Canadian Cardiovascular Society/Canadian Heart Rhythm Society 2016 Implantable Cardioverter-Defibrillator Guidelines

Rupture of Renal Angiomyolipoma Post Fibrinolysis: A rare complication of fibrinolytic therapy

Angiomyolipoma is a common benign solid tumour that accounts for up to 3% of all renal tumours; most of the cases are sporadic. However, it can be part of other diseases. Angiomyolipomas are usually found incidentally through unrelated clinically indicated images but also, they can be diagnosed after complications have occurred. We report the case of retroperitoneal haemorrhage following the rupture of renal angiomyolipoma post-fibrinolysis, we are highlighting such a rare condition, the management options and the follow-up plan. The management of angiomyolipomas ranges from conservative treatment to surgical intervention depending on the patient's condition and the tumour's radiological features. Following-up on patients with angiomyolipomas depends on the symptoms and the tumour size. Till date, there is no reported cases of renal angiomyolipoma rupture post-fibrinolysis therapy as a treatment for myocardial infarction in non-percutaneous intervention capable facility.

Disparities in Referral and Utilization of Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Cardiac Death

BACKGROUND

Implantable cardioverter-defibrillators (ICDs) reduce mortality in patients with reduced left ventricular ejection fraction (LVEF). We investigated sex disparities in a contemporary Canadian population for utilization of primary prevention ICDs.

METHODS

This was a retrospective cohort study on patients with reduced LVEF admitted to hospitals from 2010 to 2020 in Nova Scotia (population = 971,935).

RESULTS

There were 4406 patients eligible for ICDs: 3108 (71%) men and 1298 (29%) women. The mean follow-up time was 3.9 ± 3.0 years. Rates of coronary disease were similar between men and women (45.8% vs 44.0%; P = 0.28), but men had lower LVEF (26.6 ± 5.9% vs 27.2 ± 5.8%; P = 0.0017). The referral rate for ICD was 11% (n = 487), with 13% of men (n = 403) and 6.5% of women (n = 84) referred (P < 0.001). The ICD implantation rate in the population was 8% (n = 358), with 9.5% of men (n = 296) and 4.8% of women (n = 62) (P < 0.001) receiving the device. Men were more likely than women to receive an ICD (odds ratio 2.08, 95% confidence interval 1.61-2.70; P < 0.0001)). There was no significant difference in mortality between men and women (P = 0.2764). There was no significant difference in device therapies between men and women (43.8% vs 31.1%; P = 0.0685).

CONCLUSIONS

A significant disparity exists in the utilization of primary prevention ICDs between men and women in a contemporary Canadian population.

Cardiac defibrillator implantation in patients with syncope and inducible ventricular arrhythmia: insights from the German Device Registry

History of syncope is an independent predictor for sudden cardiac death. Programmed stimulation may be considered for risk stratification, but data remain sparse among different populations. Here, we analyzed the prognostic value of inducible ventricular arrhythmia (VA) regarding clinical outcome in patients with syncope undergoing defibrillator implantation. Among 4196 patients enrolled in the prospective, multi-center German Device Registry, patients with syncope and inducible VA (n = 285, 6.8%) vs. those with a secondary preventive indication (n = 1885, 45.2%), defined as previously documented sustained ventricular tachycardia or ventricular fibrillation, serving as a control group were studied regarding demographics, device implantation and post-procedural adverse events. Patients with syncope and inducible VA (64.9 ± 14.4 years, 81.1% male) presented less frequently with congestive heart failure (15.1% vs. 29.1%; p < 0.001) and any structural heart disease (84.9% vs. 89.3%; p = 0.030) than patients with a secondary preventive indication (65.0 ± 13.8 years, 81.0% male). Whereas dilated cardiomyopathy (16.8% vs. 23.8%; p = 0.009) was less common, hypertrophic cardiomyopathy (5.6% vs. 2.8%; p = 0.010) and Brugada syndrome (2.1% vs. 0.3%; p < 0.001) were present more often. During 1-year-follow-up, mortality (5.1% vs. 8.9%; p = 0.036) and the rate of major adverse cardiac or cerebrovascular events (5.8% vs. 10.0%; p = 0.027) were lower in patients with syncope and inducible VA. Among patients with inducible VA, post-procedural adverse events including rehospitalization (27.6% vs. 21.7%; p = 0.37) did not differ between those with vs. without syncope. Taken together, patients with syncope and inducible VA have better clinical outcomes than patients with a secondary preventive defibrillator indication, but comparable outcomes to patients without syncope, which underlines the relevance of VA inducibility, potentially irrespective of a syncope.

Use of Sacubitril/Valsartan Prior to Primary Prevention Implantable Cardioverter Defibrillator Implantation

Background

Implantable cardioverter defibrillators (ICDs) are an adjunct to guideline-directed medical therapy for heart failure with reduced ejection fraction. The uptake of sacubitril/valsartan in this population is not well described. We report the uptake and factors associated with sacubitril/valsartan use in patients with left ventricular dysfunction undergoing ICD implantation.

Methods

A retrospective chart review was performed on all patients with left ventricular dysfunction who underwent de novo primary prevention ICD implantation between October 2015 and December 2021 (n = 422) at Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Pre-procedure sacubitril/valsartan use was determined. Logistic regression analysis was performed to examine factors associated with sacubitril/valsartan use. A Bayesian estimator of abrupt change was employed to determine a time period in which a change in the rate of sacubitril/valsartan use occurred.

Results

Loop diuretic use (odds ratio [OR] = 2.20) and higher severity of New York Heart Association class symptoms (OR = 1.62) were associated with sacubitril/valsartan use. Sacubitril/valsartan use increased during the study period, to 59% in December 2021. This increase was larger among those aged ≥ 65 years (OR = 1.09). A change in the rate of sacubitril/valsartan use occurred 3 years after drug approval, 1 year after provincial drug coverage became available, and 6 months after being strongly recommended in clinical guidelines.

Conclusions

In a contemporary cohort of ICD patients, sacubitril/valsartan use increased between 2015 and 2021, notably in those aged ≥ 65 years and after government drug coverage became available. Understanding barriers to sacubitril/valsartan use in ICD patients is recommended to improve clinical outcomes and survival in this population.

Incidence and Predictors of Implantable Cardioverter-defibrillator Therapies After Generator Replacement-A Pooled Analysis of 31,640 Patients' Data

Among primary prevention implantable cardioverter-defibrillator (ICD) recipients, 75% do not experience any appropriate ICD therapies during their lifetime, and nearly 25% have improvements in their left ventricular ejection fraction (LVEF) during the lifespan of their first generator. The practice guidelines concerning this subgroup's clinical need for generator replacement (GR) remain unclear. We conducted a proportional meta-analysis to determine the incidence and predictors of ICD therapies after GR and compared this to the immediate and long-term complications. A systematic review of existing literature on ICD GR was performed. Selected studies were critically appraised using the Newcastle-Ottawa scale. Outcomes data were analyzed by random-effects modeling using R (R Foundation for Statistical Computing, Vienna, Austria), and covariate analyses were conducted using the restricted maximum likelihood function. A total of 31,640 patients across 20 studies were included in the meta-analysis with a median (range) follow-up of 2.9 (1.2-8.1) years. The incidences of total therapies, appropriate shocks, and anti-tachycardia pacing post-GR were approximately 8, 4, and 5 per 100 patient-years, respectively, corresponding to 22%, 12%, and 12% of patients of the total cohort, with a high level of heterogeneity across the studies. Greater anti-arrhythmic drug use and previous shocks were associated with ICD therapies post-GR. The all-cause mortality was approximately 6 per 100 patient-years, corresponding to 17% of the cohort. Diabetes mellitus, atrial fibrillation, ischemic cardiomyopathy, and the use of digoxin were predictors of all-cause mortality in the univariate analysis; however, none of these were found to be significant predictors in the multivariate analysis. The incidences of inappropriate shocks and other procedural complications were 2 and 2 per 100 patient-years, respectively, which corresponded to 6% and 4% of the entire cohort. Patients undergoing ICD GR continue to require therapy in a significant proportion of cases without any correlation with an improvement in LVEF. Further prospective studies are necessary to risk-stratify ICD patients undergoing GR.

Utilization and impact of cardiovascular magnetic resonance on patient management in heart failure: insights from the SCMR Registry

BACKGROUND

Cardiovascular magnetic resonance (CMR) is an important diagnostic test used in the evaluation of patients with heart failure (HF). However, the demographics and clinical characteristics of those undergoing CMR for evaluation of HF are unknown. Further, the impact of CMR on subsequent HF patient care is unclear. The goal of this study was to describe the characteristics of patients undergoing CMR for HF and to determine the extent to which CMR leads to changes in downstream patient management by comparing pre-CMR indications and post-CMR diagnoses.

METHODS

We utilized the Society for Cardiovascular Magnetic Resonance (SCMR) Registry as our data source and abstracted data for patients undergoing CMR scanning for HF indications from 2013 to 2019. Descriptive statistics (percentages, proportions) were performed on key CMR and clinical variables of the patient population. The Fisher's exact test was used when comparing categorical variables. The Wilcoxon rank sum test was used to compare continuous variables.

RESULTS

3,837 patients were included in our study. 94% of the CMRs were performed in the United States with China, South Korea and India also contributing cases. Median age of HF patients was 59.3 years (IQR, 47.1, 68.3 years) with 67% of the scans occurring on women. Almost 2/3 of the patients were scanned on 3T CMR scanners. Overall, 49% of patients who underwent CMR scanning for HF had a change between the pre-test indication and post CMR diagnosis. 53% of patients undergoing scanning on 3T had a change between the pre-test indication and post CMR diagnosis when compared to 44% of patients who were scanned on 1.5T (p < 0.01).

CONCLUSION

Our results suggest a potential impact of CMR scanning on downstream diagnosis of patients referred for CMR for HF, with a larger potential impact on those scanned on 3T CMR scanners.

Arrhythmic events and mortality in patients with cardiogenic shock on inotropic support: results of the DOREMI randomized trial

BACKGROUND

Inotropic support is widely used in the management of cardiogenic shock (CS). Existing data on the incidence and significance of arrhythmic events in patients with CS on inotropic support is at high risk of bias.

METHODS

The DObutamine compaREd to MIlrinone (DOREMI) trial randomized patients to receive dobutamine or milrinone in a double-blind fashion. Patients with and without arrhythmic events (defined as arrhythmias requiring intervention or sustained ventricular arrhythmias) were compared to (1) identify factors associated with their occurrence and (2) examine their association with in-hospital mortality and secondary outcomes.

RESULTS

Ninety-two patients (47.9%) had arrhythmic events, occurring equally with dobutamine and milrinone (P=0.563). The need for vasopressor support at inotrope initiation and a history of atrial fibrillation were positively associated with arrhythmic events whereas predominant right ventricular dysfunction, previous myocardial infarction, and increasing left ventricular ejection fraction were negatively associated with them. Supraventricular arrhythmic events were not associated with mortality (RR 0.97, 95% CI 0.68-1.40, P=0.879) but were positively associated with resuscitated cardiac arrests and hospital length of stay. Ventricular arrhythmic events were positively associated with mortality (RR 1.66, 95% CI 1.13-2.43; P=0.026) and resuscitated cardiac arrests. Arrhythmic events were most often treated with amiodarone (97%) and electrical cardioversion (27%), which were not associated with mortality.

CONCLUSIONS

Clinically relevant arrhythmic events occur in approximately half of patients with CS treated with dobutamine or milrinone and are associated with adverse clinical outcomes. Five factors may help identify patients most at risk of arrhythmic events.

Implantable Cardioverter Defibrillator in Primary and Secondary Prevention of SCD-What We Still Don't Know

Implantable cardioverter defibrillators (ICDs) are the cornerstone of primary and secondary prevention of sudden cardiac death (SCD) all around the globe. In almost 40 years of technological advances and multiple clinical trials, there has been a continuous increase in the implantation rate. The purpose of this review is to highlight the grey areas related to actual ICD recommendations, focusing specifically on the primary prevention of SCD. We will discuss the still-existing controversies strongly reflected in the differences between the international guidelines regarding ICD indication class in non-ischemic cardiomyopathy, and also address the question of early implantation after myocardial infarction in the absence of clear protocols for patients at high risk of life-threatening arrhythmias. Correlating the insufficient data in the literature for 40-day waiting times with the increased risk of SCD in the first month after myocardial infarction, we review the pros and cons of early ICD implantation.

Clinical electrophysiology of the aging heart

INTRODUCTION

Advancements in medical and consumer-grade technologies have made it easier than ever to monitor a patient's heart rhythm and to diagnose arrhythmias. Octogenarians with symptomatic arrhythmias have unique management challenges due to their frailty, complex drug interactions, cognitive impairment, and competing comorbidities. The management decisions are further complicated by the lack of randomized evidence to guide treatment.

AREAS COVERED

A comprehensive literature review was undertaken to outline various tachyarrhythmias and bradyarrhythmias and their management, the role of cardiac implantable electronic devices, cardiac ablations, and specific geriatric arrhythmia considerations as recommended in international guidelines.

EXPERT OPINION

Atrial fibrillation (AF) is arguably the most important arrhythmia in the elderly and is associated with significant morbidity and mortality. Early diagnosis of AF, potentially with smart devices (wearables), has the potential to reduce the incidence of stroke, systemic emboli, and the risk of dementia. Bradyarrhythmias have a high incidence in the elderly as well, often requiring implantation of a permanent pacemaker. Leadless pacemakers implanted directly into the right ventricle are great options for gaining traction in elderly patients.

DREAM-ICD-II Study

BACKGROUND

Regulatory authorities of most industrialized countries recommend 6 months of private driving restriction after implantation of a secondary prevention implantable cardioverter-defibrillator (ICD). These driving restrictions result in significant inconvenience and social implications. This study aimed to assess the incidence rate of appropriate device therapies in contemporary recipients of a secondary prevention ICD.

METHODS

This retrospective study at 3 Canadian tertiary care centers enrolled consecutive patients with new secondary prevention ICD implants between 2016 and 2020.

RESULTS

For a median of 760 days (324, 1190 days), 721 patients were followed up. The risk of recurrent ventricular arrhythmia was highest during the first 3 months after device insertion (34.4%) and decreased over time (10.6% between 3 and 6 months, 11.7% between 6 and 12 months). The corresponding incidence rate per 100 patient-days was 0.48 (95% CI, 0.35-0.64) at 90 days, 0.28 (95% CI, 0.17-0.45) at 180 days, and 0.21 (95% CI, 0.13-0.33) between 181 and 365 days after ICD insertion (P<0.001). The cumulative incidence of arrhythmic syncope resulting in sudden cardiac incapacitation was 1.8% within the first 90 days and subsequently dropped to 0.4% between 91 and 180 days (P<0.001) after ICD insertion.

CONCLUSIONS

The incidence rate of appropriate therapies resulting in sudden cardiac incapacitation in contemporary recipients of a secondary prevention ICD is much lower than previously reported and declines significantly after the first 3 months. Lowering driving restrictions to 3 months after the index cardiac event seems safe, and revision of existing guidelines should be considered in countries still adhering to a 6-month period. Existing restrictions for private driving after implantation of a secondary prevention ICD should be reconsidered.

Axillary vein access using ultrasound guidance, Venography or Cephalic Cutdown-What is the optimal access technique for insertion of pacing leads?

We reviewed the different approaches used for central vein access during insertion of cardiac implantable electronic devices. The benefits and hazards of each approach (cephalic vein cutdown, axillary vein cannulation using venography and ultrasound) are discussed. Each approach has its advantages and hazards that need to be considered for the individual patient and balanced against the skills of the operator. The benefits of ultrasound guided venous access in reducing radiation exposure to the patient and implanter, avoiding the need for angiographic contrast and in minimizing the risk of pneumothorax and inadvertent arterial puncture are highlighted. Trainees should be taught each approach to deal with patient variability. Ultrasound guidance should be considered as a mainstream option for most patients.

Variability in Reassessment of Left Ventricular Ejection Fraction After Myocardial Infarction in the Acute Myocardial Infarction Quality Assurance Canada Study

IMPORTANCE

Persistently depressed left ventricular ejection fraction (LVEF) after myocardial infarction (MI) is associated with adverse prognosis and directs the use of evidence-based treatments to prevent sudden cardiac death and/or progressive heart failure.

OBJECTIVE

To assess adherence with guideline-recommended LVEF reassessment and to study the evolution of LVEF over 6 months of follow-up.

DESIGN, SETTING, AND PARTICIPANTS

This was a multicenter cohort study at Canadian academic and community hospitals with on-site cardiac catheterization services. Patients with type 1 acute MI and LVEF less than or equal to 45% during the index hospitalization were enrolled between January 2018 and August 2019 and were followed-up for 6 months. Data analysis was performed from May 2020 to September 2021.

EXPOSURES

Baseline clinical factors, in-hospital care and LVEF, and site-specific features.

MAIN OUTCOMES AND MEASURES

The main outcomes were receipt of repeat LVEF assessment by 6 months and the presence of a persistent LVEF reduction at 2 thresholds: LVEF less than or equal to 40%, prompting consideration of additional medical therapy for heart failure, or LVEF less than or equal to 35%, prompting referral for implanted cardioverter defibrillator in addition to medical therapy.

RESULTS

This study included 501 patients (mean [SD] age, 63.3 [13.0] years; 113 women [22.6%]). Overall, 370 patients (73.4%) presented with STEMI, and 454 (90.6%) had in-hospital revascularization. The median (IQR) baseline LVEF was 40% (34%-43%). Of 458 patients (91.4%) who completed the 6-month follow-up, 303 (66.2%; 95% CI, 61.7%-70.5%) had LVEF reassessment, with a range of 46.7% to 90.0% across sites (χ213 = 19.6; P = .11). Participants from community hospitals were more likely than those from academic hospitals to undergo LVEF reassessment (73.6% vs 63.2%; χ21 = 4.50; P = .03), as were those with worse LVEF at baseline. Follow-up LVEF improved by an absolute median (IQR) of 8% (3%-15%). However, 103 patients (34.1%) met the definitions of clinically relevant LVEF reduction, including 52 patients (17.2%) with LVEF less than or equal to 35% and 51 patients (16.9%) with LVEF of 35.1% to 40.0%.

CONCLUSIONS AND RELEVANCE

In this cohort study, approximately 1 in 3 patients with at least mild LVEF reduction after acute MI did not undergo indicated LVEF reassessment within 6 months, suggesting that programs to improve the quality of post-MI care should include measures to ensure that indicated repeat cardiac imaging is performed. In those with follow-up imaging, clinically relevant persistent LVEF reduction was identified in more than one-third of patients.

Characteristics of Clinicians Are Associated With Their Beliefs About ICD Deactivation: Insight From the DECIDE-HF Study

Background

Discussing goals of care with heart failure patients is recommended but is not done systematically, due to factors such as time and personal beliefs. A recent survey showed that one-fifth of clinicians believe that implantable cardioverter defibrillator deactivation (ICDD) is unethical or constitutes physician-assisted suicide. We investigated whether individuals’ characteristics are associated with these beliefs.

Methods

The Decision-Making About Goals of Care for Hospitalized Patients With Heart Failure (DECIDE-HF) survey was given to healthcare providers at 9 hospitals to assess their perceived barriers to goals-of-care discussions. The association between respondent characteristics and their beliefs was examined using 2 adjusted logistic regression models.

Results

We included 760 clinicians (459 nurses, 94 fellows, and 207 cardiologists). The responses varied among professions, with the belief that ICDD is unethical considered to be important barrier by nurses (24%), fellows (10%), and staff (7%); P < 0.001). After adjusting for site, spirituality being more important in life (odds ratio [OR]: 2.21; 95% confidence interval [CI]:1.37-3.56; P = 0.001, compared to less important), region of training (Asia [OR: 5.88; 95% CI: 2.12-16.31; P = 0.001] and Middle East [OR: 5.55; 95% CI:1.57-19.63; P = 0.008] compared to Canada), and years in practice (OR: 1.32; 95% CI: 1.07-1.63; P = 0.01 per decade) influenced beliefs about ICDD being unethical, with similar results for the belief that ICDD represents physician-assisted suicide.

Conclusions

Sociocultural factors, region of training, and profession influence clinicians’ beliefs about ICDD being unethical and representing physician-assisted suicide. These factors and beliefs must be acknowledged when facing the delicate issue of end-of-life discussion.

Development and external validation of prognostic models to predict sudden and pump-failure death in patients with HFrEF from PARADIGM-HF and ATMOSPHERE

Background

Sudden death (SD) and pump failure death (PFD) are the two leading causes of death in patients with heart failure and reduced ejection fraction (HFrEF).

Objective

Identifying patients at higher risk for mode-specific death would allow better targeting of individual patients for relevant device and other therapies.

Methods

We developed models in 7156 patients with HFrEF from the Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure (PARADIGM-HF) trial, using Fine-Gray regressions counting other deaths as competing risks. The derived models were externally validated in the Aliskiren Trial to Minimize Outcomes in Patients with Heart Failure (ATMOSPHERE) trial.

Results

NYHA class and NT-proBNP were independent predictors for both modes of death. The SD model additionally included male sex, Asian or Black race, prior CABG or PCI, cancer history, MI history, treatment with LCZ696 vs. enalapril, QRS duration and ECG left ventricular hypertrophy. While LVEF, ischemic etiology, systolic blood pressure, HF duration, ECG bundle branch block, and serum albumin, chloride and creatinine were included in the PFD model. Model discrimination was good for SD and excellent for PFD with Harrell’s C of 0.67 and 0.78 after correction for optimism, respectively. The observed and predicted incidences were similar in each quartile of risk scores at 3 years in each model. The performance of both models remained robust in ATMOSPHERE.

Conclusion

We developed and validated models which separately predict SD and PFD in patients with HFrEF. These models may help clinicians and patients consider therapies targeted at these modes of death.

Trial registration number

PARADIGM-HF: ClinicalTrials.gov NCT01035255, ATMOSPHERE: ClinicalTrials.gov NCT00853658.

Graphics abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-021-01888-x.

Positron Emission Tomography Imaging of Regional Versus Global Myocardial Sympathetic Activity to Improve Risk Stratification in Patients With Ischemic Cardiomyopathy

BACKGROUND

Current risk assessment approaches fail to identify the majority of patients at risk of sudden cardiac arrest (SCA). Noninvasive imaging of the cardiac sympathetic nervous system using single-photon emission computed tomography and positron emission tomography offers the potential for refining SCA risk assessment. While various [11C]meta-hydroxyephedrine quantification parameters have been proposed, it is currently unknown whether regional denervation or global innervation yields greater SCA risk discrimination. The aim of the study was to determine whether the global innervation parameters yield any independent and additive prognostic value over the regional denervation alone.

METHODS

In a post hoc competing-risks analysis of the PAREPET trial (Prediction of Arrhythmic Events With Positron Emission Tomography), we compared global innervation and regional denervation parameters using the norepinephrine analog [11C]meta-hydroxyephedrine for SCA risk discrimination. Patients with ischemic cardiomyopathy (n=174) eligible for an implantable cardioverter-defibrillator for the primary prevention of SCA were recruited into the trial. [11C]meta-hydroxyephedrine uptake and clearance rates were measured to assess global (left ventricle mean) retention index and volume of distribution. Regional defects were quantified as the percentage of the left ventricle having values <75% of the maximum.

RESULTS

During a median follow-up of 4.2 years, there were 56 cardiac-related deaths, of which 26 were SCAs. For any given regional denervation volume, there was substantial heterogeneity in global innervation scores. Global retention index and distribution volume did not decrease until regional defects exceeded 40% left ventricle. Global scale parameters, retention index, and distribution volume (area under the curve=0.61, P=0.034, P=0.046, respectively), yielded inferior SCA risk discrimination compared to regional heterogeneity (area under the curve=0.74).

CONCLUSIONS

Regional denervation volume has superior cause-specific mortality prediction for SCA versus global parameters of sympathetic innervation. These results have widespread implications for future cardiac sympathetic imaging, which will greatly simplify innervation analysis. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01400334.

Testing a nurse-led, pre-implantation educational intervention for primary prevention implantable cardioverter-defibrillator candidates: a randomized feasibility trial

AIMS

Implantable cardioverter-defibrillators (ICDs) deliver therapy for life-threatening arrhythmias. Evidence suggests that ICD candidates have misconceptions regarding ICD therapy and unmet information needs. We undertook a pilot feasibility trial comparing a nurse-led educational intervention plus standard care, vs. standard pre-ICD implantation care. Secondary aims included examination of anxiety, quality of life, and shock anxiety.

METHODS AND RESULTS

Implantable cardioverter-defibrillator candidates were consented and randomized to standard pre-ICD implantation care vs. standard care plus a nurse-led educational intervention. The primary feasibility outcomes included: recruitment rate, consent rate, randomization rate, proportion of participants able to complete all questionnaires, time to deliver intervention, and intervention topics completion. At baseline, demographic and Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety scores were collected. Four weeks post-ICD implantation, participants completed the PROMIS, Florida Patient Acceptance Survey (FPAS), and Florida Shock Anxiety Scale (FSAS). Twenty patients consented (10 per group). Feasibility targets were achieved for all but two outcomes: consent rate was 87% vs. 95% target, and completion of data collection measures was 85% vs. 90% target. Consent rate was lower than expected as one patient declined, and two could not be approached. Completion rate was lower than expected as two patients were lost to follow-up, and one did not receive an ICD during the study period, leading to incomplete post-implantation survey collections.

CONCLUSION

The results demonstrate the feasibility of conducting a trial comparing a nurse-led pre-implantation educational intervention to standard care in an outpatient setting. Further study to evaluate the effectiveness of this intervention on patient-reported outcomes is warranted.

Experiences of adults living with an implantable cardioverter defibrillator for cardiovascular disease: a systematic review of qualitative evidence

OBJECTIVE

The objective of this review was to synthesize the best available qualitative evidence on the everyday life experiences of adults living with an implantable cardioverter defibrillator for cardiovascular disease.

INTRODUCTION

Cardiovascular disease is a rising concern worldwide. The efficacy of the implantable cardioverter defibrillator as a successful treatment for cardiovascular disease has been well documented. Research suggests that living with an implantable cardioverter defibrillator is complex and can cause substantial psychosocial distress that can manifest itself at various intervals over time. The first step to developing evidence-based recommendations related to the management of implantable cardioverter defibrillator-related distress is a critical appraisal and synthesis of relevant literature to gain a more comprehensive understanding of this phenomenon.

INCLUSION CRITERIA

The participants of interest were adults 18 years or older who had an implantable cardioverter defibrillator for the management of cardiovascular disease (e.g. ischemic heart disease, angina, cardiomyopathy, myocardial infarction, congenital defect, arrhythmias, heart failure). The phenomenon of interest was the everyday life experience of adults living with an implantable cardioverter defibrillator. The review considered all qualitative research related to the phenomenon of interest.

METHODS

Key databases searched were PubMed, CINAHL, PsycINFO, Embase, International Bibliography of the Social Sciences, Sociological Abstracts, OpenGrey, MedNar, ProQuest Dissertations and Theses Global, Google, and Google Scholar. Published and unpublished papers and articles from 1990 to July 2018 were included in the search. The JBI approach to critical appraisal, study selection, data extraction, and synthesis for qualitative research was used throughout the review.

RESULTS

Twenty-seven papers were included in the review that yielded 143 findings and 13 categories. The methodological quality of the 27 included studies was moderate to strong. Based on ConQual scores, confidence in the synthesized findings was moderate. From this, three synthesized findings were extracted: i) living under the shadow of uncertainty, ii) orchestrating a new normal, and iii) crafting a positive vision for the future.

CONCLUSIONS

Evidence suggests that while implantable cardioverter defibrillator recipients do experience psychosocial distress, they gradually positively embrace the device as part of their everyday norm. Recommendations for practice and education point to the further development of best practice guidelines for implantable cardioverter defibrillator management, continuing education programs for health care providers, and strategies to support implantable cardioverter defibrillator recipients and their families to cope with the device. Research that examines onset, level, and duration of implantable cardioverter defibrillator psychosocial distress is needed to target specific interventions reflective of this population's needs. While findings suggest the experiences of women living with an implantable cardioverter defibrillator are similar to men, the low number of women in included studies limits the strength of this conclusion.

Predictors of appropriate shock after generator replacement in patients with an implantable cardioverter defibrillator

BACKGROUND

Implantable cardioverter defibrillators (ICDs) are indicated for the primary prevention of sudden cardiac death in patients with reduced left ventricular ejection fraction (LVEF). The ongoing risk/benefit profile of an ICD at generator replacement is unknown. This study aimed to identify predictors of appropriate ICD shocks and therapies after first ICD generator replacement, and its procedure-related complications.

METHODS

We conducted a multicenter, retrospective cohort study including patients with primary prevention ICDs who underwent generator replacement between April 2005 and July 2015 at three Canadian centers. The primary and secondary outcomes were appropriate ICD shock and any appropriate ICD therapy, respectively. Procedure-related complication rates were also reported.

RESULTS

Of the 219 patients in the cohort, 61 (28%) experienced an appropriate shock while 40 (18%) experienced appropriate antitachycardia pacing over a median follow up of 2.2 years. Independent predictors of appropriate ICD shocks included: LVEF at time of replacement (adjusted odds ratio [OR] 0.4 per 10% increase in LVEF, P < .001), a history of appropriate ICD shocks prior to replacement (OR 4.9, P < .001), and a history of inappropriate ICD shocks (OR 4.2, 95%, P < .002). Similar predictors were identified for the secondary outcome of any appropriate ICD therapy. Device-related complications were reported in 25 (11%) patients, with 1 (0.5%) resulting in death, 14 (6.3%) requiring site re-operation, and 6 (2.7%) requiring cardiac surgical management.

CONCLUSION

Not all primary prevention ICD patients undergoing generator replacement will require appropriate device therapies afterwards. Generator replacement is associated with several risks that should be weighed against its anticipated benefit. A comprehensive assessment of the risk-benefit profile of patients undergoing generator replacement is warranted.

The Optimal Timing of Primary Prevention Implantable Cardioverter-Defibrillator Referral in the Rapidly Changing Medical Landscape

The use of implantable cardioverter-defibrillators (ICDs) significantly reduces the risk of mortality in patients with heart failure with reduced ejection fraction (HFrEF). Current guidelines, which are based on seminal clinical trials published nearly 2 decades ago, recommend that patients be on optimal medical therapy for HF for a minimum of 3 months before referral for prophylactic ICD. This waiting period allows for left ventricular reverse remodelling and improvement in HF symptoms, which may render primary prevention ICD implantation unnecessary. However, medical therapy for HFrEF has significantly evolved since the publication of these landmark trials. Given the plethora of medical therapy options now available for HFrEF, it is appropriate to reassess the duration of this waiting period. In the present review, we examine the landmark randomised trials in primary prevention of sudden cardiac death in patients with HFrEF, summarise the novel medical therapies (sacubitril-valsartan, sodium-glucose cotransporter 2 inhibitors, ivabradine, vericiguat, and omecamtiv mecarbil) that have emerged since the publication of those trials, discuss the optimal timing of ICD referral, and review subtypes of nonischemic cardiomyopathy where timing of ICD insertion is guided by alternative criteria. With the steps now needed to optimise medical therapy for HFrEF, in terms of both classes of drugs and doses of each agent, it can easily take up to 6 months to achieve optimisation. Following that, waiting periods of 3 months for ischemic cardiomyopathy and 6 months for nonischemic cardiomyopathy may be required to allow adequate reverse remodelling before reevaluating for ICD implantation.

Remote Monitoring of Cardiovascular Implantable Electronic Devices in Canada: Survey of Patients and Device Health Care Professionals

Background

Remote monitoring is used to supplement in-clinic follow-up for patients with cardiac implantable electronic devices (CIEDs) every 6-12 months. There is a need to optimize remote management for CIEDs because of the consistent increases in CIED implants over the past decade. The objective of this study was to investigate real and perceived barriers to the use of remote patient management strategies in Canada and to better understand how remote models of care can be optimized.

Methods

We surveyed 512 CIED patients and practitioners in 22 device clinics in Canada.

Results

Device clinic surveys highlighted significant variation and inconsistency in follow-up care for in-clinic and remote visits across and within clinics. This survey showed that funding policies and management of additional workflow are barriers to optimal use and uptake. Despite this, device clinics perceive remote follow-up as a valuable resource and an efficient way to manage patient follow-up. Patients were broadly satisfied with their CIED follow-up care but identified barriers related to coordination of care, visit logistics, and information needs. Views varied as a function of clinical or sociodemographic characteristics. Most patients (n = 228; 91%) expressed a desire to receive a phone call from their device clinic after a remote transmission has been received.

Conclusions

Lack of a unified, guideline-supported approach to follow-up after CIED implant, and discrepant funding policies across jurisdictions, are significant barriers to the use of remote patient management strategies in Canada. Efforts to increase or expand use of remote follow-up must recognize these barriers and the needs of specific subgroups of patients.

Continued versus interrupted direct oral anticoagulation for cardiac electronic device implantation: A systematic review

BACKGROUND

Many patients undergoing cardiac device implantation are taking direct oral anticoagulation (DOAC). Continuing DOAC during device implantation may increase periprocedural bleeding risk; however, interrupting DOACs may increase thromboembolic risk.

OBJECTIVE

To compare the incidence of clinically significant pocket hematoma and thromboembolism in patients who have their DOAC continued or interrupted for cardiac device implantation.

METHODS

We searched MEDLINE, EMBASE, and randomized controlled trial (CENTRAL) until December 2019 and included randomized controlled trials (RCTs) and observational studies that compared outcomes after continuing or interrupting DOAC during cardiac device implantation. Independently and in duplicate, reviewers screened titles, abstracts, and full text of potentially eligible studies. They then evaluated risk of bias and abstracted data. RCT data were pooled using a fixed-effect model. Quality of evidence was assessed using grading of recommendations assessment, development and evaluation (GRADE).

RESULTS

Two RCTs, representing 763 patients, and three observational studies met eligibility criteria. In RCTs, continuing DOAC for device implantation compared to interrupting DOAC resulted in no significant difference in clinically significant pocket hematoma (2.1% vs 1.8%; RR 1.15; 95% CI 0.44-3.05) or thromboembolism (0.03% vs 0.03%; RR 1.02; 95% CI 0.06-16.21). Quality of evidence for both outcomes was moderate due to imprecision. Observational studies showed similar results.

CONCLUSIONS

Continuing DOACs for device implantation results in little to no difference in the incidence of clinically significant pocket hematoma or thromboembolism. Given the ease of stopping and restarting DOACs, interrupting DOACs may be the preferred strategy for most patients. However, whenever continuous therapeutic anticoagulation is desired, DOAC continuation should be preferred over bridging with parenteral anticoagulation.

Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) Study

BACKGROUND

Current guidelines recommend 4 weeks of private driving restriction after implantation of a primary-prevention implantable cardioverter-defibrillator (ICD). These driving restrictions result in significant inconvenience and social implications. Advances in medical treatment and ICD programming have lowered the overall rate of device therapies. The objective of this study was to assess the incidence of ICD therapies at 30, 60, and 180 days after implantation.

METHODS

Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) was a retrospective cohort study conducted at 2 Canadian university centres enrolling patients with new implantation of a primary-prevention ICD. Device programming was standardised according to current guidelines. A total of 803 patients were enrolled.

RESULTS

The cumulative rates of appropriate ICD therapies at 30, 60, and 180 days were 0.12%, 0.50%, and 0.75%, respectively. There was no syncope during the first 6 months. The median duration to the first appropriate ICD therapy was 208 (range 23-1109) days after implantation. The rate of inappropriate ICD therapies at 30 days was only 0.2%. Overall, < 13.6% of all appropriate ICD therapies occurred within the first 6 months after implantation.

CONCLUSIONS

The rate of appropriate ICD therapies within the first 30 days after device insertion is extremely low in contemporary primary prevention cohorts with guideline-concordant device programming. There was no increased risk for ventricular arrhythmia early after ICD insertion. The results of DREAM-ICD suggest the need for a revision of the existing driving restrictions for primary-prevention ICD recipients.

Prevalence and in-hospital outcomes of patients with malignancies undergoing de novo cardiac electronic device implantation in the USA

AIMS

To study the outcomes of cancer patients undergoing cardiac implantable electronic device (CIED) implantation.

METHODS AND RESULTS

De novo CIED implantations (2004-15; n = 2 670 590) from the National Inpatient Sample were analysed for characteristics and in-hospital outcomes, stratified by presence of cancer (no cancer, historical and current cancers) and further by current cancer type (haematological, lung, breast, colon, and prostate). Current and historical cancer prevalence has increased from 3.3% to 7.8%, and 5.8% to 7.8%, respectively, between 2004 and 2015. Current cancer was associated with increased adjusted odds ratio (OR) of major adverse cardiovascular events (MACE) [composite of all-cause mortality, thoracic and cardiac complications, and device-related infection; OR 1.26, 95% confidence interval (CI) 1.23-1.30], all-cause mortality (OR 1.43, 95% CI 1.35-1.50), major bleeding (OR 1.38, 95% CI 1.32-1.44), and thoracic complications (OR 1.39, 95% CI 1.35-1.43). Differences in outcomes were observed according to cancer type, with significantly worse MACE, mortality and thoracic complications with lung and haematological malignancies, and increased major bleeding in colon and prostate malignancies. The risk of complications was also different according to CIED subtype.

CONCLUSION

The prevalence of cancer patients amongst those undergoing CIED implantation has significantly increased over 12 years. Overall, current cancers are associated with increased mortality and worse outcomes, especially in patients with lung, haematological, and colon malignancies whereas there was no evidence that historical cancer had a negative impact on outcomes.

Decision Support for Implantable Cardioverter-Defibrillator Replacement: A Pilot Feasibility Randomized Controlled Trial

BACKGROUND

Decision support can help patients facing implantable cardioverter-defibrillator (ICD) replacement understand their options and reach an informed decision reflective of their preferences.

OBJECTIVE

The aim of this study was to evaluate the feasibility of a decision support intervention for patients faced with the decision to replace their ICD.

METHODS

A pilot feasibility randomized trial was conducted. Patients approaching ICD battery depletion were randomized to decision support intervention or usual care. Feasibility outcomes included recruitment rates, intervention use, and completeness of data; secondary outcomes were knowledge, values-choice concordance, decisional conflict, involvement in decision making, and choice.

RESULTS

A total of 30 patients were randomized to intervention (n = 15) or usual care (n = 15). The intervention was used as intended, with 2% missing data. Patients in the intervention arm had better knowledge (77.4% vs 51.1%; P = .002). By 12 months, 8 of 13 (61.5%) in the intervention arm and 10 of 14 (71.4%) in the usual care arm accepted ICD replacement; 1 per arm declined (7.7% vs 7.1%, respectively).

CONCLUSION

It was feasible to deliver the intervention, collect data, despite slow recruitment. The decision support intervention has the potential to improve ICD replacement decision quality.

Awake and aware with ongoing ventricular fibrillation during LVAD treatment: is it possible?

Left ventricular assist devices (LVADs) are currently used as destination therapy or bridge to heart transplantation in patients with advanced chronic heart failure (CHF). It has been proved to reduce mortality and symptoms in these patients. Patients with advanced CHF are known to have increased risk of ventricular arrhythmias (ventricular tachycardia or ventricular fibrillation (VF)) despite the presence of LVAD. We report the case of patients with ongoing VF during LVAD treatment while being awake and aware. We discuss the challenges introduced along with the increasing use of LVAD treatment. The decision whether a patient with LVAD automatically should have an implantable cardioverter-defibrillator is challenging. Randomised trials are warranted to shed light on these challenging decisions.

Mortality and Heart Failure After Upgrade to Cardiac Resynchronization Therapy

Background

Cardiac resynchronization therapy (CRT) is effective in treating advanced heart failure (HF), but data describing benefits and long-term outcomes for upgrades from a preexisting device are limited. This study sought to compare long-term outcomes in de novo CRT implants with those eligible for CRT with a prior device.

Methods

This is a retrospective cohort study using data from a provincial registry (2002-2015). Patients were included if they had mild-moderate HF, left ventricular ejection fraction ≤ 35%, and QRS duration ≥ 130 ms. Patients were classified as de novo CRT or upgraded to CRT from a prior device. Outcomes were mortality and composite mortality and HF hospitalization.

Results

There were 342 patients included in the study. In a multivariate model, patients in the upgraded cohort (n = 233) had a higher 5-year mortality rate (adjusted hazard ratio, 2.86; 95% confidence interval, 1.59-5.15; P = 0.0005) compared with the de novo cohort (n = 109) and higher composite mortality and HF hospitalization (adjusted hazard ratio, 2.60; 95% confidence interval, 1.54-4.37; P = 0.0003).

Conclusions

Implantation of de novo CRTs was associated with lower mortality and HF hospitalization compared with upgraded CRTs from preexisting devices. It is unknown whether these differences are due to the timing of CRT implementation or other clinical factors. Further work in this area may be helpful to determine how to improve outcomes for these patients.

A Population-Based Study of Device Eligibility, Use, and Reasons for Nonimplantation in Patients at Heart Function Clinics

Background

Implantable cardioverter defibrillator (ICD) therapy is lifesaving; however, real-world data regarding the proportion of patients eligible for a primary prevention ICD and subsequent use remain sparse. This study evaluated rates of primary prevention ICD eligibility and use among patients in heart function clinics (HFCs) and to identify reasons for nonimplantation.

Methods

A retrospective study was performed of patients seen at HFCs in Alberta, Canada, from 2013 to 2015. Demographics, comorbidities, clinical indications, and reasons for nonimplantation were abstracted. Eligibility was defined according to the 2008 American College of Cardiology/American Heart Association/Heart Rhythm Society ICD, 2012 American College of Cardiology/American Heart Association/Heart Rhythm Society Focused Update, and 2013 Canadian Cardiovascular Society Cardiac Resynchronization Therapy guidelines. Logistic regression was used to calculate an odds ratio (OR) and 95% confidence interval (CI) for predictors of nonimplantation.

Results

Among 1239 patients in HFCs, the median age was 70 years (interquartile range, 59-80), 67% were male, and the median left ventricular ejection fraction was 0.40 (interquartile range, 0.28-0.53). Overall, 45% of patients (n = 553) met guideline criteria for an ICD, and of those, 36% (n = 198) received a device. Among device nonrecipients, 52% (n = 185) had no documented reason for nonimplantation. The most common reason for nonimplantation among nonrecipients was patient preference (48%). Predictors associated with nonimplantation were age more than 75 years (OR, 1.92; 95% CI, 1.31-2.82) and history of cancer (OR, 2.26; 95% CI, 1.07-4.78). At 3 years follow-up, 27% of nonrecipients were deceased.

Conclusions

We found that one-third of patients who met guideline criteria received an ICD and that documentation for nonimplantation was poor.

Irreversible Acquired Noncompaction Cardiomyopathy in a Parturient with Corrected Atrial Septal Defect: A Case Report and Clinical Implications

Left ventricular noncompaction (LVNC) is described as a cardiomyopathy with an increase in left ventricle trabeculations and recesses. We report a rare case of persistent pregnancy-acquired LVNC cardiomyopathy and review the anesthetic peripartum management strategies. A 33-year-old parturient was followed closely by the high-risk obstetric service for her second pregnancy. She had an unresolved LVNC cardiomyopathy that was diagnosed during her first pregnancy for which she had a caesarean section. Her symptoms included occasional palpitations and dyspnea. She was started on metoprolol and enoxaparin. A successful caesarean section was performed at 37 weeks gestation under regional anesthesia. Echocardiograms prior to and during the second pregnancy demonstrated persistence of the LV hypertrabeculations, LV systolic dysfunction, and a left ventricular ejection fraction (LVEF) of 35%. Pregnancy-induced LV hypertrabeculations occur in a significant proportion of women, but most cases spontaneously resolve completely. Favorable maternal and fetal outcomes require multidisciplinary care and careful selection of the anesthetic technique and drugs that maintain stable hemodynamics.

Co-construction of health technology assessment recommendations with patients: An example with cardiac defibrillator replacement

CONTEXT

The National Institute of Excellence in Health and Social Services (INESSS), which functions as the Québec health technology assessment (HTA) agency, tested a new way to engage patients along with health-care professionals in the co-construction of recommendations regarding implantable cardioverter-defibrillator replacement.

OBJECTIVE

The objective of this article was to describe the process of co-construction of recommendations and to propose methods of building best practices for patient involvement (PI) in HTA.

DESIGN

Throughout the process, documents were collected and participant observations were made. Individual interviews were conducted with patients, health-care professionals and the INESSS scientific team, from January to March 2018.

RESULTS

Three committees were established: an expert patient committee to reflect on patient experience literature; an expert health professional committee to reflect on medical literature; and a co-construction committee through which both patients and health-care professionals contributed to develop the recommendations. The expert patients validated and contextualized a literature review produced by the scientific team. This allowed the scientists to consider aspects related to the patient experience and to integrate the feedback from patients into HTA recommendations. The most important factor contributing to a positive PI experience was the structured methodology for selecting patient participants, and a key factor that inhibited the process was a lack of training in PI on the part of the scientific team.

CONCLUSIONS

This experience demonstrates that it is possible to co-construct recommendations, even for technically complex HTA subjects, through a more democratic process than usual which led to more patient-focused guidance.

Medical Management of Left Ventricular Assist Device Patients: A Practical Guide for the Nonexpert Clinician

Left ventricular assist devices (LVADs) provide short- or long-term circulatory support to improve survival and reduce morbidity in selected patients with advanced heart failure. LVADs are being used increasingly and now have expanded indications. Health care providers across specialties will therefore not only encounter LVAD patients but play an integral role in their care. To accomplish that, they need to understand the elements of LVAD function, physiology and clinical use. This article provides a concise overview of the medical management of LVAD patients for nonexpert clinicians. Our presentation includes the basics of LVAD physiology, design, and operation, patient selection and assessment, medical management, adverse event identification and management, multidisciplinary care, and management of special circumstances, such as noncardiac surgery, cardiac arrest, and end-of-life care. The clinical examination of LVAD patients is unique in terms of blood pressure and heart rate assessment, LVAD "hum" auscultation, driveline and insertion site inspection, and device parameter recording. Important potential device-related adverse events include stroke, gastrointestinal bleeding, hematologic disorders, device infection, LVAD dysfunction, arrhythmias, and heart failure. Special considerations include the approach to the unconscious or pulseless patient, noncardiac surgery, and palliative care. An understanding of the principles presented in this paper will enable the nonexpert clinician to be effective in collaborating with an LVAD center in the assessment, medical management, and follow-up of LVAD patients. Future opportunities and challenges include the improvement of device designs, greater application of minimally invasive surgical implantation techniques, and management of health economics in cost-constrained systems like those of Canada and many other jurisdictions.

Prevalence, Outcomes, and Costs According to Patient Frailty Status for 2.9 Million Cardiac Electronic Device Implantations in the United States

BACKGROUND

Little is known about the impact of frailty on length of stay (LOS), cost, and in-hospital procedural outcomes of cardiac implantable electronic device (CIED) implantation procedures.

METHODS

All de novo CIED implantations recorded in the United States (2004-2014) from a national database were stratified according to the Hospital Frailty Risk Score into low-risk (LRF; <5), intermediate-risk (IRF; 5-15), and high-risk (HRF; > 15) frailty groups. Regression analyses were performed to assess the association between frailty and procedural outcomes.

RESULTS

Of 2,902,721 implantations, LRF, IRF, and HRF were 77.6%, 21.2%, and 1.2%, respectively. Frailty increased from 2004 to 2014 (IRF: 14.3% to 32.5%, HRF: 0.2% to 3.3%). Complications were 2- to 3-fold higher in the IRF and HRF groups, whereas all-cause mortality was 4- to 9-fold higher in the IRF (2.9%) and HRF (5.3%) groups, depending on the type of CIED (P < 0.001 for all). Rates of complications increased over the study years and all-cause mortality declined, especially in the higher frailty risk groups (2004 vs 2014; mortality: IRF: 3.8% vs 2.2%, HRF: 9.9% vs 4.5%; bleeding: IRF: 3.7% vs 9.0%, HRF: 3.9% vs 12.2%; thoracic: IRF: 4.3% vs 6.0%, HRF: 2.9% vs 9.1%; cardiac: IRF: 0.5% vs 0.9%, HRF: 0.5% vs 0.9%). Rising frailty was associated with an increase in cost (P < 0.001) and LOS (median 3, 8, 11 days for LRF, IRF, HRF, respectively, P < 0.001). The cost for patients with HRF receiving a defibrillator was approximately a quarter million USD$ per patient.

CONCLUSIONS

Frailty is associated with worse clinical outcomes, higher cost, and LOS independent of age or CIED type. Our findings emphasize the importance of frailty assessment.

Anti-arrhythmic drug therapy in implantable cardioverter-defibrillator recipients

Implantable cardioverter-defibrillators (ICDs) have revolutionized the primary and secondary prevention of patients with ventricular arrhythmias. However, the adverse effects of appropriate or inappropriate shocks may require the adjunctive use of anti-arrhythmic drugs (AADs). Beta blockers are the cornerstone of pharmacological primary and secondary prevention of ventricular arrhythmias. In addition to their established efficacy at reducing the incidence of ventricular arrhythmias, beta-blockers are safe with few side effects. Amiodarone is superior to beta blockers and sotalol for the prevention of ventricular arrhythmia recurrence. However, long-term amiodarone use is associated with significant side effects that limit its utility. Sotalol and mexiletine are the main alternatives to amiodarone with a better side effect profile though they are less efficacious at preventing ventricular arrhythmia recurrence. Dofetilide, azimilide and ranolazine are emerging as therapeutic options for secondary prevention; more studies are needed to assess efficacy and safety in comparison to currently used agents. Beta blockers and amiodarone are the mainstay of therapy in patients experiencing electrical storm; their use reduces the frequency of ventricular arrhythmias and ICD intervention as well as affording time until catheter ablation can be considered.

Clinical outcomes of cardiac resynchronization therapy with and without a defibrillator in elderly patients with heart failure

BACKGROUND

Evidence regarding the incremental benefit of cardiac resynchronization therapy (CRT) with a defibrillator (CRT-D) versus without (CRT-P) in elderly patients with heart failure is limited. We compared mortality and cardiac hospitalisation between CRT-D and CRT-P in the elderly.

METHODS

A retrospective chart review identified all consecutive patients with age ≥75 with CRT implantation over the last 10 years at a Canadian tertiary care cardiac centre. Kaplan-Meier survival analyses and cumulative incidence curves were used to compare mortality and time to first cardiac hospitalisation, respectively, with CRT-D versus CRT-P over a 3 year period. Analyses were also repeated with propensity score matching based on age, sex, primary versus secondary prevention, date of implant, and Charlson Comorbidity Index.

RESULTS

One hundred and seventy CRT patients were identified. A total of 128 received CRT-D while 42 received CRT-P. Median age was 79 (IQR 77-81), and the majority were male (83%). CRT-P patients had a higher burden of comorbidities (Charlson score 7, IQR 6-8) than CRT-D patients (Charlson score 5, IQR 5-7; P < 0.001). There was no significant difference in survival between the two groups in an unmatched comparison (P = 0.69) and with a propensity score-matched cohort (P = 0.91). Secondary prevention CRT-D patients had a higher risk of hospitalisation compared to primary prevention CRT-D patients; however, there was no significant difference in hospitalisation between the CRT-D and CRT-P groups.

CONCLUSION

This study suggests there is no significant difference in mortality or cardiac hospitalisation between CRT-D and CRT-P in elderly patients with heart failure.