Reduced LV Pacing Percentages are Associated with Progressively Worse Measures of Heart Failure Physiology in CRT Patients (original) (raw)
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Pacing and Clinical Electrophysiology Pace, 2010
Background: Prior studies of cardiac rhythm management devices (pacemakers [PM] and implantable cardioverter defibrillators [ICD]) utilization in the United States have been limited to the Medicare population. We evaluated the national trends for the implantation of PMs and ICDs including the burden of device replacement.Methods: The Nationwide Inpatient Sample was queried to identify PM and ICD patients between 1993 and 2006 using ICD-9-CM codes, including demographics, health profile, and economic data. The Charlson Comorbidity Index (CCI) and replacement burden were calculated, and changes over time studied.Results: From 1993 to 2006, 2.4 million patients received a primary PM and 0.8 million received an ICD, while there were 369,000 PM replacements and 74,000 ICD replacements. Women comprised 49% of PM and 24% of ICD patients. The mean ICD replacement burden was 8.4% (range 5–22%) and decreased significantly over time (P < 0.0001) while the replacement burden for PMs was constant (mean = 13.4%, range 11–16%). ICD patients had more comorbidities than PM patients (CCI: 0.8 vs 1.1, P < 0.0001).Conclusions: The replacement burden for PMs has remained constant, while the replacement burden for ICDs has decreased. This is likely due to the stability of the patient population receiving PMs and technology maturity. Alternatively, the indications for ICD implantation have broadened, resulting in an increased number of primary ICD implantations. The age and comorbidities are increasing in those patients receiving ICDs while the PM population is stable. These data suggest that monitoring of replacement burden is warranted, given the changing populations, their disparate clinical outcomes, and economic implications to the health care system. (PACE 2010; 33:705–711)
European Heart Journal - Quality of Care and Clinical Outcomes, 2020
Aims Current treatment guidelines recommend implantable cardioverter-defibrillators (ICDs) in eligible patients with an estimated survival beyond 1 year. There is still an unmet need to identify patients who are unlikely to benefit from an ICD. We determined cause-specific 1-year mortality after ICD implantation and identified associated risk factors. Methods and results Using Danish nationwide registries (2000–2017), we identified 14 516 patients undergoing first-time ICD implantation for primary or secondary prevention. Risk factors associated with 1-year mortality were evaluated using multivariable logistic regression. The median age was 66 years, 81.3% were male, and 50.3% received an ICD for secondary prevention. The 1-year mortality rate was 4.8% (694/14 516). ICD recipients who died within 1 year were older and more comorbid compared to those who survived (72 vs. 66 years, P < 0.001). Risk factors associated with increased 1-year mortality included dialysis [odds ratio (OR...
Journal of Cardiology, 2020
Background: The risk of sudden cardiac death in patients with heart failure has declined over time thanks to the sequential introduction of new treatments. However, current guidelines recommendations for implantable cardioverter-defibrillator (ICD) are based on randomized controlled trials (RCTs) carried out in the past three decades and their meta-analyses. To highlight potential changes over time in ICD clinical benefit in primary prevention of sudden cardiac death, we analyzed the temporal trends of RCT risk of mortality outcomes in this time frame. Methods: By searching MEDLINE and the Cochrane Library electronic databases we identified seven RCTs (6095 patients enrolled between 1990 and 2014) on ICD versus contemporary standard medical therapy for sudden cardiac death prevention, in patients with chronic heart failure of ischemic and non-ischemic origin and reduced ejection fraction. Linear regression analysis was applied to identify the association between RCT mortality outcomes and time. Results: Ordered according to the start of randomization, the trials showed a statistically significant (p = 0.03) progressive decline in the baseline annualized event rate of sudden cardiac death in RCT control arms, and a significant (p = 0.04) increase in the number of patients unresponsive to ICD treatment (i.e. patients experiencing sudden cardiac death in ICD arms). These two factors synergistically contributed to a significant (p < 0.01) and progressive reduction in the clinical benefit of ICD, assessed by the number needed to treat for total mortality at 3 years. Conclusions: The clinical benefit of ICD, implanted according to the current guidelines, has significantly and progressively declined over time due to the reduction in sudden cardiac death risk and to the increase of ICD unresponsive patients.
The American Journal of Cardiology, 2015
Implantable cardioverter-defibrillator (ICD) implantation outside practice guidelines remains contentious, particularly during the mandated waiting periods in patients with recent cardiac events. We assessed the prevalence and outcomes of noneguideline-based (NGB) ICD implantations in a tertiary academic medical center, with a specific focus on adjudication of arrhythmia events. All patients who underwent initial primary prevention ICD implantation at our institution from 2004 to 2012 were categorized as having received guideline-based (GB) or NGB implants and were retrospectively assessed for first episode of appropriate ICD therapy and total mortality. Of 807 patients, 137 (17.0%) received NGB implants. During a median follow-up of 2.9 years, patients with NGB implants had similar times to first appropriate ICD therapy (median time to event 1.94 vs 2.17 years in patients with GB implants, p [ 0.20). After multivariable analysis, patients with NGB implants remained at higher risk for death (hazard ratio 1.54, 95% confidence interval 1.1 to 2.2, p [ 0.03) but not appropriate ICD therapy (hazard ratio 0.83, 95% confidence interval 0.5 to 1.3, p [ 0.51). Furthermore, only 1 of 125 patients who underwent implant within the 40-day waiting period after myocardial infarction or 3-month waiting period after revascularization or cardiomyopathy diagnosis received an appropriate therapy within this period. In conclusion, few patients received NGB ICD implants in our academic medical center. Although these patients have similar long-term risk of receiving appropriate ICD therapy compared with patients with GB implants, this risk is very low during the waiting periods mandated by clinical practice guidelines. These results suggest that there is little need to rush into implanting ICDs during these waiting periods. Ó 2015 Elsevier Inc. All rights reserved. (Am J Cardiol 2015;-:-e-) Current practice guidelines for primary prevention implantable cardioverter-defibrillator (ICD) implantation mandate a 40-day period after a myocardial infarction (MI) before ICD implantation, recommend against ICD implantation for patients with New York Heart Association (NYHA) class IV symptoms, and emphasize that ICDs have not been shown to improve survival when implanted within 3 months of myocardial revascularization. The guidelines also state that ICD therapy should be considered in patients with a recent cardiomyopathy diagnosis only after their response to optimal medical therapy for !3 months has been assessed. 1e3 For a variety of reasons, however, ICDs may be implanted in patients who do not meet guideline-based (GB) criteria. A retrospective cohort study of cases submitted to the National Cardiovascular Data Registry-ICD Registry found that 22.5% of patients did not meet evidence-based criteria. This study was controversial in part because of the possibility that some variables in the ICD Registry may not have been recorded accurately. 5 Furthermore, no information was available regarding long-term rates of appropriate ICD therapy or overall mortality. We undertook the present study to assess the prevalence of noneguideline-based (NGB) ICD implants at an academic medical center using prespecified criteria, leveraging full access to patients' medical records and associated clinical decision making. In addition, we compared rates of appropriate ICD therapy and survival between patients with NGB and GB implants, with particular emphasis on the rates of appropriate ICD therapy during the waiting periods mandated by the clinical guidelines.
BMC Research Notes, 2012
Background: Coronary artery disease (CAD) is associated with an increased risk for sudden cardiac death. Randomized controlled trials have shown that implantable cardioverter defibrillators (ICD) improve life expectancy unless they are implanted within the first days after an acute myocardial infarction and guidelines recommend their use. We aimed to validate that these results also apply to patients of a typical community hospital in Germany. Methods: This was a retrospective analysis of patients undergoing coronary angiography in the Lippe-Detmold Hospital between 2003 and 2006. They had to have significant CAD and an ejection fraction (EF) ≤ 35% and no acute myocardial infarction within 28 days of implantation and no history of ventricular fibrillation. Results: 213 patients were included; 70 of which received an ICD. Patients with an ICD implantation were younger (64.8 ± 9.9 vs. 67.9 ± 9.8 years; p = 0.034), had single vessel CAD more frequently (22.9 vs. 11.2%; p = 0.025) and a lower EF (26.7 ± 6.3 vs. 29.1 ± 4.6%; p = 0.006). Hospital readmissions were comparable between the ICD and the control group (68.6 vs. 72.0%; p = 0.602). ICD therapy was associated with a considerable survival benefit compared to conventional therapy (HR 0.52; 95%CI 0.29-0.93; p = 0.027) in a Cox-Proportional Hazards Regression analysis.