Clinical risk profile score predicts all cause mortality but not implantable cardioverter defibrillator intervention rate in a large unselected cohort of patients with congestive heart failure

Cardiac sympathetic innervation and mortality risk scores in patients with heart failure

INTRODUCTION

In the risk stratification and selection of patients with heart failure (HF) eligible for implantable cardioverter-defibrillator (ICD) therapy, ¹²³ I-meta-IodineBenzylGuanidine (¹²³ I-mIBG) scintigraphy has emerged as an effective non-invasive method to assess cardiac adrenergic innervation. Similarly, clinical risk scores have been proposed to identify patients with HF at risk of all-cause mortality, for whom the net clinical benefit of device implantation would presumably be lower. Nevertheless, the association between the two classes of tools, one suggestive of arrhythmic risk, the other of all-cause mortality, needs further investigation.

OBJECTIVE

To test the relationship between the risk scores for predicting mortality and cardiac sympathetic innervation, assessed through myocardial ¹²³ I-mIBG imaging, in a population of patients with HF.

METHODS

In HF patients undergoing ¹²³ I-mIBG scintigraphy, eight risk stratification models were assessed: AAACC, FADES, MADIT, MADIT-ICD non-arrhythmic mortality score, PACE, Parkash, SHOCKED and Sjoblom. Cardiac adrenergic impairment was assessed by late heart-to-mediastinum ratio (H/M) <1.6.

RESULTS

Among 269 patients suffering from HF, late H/M showed significant negative correlation with all the predicting models, although generally weak, ranging from -0.15 (p = .013) for PACE to -0.32 (p < .001) for FADES. The scores showed poor discrimination for cardiac innervation, with areas under the curve (AUC) ranging from 0.546 for Parkash to 0.621 for FADES.

CONCLUSION

A weak association emerged among mortality risk scores and cardiac innervation, suggesting to integrate in clinical practice tools indicative of both arrhythmic and general mortality risks, when evaluating patients affected by HF eligible for device implantation.

Influence of diabetes on mortality and ICD therapies in ICD recipients: a systematic review and meta-analysis of 162,780 patients

Background

The influence of diabetes on the mortality and risk of implantable cardioverter defibrillator (ICD) therapies is still controversial, and a comprehensive assessment is lacking. We performed this systematic review and meta-analysis to address this controversy.

Methods

We systematically searched the PubMed, Embase, Web of Science and Cochrane Library databases to collect relevant literature. Fixed and random effects models were used to estimate the hazard ratio (HR) with 95% CIs.

Results

Thirty-six articles reporting on 162,780 ICD recipients were included in this analysis. Compared with nondiabetic ICD recipients, diabetic ICD recipients had higher all-cause mortality (HR = 1.45, 95% CI 1.36–1.55). The subgroup analysis showed that secondary prevention patients with diabetes may suffer a higher risk of all-cause mortality (HR = 1.89, 95% CI 1.56–2.28) (for subgroup analysis, P = 0.03). Cardiac mortality was also higher in ICD recipients with diabetes (HR = 1.68, 95% CI 1.35–2.08). However, diabetes had no significant effect on the risks of ICD therapies, including appropriate or inappropriate therapy, appropriate or inappropriate shock and appropriate anti-tachycardia pacing (ATP). Diabetes was associated with a decreased risk of inappropriate ATP (HR = 0.56, 95% CI 0.39–0.79).

Conclusion

Diabetes is associated with an increased risk of mortality in ICD recipients, especially in the secondary prevention patients, but does not significantly influence the risks of ICD therapies, indicating that the increased mortality of ICD recipients with diabetes may not be caused by arrhythmias. The survival benefits of ICD treatment in diabetes patients are limited.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01580-y.

One-year mortality after implantable defibrillator implantation: do risk stratification models help improving clinical practice?

PURPOSE

The purpose of this study was to assess the available mortality risk stratification models for implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy defibrillator (CRT-D) patients.

METHODS

We conducted a review of mortality risk stratification models and tested their ability to improve prediction of 1-year survival after implant in a database of patients who received a remotely controlled ICD/CRT-D device during routine care and included in the independent Home Monitoring Expert Alliance registry.

RESULTS

We identified ten predicting models published in peer-reviewed journals between 2000 and 2021 (Parkash, PACE, MADIT, aCCI, CHA2DS2-VASc quartiles, CIDS, FADES, Sjoblom, AAACC, and MADIT-ICD non-arrhythmic mortality score) that could be tested in our database as based on common demographic, clinical, echocardiographic, electrocardiographic, and laboratory variables. Our cohort included 1,911 patients with left ventricular dysfunction (median age 71, 18.3% female) from sites not using any risk stratification score for systematic patient screening. Patients received an ICD (53.8%) or CRT-D (46.2%) between 2011 and 2017, after standard physician evaluation. There were 56 deaths within 1-year post-implant, with an all-cause mortality rate of 2.9% (95% confidence interval [CI], 2.3-3.8%). Four predicting models (Parkash, MADIT, AAACC, and MADIT-ICD non-arrhythmic mortality score) were significantly associated with increased risk of 1-year mortality with hazard ratios ranging from 3.75 (CI, 1.31-10.7) to 6.53 (CI 1.52-28.0, p ≤ 0.014 for all four). Positive predictive values of 1-year mortality were below 25% for all models.

CONCLUSION

In our analysis, the models we tested conferred modest incremental predicting power to ordinary screening methods.

Clinical risk profile score predicts all cause mortality but not implantable cardioverter defibrillator intervention rate in a large unselected cohort of patients with congestive heart failure

BACKGROUND

Primary prophylactic implantable cardioverter defibrillator (ICD) therapy is indicated for patients with reduced left ventricular ejection fraction (LVEF). We aimed to determine if preoperative clinical risk profiling can predict long-term benefit, and if clinical risk scores can be applied and improved in a patient cohort outside the clinical trial setting.

METHODS

Using registry data, 789 patients with reduced LVEF who received ICDs for primary prevention during 2006-2011 were identified (age 64 ± 11 years, 82% men, 63% ischemic etiology, 52% cardiac resynchronization therapy with defibrillator). The patients were divided into three risk groups, based on the presence of baseline clinical risk factors (age >70, QRS duration >120 ms, New York Heart Association class III-IV, atrial fibrillation history, or creatinine >106 μmol/L). Endpoints were all-cause mortality and survival free of adequate ICD therapy.

RESULTS

Mean follow-up was 39 ± 18 months. Annual mortality was 7.6%, and increased with risk group (p < .001). Rates of appropriate antitachycardia pacing and shock therapy were not statistically different between the groups, and ranged from 11%-16% and 6%-14%, respectively. By combining the previous risk score with data on diabetes, a better independent prediction of mortality was achieved; mortality rates then ranged from 11% (low-risk) to 46% (high-risk) (p < .0001).

CONCLUSIONS

Implantable cardioverter defibrillator therapies occur across the spectrum of comorbidities in a population with systolic heart failure. However, all-cause mortality is considerably higher in the group of patients with accumulated risk factors, and using the proposed scoring system can be helpful for the evaluation and risk stratification of the patient prior to making a decision for a primary prophylactic ICD implantation.