Atrial high rate episodes predict clinical outcome in patients with cardiac resynchronization therapy

OBJECTIVES: Up to 50% of patients qualified for cardiac resynchronization therapy (CRT) have documented atrial fibrillation (AF) prior to CRT-implantation. This finding is associated with worse prognosis but few studies have evaluated the importance of post-implant device-detected AF. This study aimed to assess the prognostic impact of device-detected atrial high rate episodes (AHRE), as a surrogate for atrial fibrillation (AF).DESIGN: Data was retrospectively obtained from consecutive patients receiving CRT. Baseline clinical data and data from CRT device-interrogations, performed at a median of 12.2 months after CRT-implantation, were evaluated with regard to prediction of the composite endpoint of death, heart transplant or appropriate shock therapy. Median follow-up time was 51 months post-implant.RESULTS: The study included 377 patients. Preoperative AF was present in 49% and associated with worse outcome. The cumulative burden of AHRE at 12 months post-implant was an independent predictor of the primary endpoint. During the first 12 months after CRT-implantation, AHRE were detected in 25% of the patients with no preoperative diagnosis of AF. This finding was not associated with worse outcome.CONCLUSIONS: In CRT recipients, the cumulative burden of AHRE during first year of follow-up was associated with worse long-term clinical outcome. Prospective trials are needed to determine if a rhythm control strategy is to be preferred in patients with CRT

Cardiovascular drug utilization post-implant is related to clinical outcome in heart failure patients receiving cardiac resynchronization therapy

    Background: In select patients with heart failure, cardiac resynchronization therapy (CRT) is the most common complementary treatment besides medical treatment. We aimed to assess the association between post CRT-implant changes in cardiovascular medication and cardiovascular mortality and heart failure hospitalization. Methods: 211 patients on optimal medical therapy eligible for CRT were retrospectively included in this study (72 ± 7 years, 80% male, 66% left bundle branch block, 48% dilated cardiomyopathy and investigated at baseline and after 6 months. Follow-up with medication, biochemical markers and echocardiography was performed and 3-year mortality data was collected. Results: At 6 months post-implant the cohort was divided into two groups; 157 patients had low dosage furosemide treatment (up to 40 mg) and 54 patients were treated with high dosage (> 40 mg). A composite endpoint of heart failure hospitalization and all-cause mortality was evaluated at 30 months (881 ± 267 days) after the 6-month visit. In multivariate Cox regression analysis, pa­tients in the high dose diuretics group had a higher risk of the primary endpoint (HR 1.9 [1.1–3.4], p = 0.033), but treatment with high dose diuretics was not associated with improved clinical symptoms (r = 0.031, p = 0.64). Conclusions: High dosage of loop-diuretics was associated with worse medium-term clinical outcome in CRT treated patients. It is unclear whether there is a direct causality between these associations, or if higher prescribed dosage of loop-diuretics is just a marker of more severe disease. Higher dose loop diuretics do not necessarily improve the symptoms and may be harmful to the patient. Prospective trials are warranted to further elucidate these findings. (Cardiol J 2017; 24, 4: 374–384

Patient-assessed short-term positive response to cardiac resynchronization therapy is an independent predictor of long-term mortality.

Cardiac resynchronization therapy (CRT) has a well-documented positive effect on mortality and heart failure morbidity. The aim of this study was to assess the long-term survival and the predictive value of self-assessed functional status on the long-term prognosis of patients treated with CRT-pacemaker (CRT-P).METHODS AND RESULTS: Data were retrospectively collected from medical records of 446 consecutive patients implanted with CRT-P at a large-volume Swedish tertiary care centre. Primary outcome was all-cause mortality, predictive variables were assessed by log-rank test and univariate cox regression. Three hundred and nine patients had reliable information available on early improvement after implantation and were included in the multivariate analyses. The cohort was followed for a median of 79 months and was similar in baseline characteristics compared with major controlled trials. During follow-up 204 patients died, yearly mortality was 11.7%. Early improvement of self-assessed functional status was a strong independent predictor of survival [hazard ratio, HR 0.59, confidence interval (CI) 0.40-0.87, P = 0.007], together with well-known predictors; NYHA III-IV vs I-II (HR 1.66, CI 1.09-2.536, P = 0.018), age (HR 1.05, CI 1.03-1.08, P < 0.001), male gender (HR 2.0, CI 1.11-3.45, P = 0.021), and loop diuretic use (HR 4.41, CI 1.08-18.02). Patients with early improvement of self-assessed functional status had better 2-year and 5-year survival (P < 0.001).CONCLUSIONS: Real-life patient characteristics and predictors of outcome compare well with those in published prospective trials. Self-assessed functional status is a strong predictor of long-term survival, which may have implications for a more active follow-up of patients without spontaneous improvement

Coronary Heart Disease and Erectile Dysfunction

Coronary heart disease (CHD) is a common condition associated with a high mortality. There is now growing evidence that erectile dysfunction (ED) in men may be a suitable marker of sub-clinical cardiovascular disease, identifying patients at high risk for future CHD. We investigated the association between CHD risk factors and ED during a period of 25 years, in a population based cohort of men, aged 58-78 at follow-up. Risk factors were assessed at baseline and at study-end, and analyses were made in relation to ED prevalence at study end. ED evaluation was by the validated IIEF-5 questionnaire. We also examined if coronary endothelial and smooth muscle cell function was impaired, expressed as reduced coronary flow velocity reserve (CFVR), in otherwise healthy men with ED. CFVR in men with ED was compared to age-matched healthy controls and to men with diabetes or impaired fasting glucose. The results showed that: Men with ED had a reduced CFVR, independently of other risk factors for CHD. The magnitude of the CFVR reduction was similar in men with ED, as compared to men with diabetes or impaired fasting glucose. A number of classical CHD risk factors, identified at the baseline examination 25 years earlier, were associated with increased risk of ED. During the follow-up period, men with ED at study-end had a greater increase in fasting glucose levels, and were more likely to have developed the metabolic syndrome or diabetes, compared to men without ED. At study-end, several CHD risk factors including diabetes, low physical activity and low self rated health, were independently associated with ED. Furthermore, men with ED were more likely to be on antihypertensive and cholesterol-lowering medications at study-end. Our studies support the close epidemiological and pathophysiological links between ED and CHD. Men presenting with ED should be carefully evaluated for risk factors regarding CHD. Primary prevention can then be instituted, with modification of CHD risk factors, thus reducing future cardiovascular risk and in some cases simultaneously resulting in improvement of erectile function

Anatomy of the coronary sinus with regard to cardiac resynchronization therapy implantation

Knowledge of the coronary sinus (CS) anatomy is crucial for implantation of cardiac resynchronization therapy (CRT). Obstacles to CS entry, such as the Eustachian ridge and Thebesian valve, as well as within the CS, such as Vieussen’s valve and the vein of Marshall, are important to understand and differentiate during implantation or to identify earlier by imaging. Anatomic knowledge is mandatory to select the most suitable side branch for lead implantation. Modern tools and techniques almost always enable other anatomic problems, such as tortuous, small, short, or overly straight side branches, to also be overcome