología , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/terapia , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Pronóstico , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Insuficiencia del TratamientoRESUMEN
BACKGROUND: Patients with cardiac sarcoidosis (CS) are at increased risk of atrioventricular blocks, ventricular arrhythmias, and sudden cardiac death. Objectives We aimed to investigate the characteristics associated with appropriate therapy in implantable cardiac defibrillator (ICD) -implanted CS patients. METHODS: We performed a PubMed and Web of Science search for studies reporting patients with CS who underwent an ICD implantation. The primary criterion was an appropriate therapy. RESULTS: We screened 705 studies, of which 5 were included in the final analysis. We conducted a meta-analysis including 464 patients (mean age 55 years, 282 males (60%)). The mean follow-up was 3.5 years. Among the 464 patients, 180 received an appropriate therapy (39%). Patients who received an appropriate therapy were younger (-3.33, 95% confidence interval (CI) -6.42 to -0.23, p=0.004), were more likely to be male (OR 2.06, 95% CI 1.37-3.09, p=0.0005), had a lower left ventricular ejection fraction (LVEF) (-10.5, 95% CI -18.23 to -2.78, p=0.008), had a higher rate of complete heart block (OR 2.19, 95% CI 1.20 to 3.99, p=0.01), and more frequently had ventricular pacing (OR 6.44 95% CI 2.57 to 16.16, p<0.0001). CONCLUSIONS: Appropriate ICD therapy during CS is associated with young age, male sex, low LVEF, history of complete heart block, and ventricular pacing. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (1): 17-23).
Asunto(s)
Cardiomiopatías/terapia , Desfibriladores Implantables , Cardioversión Eléctrica/instrumentación , Bloqueo Cardíaco/terapia , Sarcoidosis/terapia , Adulto , Factores de Edad , Anciano , Cardiomiopatías/diagnóstico por imagen , Cardiomiopatías/mortalidad , Cardiomiopatías/fisiopatología , Muerte Súbita Cardíaca/prevención & control , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/mortalidad , Femenino , Bloqueo Cardíaco/diagnóstico por imagen , Bloqueo Cardíaco/mortalidad , Bloqueo Cardíaco/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Medición de Riesgo , Factores de Riesgo , Sarcoidosis/diagnóstico por imagen , Sarcoidosis/mortalidad , Sarcoidosis/fisiopatología , Factores Sexuales , Volumen Sistólico , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
BACKGROUND: The randomized DAPA trial (Defibrillator After Primary Angioplasty) aimed to evaluate the survival benefit of prophylactic implantable cardioverter defibrillator (ICD) implantation in early selected high-risk patients after primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction. METHODS: A randomized, multicenter, controlled trial compared ICD versus conventional medical therapy in high-risk patients with primary percutaneous coronary intervention, based on one of the following factors: left ventricular ejection fraction <30% within 4 days after ST-segment-elevation myocardial infarction, primary ventricular fibrillation, Killip class ≥2 or TIMI (Thrombolysis in Myocardial Infarction) flow <3 after percutaneous coronary intervention. ICD was implanted 30 to 60 days after MI. Primary end point was all-cause mortality at 3 years follow-up. The trial prematurely ended after inclusion of 266 patients (38% of the calculated sample size). Additional survival assessment was performed in February 2019 for the primary end point. RESULTS: A total of 266 patients, 78.2% males, with a mean age of 60.8±11.3 years, were enrolled. One hundred thirty-one patients were randomized to the ICD arm and 135 patients to the control arm. All-cause mortality was significant lower in the ICD group (5% versus 13%, hazard ratio, 0.37 [95% CI, 0.15-0.95]) after 3 years follow-up. Appropriate ICD therapy occurred in 9 patients at 3 years follow-up (5 within the first 8 months after implantation). After a median long-term follow-up of 9 years (interquartile range, 3-11), total mortality (18% versus 38%; hazard ratio, 0.58 [95% CI, 0.37-0.91]), and cardiac mortality (hazard ratio, 0.52 [95% CI, 0.28-0.99]) was significant lower in the ICD group. Noncardiac death was not significantly different between groups. Left ventricular ejection fraction increased ≥10% in 46.5% of the patients during follow-up, and the extent of improvement was similar in both study groups. CONCLUSIONS: In this prematurely terminated and thus underpowered randomized trial, early prophylactic ICD implantation demonstrated lower total and cardiac mortality in patients with high-risk ST-segment-elevation myocardial infarction treated with primary percutaneous coronary intervention. Registration: URL: https://www.trialregister.nl; Unique identifier: Trial NL74 (NTR105).