Should we increase betablocker after cardiac resynchronization therapy: the results of the caribe-hf study (cardiac resynchronization in combination with betablocker treatment in advanced chronic heart failure)

Cardiac resynchronization therapy (CRT), combined with optimal medical therapy (OMT), is an established treatment for patients with advanced chronic heart failure (ACHF). In ACHF, carvedilol at the dose used in clinical trials reduces morbidity and mortality. However, patients often cannot tolerate the drug at the targeted dosage. Aim of the CARIBE-HF prospective observational study was to investigate the role of CRT in the implementation of carvedilol therapy in patients with ACHF. Methods: One hundred and 6 patients (aged 65±12 [mean±sd] years) with ACHF were enrolled and treated with OMT, in which carvedilol was titrated up to the maximal dose (phase 1). Subsequently, patients with left ventricular (LV) ejection fraction < 35%, NYHA class III-IV and QRS interval ≥ 120 msec were assigned to CRT. Both CRT and NO-CRT patients underwent long-term follow-up till 7 years (1193,98±924 days), while efforts to up-titrate the carvedilol dose were continued during the second phase (471±310 days). Phase 1 was completed by 84 patients (79%), and 15 (18%) underwent CRT. The mean carvedilol dose in the CRT group was 19.0±17.8 mg, against 32.7±19.1 mg in the remaining 69 patients (p=0.018). At the end of phase 2, CRT patients presented a significantly greater variation of increasing in the carvedilol dose than NO-CRT patients ( 20.0±19.8 mg vs –0.3±20.5 mg; p=0.015), a greater NYHA class reduction (-0.8±0.6 vs -0.2±0.7; p=0.011), and a greater increase in LV ejection fraction ( 10.8±9 vs 3.1±6.1; p=0.018). In conclusion, the data from the CARIBE study suggest that, in ACHF, CRT may be effective in enabling the target dose of carvedilol to be reached. The significant improvement seen in LV function was probably due to a synergistic effect of CRT and carvedilol. During the extended follow-up (mean 1193,98±924 days) the mean dosage of carvedilol in CRT group was significantly higher (

Long-term reduction of atrial tachyarrhythmia recurrences in patients paced for bradycardia-tachycardia syndrome

Background: Atrial tachyarrhythmias (AT) are considered progressive diseases. Several rhythm control therapies for treatment of AT have been proposed. Objectives: The Italian AT500 Registry was designed to prospectively study long-term AT evolution in patients paced for the brady-tachy form of sinus node disease (BT-SND). Methods: Three hundred forty-six BT-SND patients received an antitachycardia dual-chamber pace-maker and were followed-up for a minimum of 12 months (median 19 months). Prevention and antitachycardia pacing (ATP) features were enabled in all patients. Results: During the observation period, 224 (65%) patients were treated by antiarrhythmic drugs and 45 (13%) patients were cardioverted. Five patients suffered a stroke, 4 transient ischemic attack, 22 permanent AT, and 98 AT recurrences longer than 7 days. AT mean cycle length changed from 246 to 2 70 ms, and the percentage of patients with AT-related hospitalizations significantly decreased with an annual 28% relative reduction. AT burden and the percentage of patients with AT recurrences longer than 2 days remained constant with time in the overall population but decreased significantly in the subgroup of patients who did not develop permanent AT. High ATP efficacy was associated with an increasingly higher prevention of AT recurrences longer than 2 days. Conclusion: In a long-term observation of BT-SND patients, AT-related hospitalizations decreased significantly and mean AT cycle length increased significantly. The data suggest that rhythm control therapies induce inversion of AT progression. © 2005 Heart Rhythm Society. All rights reserved