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

Levels of detail in building information models : A study of how different levels of detail affects the information in building models

BIM, Building Information Modelling, är inget nytt begrepp för byggbranschen och ämnet är välutforskat i teorin. Den praktiska tillämpningen har dock inte nått ut till hela den svenska branschen och lägst implementation finns idag hos förvaltningen. För att BIM ska nå ut till denna del av branschen, behöver beställarna förstå vilken funktion BIM kan bistå med och ställa BIM-krav i sina projekt. Då det inte finns någon övre gräns på hur mycket information en modell kan innehålla, behöver beställarna också definiera vilken information som är nödvändig för sökta funktioner. Denna studie ämnar att tydliggöra hur informationsinnehållet i en modell påverkas av olika detaljeringsnivåer. Genom en sammanställning av befintliga standarder och nivåsystem har en utbildningslokal på 150kvm modellerats med hjälp av Autodesk Revit Architecture. Med hjälp av denna modell och sammanställd teori dras följande slutsatser. Det är möjligt att säkerställa informationsbehoven hos beställarens organisation med hjälp av ett detaljeringsnivåsystem. Olika fastigheter har olika funktionsbehov och kräver olika detaljeringsnivåer. En generell nivå på vilken information som ska ingå i dessa modeller borde gå att fastställa. En förutsättning för lyckade BIM-projekt är att tydliga anvisningar och krav upprättas inför modellering och att dessa är förankrade i byggprojektets och förvaltningens informationsbehov.BIM, Building Information Modelling, is not a new concept for the construction industry and the subject is well reviewed in theory. The practical application has not yet reached out to the whole Swedish construction industry and the lowest implementation of BIM can be found in facility management. For BIM to reach this part of the industry, clients’ needs to understand the functions that BIM can assist with and set BIM requirements for their projects. Since there is no upper limit on the level of information a model may contain, clients also needs to define which information is necessary for the sought functions. This study aims to clarify how the information content of a model is affected by different levels of detail. Through a compilation of existing standards and level system has an education facility of 150sqm been modeled using Autodesk Revit Architecture. With the help of this model and the compiled theory, following conclusions has been drawn. It is possible to ensure the information needs of the client's organization with the help of a system for level of development. Different buildings have different functional needs and require different levels of detail. A general level of detail to be included with these models should be possible to determine. A prerequisite for successful BIM project is that clear instructions and requirements are established for the modeling process and that these are anchored in the needs of the project and management

Levels of detail in building information models : A study of how different levels of detail affects the information in building models

BIM, Building Information Modelling, är inget nytt begrepp för byggbranschen och ämnet är välutforskat i teorin. Den praktiska tillämpningen har dock inte nått ut till hela den svenska branschen och lägst implementation finns idag hos förvaltningen. För att BIM ska nå ut till denna del av branschen, behöver beställarna förstå vilken funktion BIM kan bistå med och ställa BIM-krav i sina projekt. Då det inte finns någon övre gräns på hur mycket information en modell kan innehålla, behöver beställarna också definiera vilken information som är nödvändig för sökta funktioner. Denna studie ämnar att tydliggöra hur informationsinnehållet i en modell påverkas av olika detaljeringsnivåer. Genom en sammanställning av befintliga standarder och nivåsystem har en utbildningslokal på 150kvm modellerats med hjälp av Autodesk Revit Architecture. Med hjälp av denna modell och sammanställd teori dras följande slutsatser. Det är möjligt att säkerställa informationsbehoven hos beställarens organisation med hjälp av ett detaljeringsnivåsystem. Olika fastigheter har olika funktionsbehov och kräver olika detaljeringsnivåer. En generell nivå på vilken information som ska ingå i dessa modeller borde gå att fastställa. En förutsättning för lyckade BIM-projekt är att tydliga anvisningar och krav upprättas inför modellering och att dessa är förankrade i byggprojektets och förvaltningens informationsbehov.BIM, Building Information Modelling, is not a new concept for the construction industry and the subject is well reviewed in theory. The practical application has not yet reached out to the whole Swedish construction industry and the lowest implementation of BIM can be found in facility management. For BIM to reach this part of the industry, clients’ needs to understand the functions that BIM can assist with and set BIM requirements for their projects. Since there is no upper limit on the level of information a model may contain, clients also needs to define which information is necessary for the sought functions. This study aims to clarify how the information content of a model is affected by different levels of detail. Through a compilation of existing standards and level system has an education facility of 150sqm been modeled using Autodesk Revit Architecture. With the help of this model and the compiled theory, following conclusions has been drawn. It is possible to ensure the information needs of the client's organization with the help of a system for level of development. Different buildings have different functional needs and require different levels of detail. A general level of detail to be included with these models should be possible to determine. A prerequisite for successful BIM project is that clear instructions and requirements are established for the modeling process and that these are anchored in the needs of the project and management

Ventricular high-rate episodes predict increased mortality in heart failure patients treated with cardiac resynchronization therapy.

Abstract Objectives. Cardiac Resynchronization Therapy (CRT) for heart-failure patients has a well-documented positive effect, but the overall mortality in this group remains high. This study aimed to explore whether additional information from the device post-implant (occurrence of ventricular high-rate episodes), could add prognostic value for patients on CRT-pacemaker (CRT-P) treatment. Design. Clinical data and device-interrogation data were retrospectively gathered from the medical records of 220 patients treated with CRT-P. Ventricular high-rate (VHR) episodes were defined as a ventricular rate ≥ 180 beats per minute. The primary outcome was 5-year mortality. Results. During follow-up, 132 patients (60%) died or underwent heart transplant. Overall, the 5-year mortality rate was 52%; 77% for patients with VHR during the first year of follow-up and 48% for patients without VHR during the first year of follow-up (p = 0.001). In a multivariate model, the occurrence of VHR episodes was an independent predictor of 5-year mortality (HR 9.96, p = 0.022). The most common cause of death was heart failure, and death from arrhythmia did not differ between groups (p = 0.065). Conclusions. In heart-failure patients with CRT-P therapy, occurrence of VHR episodes within the first year post-implant was an independent predictor of higher 5-year mortality and inferior long-term survival, but not of death from malignant arrhythmia

Interatrial Block Predicts Atrial Fibrillation and Total Mortality in Patients with Cardiac Resynchronization Therapy

Background: Interatrial block (IAB) and abnormal P-wave terminal force in lead V1 (PTFV1) are electrocardiographic (ECG) abnormalities that have been shown to be associated with new-onset atrial fibrillation (AF) and death. However, their prognostic importance has not been proven in cardiac resynchronization therapy (CRT) recipients. Objective: To assess if IAB and abnormal PTFV1 are associated with new-onset AF or death in CRT recipients. Methods: CRT recipients with sinus rhythm ECG at CRT implantation and no AF history were included (n = 210). Automated analysis of P-wave duration (PWD) and morphology classified patients as having either no IAB (PWD 0.04 mm•s was considered abnormal. Adjusted Cox regression analyses were performed to assess the impact of IAB and abnormal PTFV1 on the primary endpoint new-onset AF, death, or heart transplant (HTx) and the secondary endpoint death or HTx at 5 years of follow-up. Results: IAB was found in 45% of all patients and independently predicted the primary endpoint with HR 1.9 (95% CI 1.2-2.9, p = 0.004) and the secondary endpoint with HR 2.1 (95% CI 1.2-3.4, p = 0.006). Abnormal PTFV1 was not associated with the endpoints. Conclusions: IAB is associated with new-onset AF and death in CRT recipients and may be helpful in the risk stratification in the context of heart failure management. Abnormal PTFV1 did not demonstrate any prognostic value

Short-term glucocorticoids reduce risk of chronic NSAID and analgesic use in early methotrexate-treated rheumatoid arthritis patients with favourable prognosis: subanalysis of the CareRA randomised controlled trial

Objective To explore non-steroidal anti-inflammatory drug (NSAID) and analgesic use in early rheumatoid arthritis (eRA) patients with a favourable risk profile initiating methotrexate (MTX) with or without glucocorticoid (GC) bridging.Methods Patients with eRA (≤1 year) and favourable risk profile (no erosions, negative rheumatoid factor and anticitrullinated protein antibodiesor low disease activity) in the 2-year CareRA trial were randomised to MTX 15 mg with a step-down GC scheme (COBRA Slim), or MTX without oral GCs, Tight-Step-Up (TSU). Used analgesics were recorded, including frequency, start/end date and indication. Chronic intake (≥90 consecutive days in trial) of NSAIDs, acetaminophen, opioids including tramadol and antidepressants for the indication of musculoskeletal (MSK) pain was considered. Treatments were compared using χ2 and analysis of variance with Holm’s correction for multiple testing.Results In total, 43 patients were randomised to COBRA Slim and 47 to TSU. At study inclusion, 33/43 (77%) of patients in the COBRA Slim and 32/47 (68%) in the TSU arm had been using analgesics (p=0.5). During the trial, 67 NSAID and analgesics were used for MSK pain in 26/43 (60%) COBRA Slim patients of which 9/43 (21%) daily chronically (DC), while 107 NSAID and analgesics were used in 43/47 (92%) TSU patients, of which 25/47 (53%) DC. The total number of patients on NSAID and analgesics at any time during the study (p<0.01) and chronically (p=0.01) was significantly different between treatment arms. Number of patients on DC NSAIDs was also significantly different (p<0.01) between COBRA Slim 6/43 (14%) and TSU 19/47 (40%).Conclusion In eRA patients considered to have a favourable prognosis, initial oral GC bridging resulted in lower chronic NSAID and analgesic use.Trial registration number NCT01172639

Cardiovascular risk factors in gout, psoriatic arthritis, rheumatoid arthritis and ankylosing spondylitis: a cross-sectional survey of patients in Western Sweden

Objectives We aimed to compare traditional (trad) cardiovascular risk factors (CVRFs) among patients with gout, psoriatic arthritis (PsA), rheumatoid arthritis (RA) and ankylosing spondylitis (AS) stratified by sex.Methods A survey was sent to patients with gout (n=1589), PsA (n=1200), RA (n=1246) and AS (n=1095). Patients were retrieved from Sahlgrenska University Hospital, the hospitals of Uddevalla and Skövde, and 12 primary care centres in Western Sweden. The prevalence of self-reported trad-CVRFs was compared between diagnoses by age standardisation with the 2018 population of Sweden as the standard population.Results In total, 2896 (56.5%) of 5130 patients responded. Hypertension was the most frequently found comorbidity, reported by 65% of patients with gout, 41% with PsA, 43% with RA and 29% with AS. After age standardisation, women and men with gout had significantly more obesity (body mass index ≥30 kg/m2), hypertension, diabetes, hyperlipidaemia and multiple trad-CVRFs, compared with those with PsA, RA and AS. Obesity was significantly more common in PsA than in RA. In women, obesity, hypertension and multiple trad-CVRFs were more frequently reported in PsA than in RA and AS, whereas similar prevalence of CVRFs and coexistence of multiple trad-CVRFs were found in men with PsA, RA and AS.Conclusions Women and men with gout had the highest prevalence of trad-CVRFs. Differences in occurrence of CVRFs by sex were found in patients with PsA, RA and AS. In women, patients with PsA had higher occurrence of trad-CVRFs than those with RA and AS, whereas in men the distribution of CVRFs was similar in PsA, RA and AS

Atrial fibrillation incidence and impact of biventricular pacing on long-term outcome in patients with heart failure treated with cardiac resynchronization therapy

Background: In patients with cardiac resynchronization therapy (CRT), atrial fibrillation (AF) is associated with an unfavorable outcome and may cause loss of biventricular pacing (BivP). An effective delivery of BivP of more than 98% of all ventricular beats has been shown to be a major determinant of CRT-success. Methods: At a Swedish tertiary referral center, data was retrospectively obtained from patient registers, medical records and preoperative electrocardiograms. Data regarding AF and BivP during the first year of follow-up was assessed from CRT-device interrogations. No intra-cardiac electrograms were studied. Kaplan-Meier curves and Cox-regression analyses adjusted for age, etiology of heart failure, left ventricular ejection fraction, left bundle branch block and NYHA class were performed to assess the impact of AF and BivP on the risk of death or heart transplantation (HTx) at 10-years of follow-up. Results: Preoperative AF-history was found in 54% of the 379 included patients and was associated with, but did not independently predict death or HTx. The one-year incidence of new device-detected AF was 22% but not associated with poorer prognosis. At one-year, AF-history and BivP≤98%, was associated with a higher risk of death or HTx compared to patients without AF (HR 1.9, 95%CI 1.2-3.0, p = 0.005) whereas AF and BivP> 98% was not (HR 1.4, 95%CI 0.9-2.3, p = 0.14). Conclusions: In CRT-recipients, AF-history is common and associated with poor outcome. AF-history does not independently predict mortality and is probably only a marker of a more severe underlying disease. BivP≤98% during first-year of CRT-treatment independently predicts poor outcome thus further supporting the use of 98% threshold of BivP, which should be attained to maximize the benefits of CRT