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Cha YM, Lee HC, Mulpuru SK, Deshmukh AJ, Friedman PA, Asirvatham SJ, Bradley DJ, Madhavan M, Abou Ezzeddine OF, Wen S, Liddell BW, Curran C, Li C, Dasari S, Lanza IR, Bailey KR, Chen HH. Cardiac Resynchronization Therapy for Patients With Mild to Moderately Reduced Ejection Fraction and Left Bundle Branch Block. Heart Rhythm 2024:S1547-5271(24)02556-6. [PMID: 38772431 DOI: 10.1016/j.hrthm.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND It is unknown whether cardiac resynchronization therapy (CRT) would improve or halt the progression of heart failure (HF) in patients with mild to moderately reduced ejection fraction (HFmmrEF) and left bundle branch block (LBBB). OBJECTIVE This study aimed to investigate the outcomes of CRT in patients with HFmmrEF and left ventricular conduction delay. METHODS A prospective, randomized clinical trial sponsored by the National Heart, Lung, and Blood Institute included 76 patients who met the study inclusion criteria (left ventricular ejection fraction [LVEF] of 36%-50% and LBBB). Patients received CRT-pacemaker and were randomized to CRT-OFF (right ventricular pacing 40 beats/min) or CRT-ON (biventricular pacing 60-150 beats/min). At a 6-month follow-up, pacing programming was changed to the opposite settings. New York Heart Association class, N-terminal pro-brain natriuretic peptide levels, and echocardiographic variables were collected at baseline, 6 months, and 12 months. The primary study end point was the left ventricular end-systolic volume (LVESV) change from baseline, and the primary randomized comparison was the comparison of 6-month to 12-month changes between randomized groups. RESULTS The mean age of the patients was 68.4 ± 9.8 years (male, 71%). Baseline characteristics were similar between the 2 randomized groups (all P > .05). In patients randomized to CRT-OFF first, then CRT-ON, LVESV was reduced from baseline only after CRT-ON (baseline, 116.1 ± 36.5 mL; CRT-ON, 87.6 ± 26.0 mL; P < .0001). The randomized analysis of LVEF showed a significantly better change from 6 to 12 months in the OFF-ON group (P = .003). LVEF was improved by CRT (baseline, 41.3% ±.7%; CRT-ON, 46.0% ± 8.0%; P = .002). In patients randomized to CRT-ON first, then CRT-OFF, LVESV was reduced after both CRT-ON and CRT-OFF (baseline, 109.8 ± 23.5 mL; CRT-ON, 91.7 ± 30.5 mL [P < .0001]; CRT-OFF, 99.3 ± 28.9 mL [P = .012]). However, the LVESV reduction effect became smaller between CRT-ON and CRT-OFF (P = .027). LVEF improved after both CRT-ON and CRT-OFF (baseline, 42.7% ± 4.3%; CRT-ON, 48.5% ± 8.6% [P < .001]; CRT-OFF, 45.9% ± 7.7% [P = .025]). CONCLUSION CRT for patients with HFmmrEF significantly improves LVEF and ventricular remodeling after 6 months of CRT. The study provides novel evidence that early CRT benefits patients with HFmmrEF with LBBB.
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Affiliation(s)
- Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Hon-Chi Lee
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Siva K Mulpuru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - David J Bradley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Malini Madhavan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Songnan Wen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Brian W Liddell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Caroline Curran
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Chuanwei Li
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Surendra Dasari
- Department of Biomedical Informatics, Mayo Clinic, Rochester, Minnesota
| | - Ian R Lanza
- Division of Endocrinology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kent R Bailey
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Horng H Chen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Khor J, Diaz-Canestro C, Chan KY, Guo M, Montero D. Blood volume contributes to the mechanical synchrony of the myocardium during moderate and high intensity exercise in women. Eur J Appl Physiol 2024; 124:1227-1237. [PMID: 37985476 DOI: 10.1007/s00421-023-05355-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/28/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE Whether blood volume (BV) primarily determines the synchronous nature of the myocardium remains unknown. This study determined the impact of standard blood withdrawal on left ventricular mechanical dyssynchrony (LVMD) in women. METHODS Transthoracic speckle-tracking echocardiography and central hemodynamic measurements were performed at rest and during moderate- to high-intensity exercise in healthy women (n = 24, age = 53.6 ± 16.3 year). LVMD was determined via the time to peak standard deviation (TPSD) of longitudinal and transverse strain and strain rates (LSR, TSR). Measurements were repeated within a week period immediately after a 10% reduction of BV. RESULTS With intact BV, all individuals presented cardiac structure and function variables within normative values of the study population. Blood withdrawal decreased BV (5.3 ± 0.7 L) by 0.5 ± 0.1 L. Resting left ventricular (LV) end-diastolic volume (- 8%, P = 0.040) and passive filling (- 16%, P = 0.001) were reduced after blood withdrawal. No effect of blood withdrawal was observed for any measure of LVMD at rest (P ≥ 0.225). During exercise at a fixed submaximal workload (100 W), LVMD of myocardial longitudinal strain (LS TPSD) was increased after blood withdrawal (36%, P = 0.047). At peak effort, blood withdrawal led to increased LVMD of myocardial transverse strain rate (TSR TPSD) (31%, P = 0.002). The effect of blood withdrawal on TSR TPSD at peak effort was associated with LV concentric remodeling (r = 0.59, P = 0.003). CONCLUSION Marked impairments in the mechanical synchrony of the myocardium are elicited by moderate blood withdrawal in healthy women during moderate and high intensity exercise.
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Affiliation(s)
- Joyce Khor
- Faculty of Medicine, Institute of Cardiovascular Medicine and Science, University of Hong Kong, Hong Kong SAR, China
| | | | - Koot Yin Chan
- Faculty of Medicine, Institute of Cardiovascular Medicine and Science, University of Hong Kong, Hong Kong SAR, China
| | - Meihan Guo
- Faculty of Medicine, Institute of Cardiovascular Medicine and Science, University of Hong Kong, Hong Kong SAR, China
| | - David Montero
- Faculty of Medicine, Institute of Cardiovascular Medicine and Science, University of Hong Kong, Hong Kong SAR, China.
- Institute of Cardiovascular Science and Medicine, University of Hong Kong, Hong Kong, China.
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.
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Subzposh FA, Sharma PS, Cano Ó, Ponnusamy SS, Herweg B, Zanon F, Jastrzebski M, Zou J, Chelu MG, Vernooy K, Whinnett ZI, Nair GM, Molina-Lerma M, Curila K, Ellenbogen KA, Vijayaraman P. Sex-Specific Outcomes of LBBAP Versus Biventricular Pacing: Results From I-CLAS. JACC Clin Electrophysiol 2024; 10:96-105. [PMID: 37737782 DOI: 10.1016/j.jacep.2023.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 08/30/2023] [Accepted: 08/30/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) using biventricular pacing (BVP) has been associated with greater clinical improvement in women than men. Recently, left bundle branch area pacing (LBBAP) has been shown to be an alternative form of CRT. OBJECTIVES The purpose of this study was to investigate sex-specific outcomes for death and heart failure events in a large, international, multicenter, cohort of patients undergoing CRT with BVP or LBBAP. METHODS In this international study of 1,778 patients (575 female and 1203 male), sex-specific survival analysis was performed to compare the effect of LBBAP-CRT relative to BVP-CRT on the combined endpoint of death or heart failure hospitalization (HFH), and secondary endpoints of HFH only, and death alone. RESULTS Female patients were more likely to have nonischemic cardiomyopathy and left bundle branch block (LBBB) and less likely to have hypertension, diabetes, or coronary artery disease than were male patients. Overall, female patients had a better result with LBBAP compared with BVP than did male patients, with a significant 36% reduction in death or HFH (HR: 0.64; 95% CI: 0.43 to 0.97; P = 0.03) and a significant 60% reduction in HFH alone (HR: 0.4; 95% CI: 0.24 to 0.69, P < 0.01). Women had a greater reduction in death or HFH among those with nonischemic cardiomyopathy (HR: 0.45 95% CI: 0.26 to 0.79; P < 0.01) and LBBB (HR: 0.49; 95% CI: 0.27 to 0.87; P < 0.01). Sex-specific echocardiographic outcomes were better in women than in men. CONCLUSIONS Women obtained significantly greater reductions in the combined endpoint of death or HFH (primarily driven by reduction in HFH) with LBBAP compared with BVP among patients requiring CRT than did men.
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Affiliation(s)
| | | | - Óscar Cano
- Hospital Universitari i Politècnic La Fe and Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares,Valencia, Spain
| | | | - Bengt Herweg
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | | | - Marek Jastrzebski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Jiangang Zou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Mihail G Chelu
- Baylor College of Medicine and Texas Heart Institute, Houston, Texas, USA
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Karol Curila
- Cardiocenter, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic
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Dewidar O, Dawit H, Barbeau V, Birnie D, Welch V, Wells GA. Sex Differences in Implantation and Outcomes of Cardiac Resynchronization Therapy in Real-World Settings: A Systematic Review of Cohort Studies. CJC Open 2022; 4:75-84. [PMID: 35072030 PMCID: PMC8767135 DOI: 10.1016/j.cjco.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/02/2021] [Indexed: 11/29/2022] Open
Abstract
Background Evidence from randomized trials is conflicting on the effects of cardiac resynchronization therapy (CRT) by sex, and differences in access are unknown. We examined sex differences in the implantation rates and outcomes in patients treated with CRT using cohort studies. Methods We followed a pre-specified protocol (International Prospective Register of Systematic Reviews [PROSPERO]: CRD42020204804). MEDLINE, Embase, and Web of Science were searched for cohort studies from January 2000 to June 2020 that evaluated the response to CRT in patients ≥ 18 years old and reported sex-specific information in any language. Results We included 97 studies (1,172,654 men and 486,553 women). Men received CRT more frequently than women (median ratio, 3.16; 25th to 75th interquartile range, 2.48-3.62). In the unadjusted analysis, men had a greater long-term all-cause mortality rate after CRT, compared with women (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.38-1.63; P < 0.001). Adjustment for confounders did not affect the strength or direction of association (HR, 1.45; 95% CI, 1.32-1.59; P < 0.001). Women achieved a greater rate of improvement in left ejection fraction compared with men (HR, 4.66; 95% CI, 4.23-5.13; P < 0.001). Men had a lower risk of a pneumothorax (relative risk, 0.21; 95% CI, 0.13-0.34; P < 0.001]); otherwise, there were no differences in complications. Conclusions We found in this large meta-analysis that men were more often implanted with CRT than women, yet men had a higher long-term all-cause mortality following CRT, compared with women, and smaller improvement in left ventricular ejection fraction. Reasons for this difference in implantation rates of CRT in real-world practice need to be investigated.
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Affiliation(s)
- Omar Dewidar
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Corresponding author: Omar Dewidar, 1502-1541 Lycée Place, Ottawa, Ontario K1G 4E2, Canada. Tel.: +1-613-501-0632.
| | - Haben Dawit
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Victoria Barbeau
- Bruyère Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - David Birnie
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Vivian Welch
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - George A. Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Tokodi M, Behon A, Merkel ED, Kovács A, Tősér Z, Sárkány A, Csákvári M, Lakatos BK, Schwertner WR, Kosztin A, Merkely B. Sex-Specific Patterns of Mortality Predictors Among Patients Undergoing Cardiac Resynchronization Therapy: A Machine Learning Approach. Front Cardiovasc Med 2021; 8:611055. [PMID: 33718444 PMCID: PMC7947699 DOI: 10.3389/fcvm.2021.611055] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/27/2021] [Indexed: 12/31/2022] Open
Abstract
Background: The relative importance of variables explaining sex-related differences in outcomes is scarcely explored in patients undergoing cardiac resynchronization therapy (CRT). We sought to implement and evaluate machine learning (ML) algorithms for the prediction of 1- and 3-year all-cause mortality in CRT patients. We also aimed to assess the sex-specific differences in predictors of mortality utilizing ML. Methods: Using a retrospective registry of 2,191 CRT patients, ML models were implemented in 6 partially overlapping patient subsets (all patients, females, or males with 1- or 3-year follow-up). Each cohort was randomly split into training (80%) and test sets (20%). After hyperparameter tuning in the training sets, the best performing algorithm was evaluated in the test sets. Model discrimination was quantified using the area under the receiver-operating characteristic curves (AUC). The most important predictors were identified using the permutation feature importances method. Results: Conditional inference random forest exhibited the best performance with AUCs of 0.728 (0.645-0.802) and 0.732 (0.681-0.784) for the prediction of 1- and 3-year mortality, respectively. Etiology of heart failure, NYHA class, left ventricular ejection fraction, and QRS morphology had higher predictive power, whereas hemoglobin was less important in females compared to males. The importance of atrial fibrillation and age increased, while the importance of serum creatinine decreased from 1- to 3-year follow-up in both sexes. Conclusions: Using ML techniques in combination with easily obtainable clinical features, our models effectively predicted 1- and 3-year all-cause mortality in CRT patients. Sex-specific patterns of predictors were identified, showing a dynamic variation over time.
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Affiliation(s)
- Márton Tokodi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Anett Behon
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zoltán Tősér
- Argus Cognitive, Inc., Lebanon, NH, United States
| | | | | | | | | | | | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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6
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Quesada A, Arteaga F, Romero-Villafranca R, Perez-Alvarez L, Martinez-Ferrer J, Alzueta-Rodriguez J, Fernández de la Concha J, Martinez JG, Viñolas X, Porres JM, Anguera I, Porro-Fernández R, Quesada-Ocete B, de la Guía-Galipienso F, Palanca V, Jimenez J, Quesada-Ocete J, Sanchis-Gomar F. Sex-Specific Ventricular Arrhythmias and Mortality in Cardiac Resynchronization Therapy Recipients. JACC Clin Electrophysiol 2020; 7:705-715. [PMID: 33358670 DOI: 10.1016/j.jacep.2020.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The study goal was to examine whether there are sex-related differences in the incidence of ventricular arrhythmias and mortality in CRT-defibrillator (CRT-D) recipients. BACKGROUND Few studies have evaluated sex-related benefits of cardiac resynchronization therapy (CRT). Moreover, data on sex-related differences in the occurrence of ventricular tachyarrhythmias in this population are limited. METHODS A multicenter retrospective study was conducted in 460 patients (355 male subjects and 105 female subjects) from the UMBRELLA (Incidence of Arrhythmia in Spanish Population With a Medtronic Implantable Cardiac Defibrillator Implant) national registry. Patients were followed up through remote monitoring after the first implantation of a CRT-D during a median follow-up of 2.2 ± 1.0 years. Sex differences were analyzed in terms of ventricular arrhythmia-treated incidence and death during the follow-up period, with a particular focus on primary prevention patients. RESULTS Baseline New York Heart Association functional class was worse in women compared with that in men (67.0% of women in New York Heart Association functional class III vs. 49.7% of men; p = 0.003), whereas women had less ischemic cardiac disease (20.8% vs. 41.7%; p < 0.001). Female sex was an independent predictor of ventricular arrhythmias (hazard ratio: 0.40; 95% confidence interval: 0.19 to 0.86; p = 0.020), as well as left ventricular ejection fraction and nonischemic cardiomyopathy. Mortality in women was one-half that of men, although events were scarce and without significant differences (2.9% vs. 5.6%; p = 0.25). CONCLUSIONS Women with left bundle branch block and implanted CRT have a lower rate of ventricular tachyarrhythmias than men. All-cause mortality in patients is, at least, similar between female and male subjects.
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Affiliation(s)
- Aurelio Quesada
- Arrhythmia Unit, Cardiology Service, General University Hospital Consortium of Valencia, Valencia, Spain; School of Medicine, Catholic University of Valencia San Vicente Mártir, Valencia, Spain.
| | - Francisco Arteaga
- School of Medicine, Catholic University of Valencia San Vicente Mártir, Valencia, Spain
| | | | - Luisa Perez-Alvarez
- Arrhythmia Unit, Cardiology Service, University Hospital Complex A Coruña, A Coruña, Spain
| | - José Martinez-Ferrer
- Arrhythmia Unit, Cardiology Service, University Hospital of Araba, Vitoria, Álava, Spain
| | | | | | - Juan G Martinez
- Arrhythmia Unit, Cardiology Service, General University Hospital of Alicante, Alicante, Spain
| | - Xavier Viñolas
- Arrhythmia Unit, Cardiology Service, Santa Creu and Sant Pau Hospital, Barcelona, Spain
| | - Jose M Porres
- Arrhythmia Unit, Intensive Care Service, University Hospital of Donostia, San Sebastian, Spain
| | - Ignasi Anguera
- Arrhythmia Unit, Cardiology Service, Bellvitge Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Rosa Porro-Fernández
- Arrhythmia Unit, Cardiology Service, San Pedro de Alcántara Hospital, Cáceres, Spain
| | - Blanca Quesada-Ocete
- Department of Cardiology II/Electrophysiology, Center of Cardiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | - Victor Palanca
- Arrhythmia Unit, Cardiology Service, General University Hospital Consortium of Valencia, Valencia, Spain
| | - Javier Jimenez
- Arrhythmia Unit, Cardiology Service, General University Hospital Consortium of Valencia, Valencia, Spain
| | - Javier Quesada-Ocete
- Arrhythmia Unit, Cardiology Service, General University Hospital Consortium of Valencia, Valencia, Spain; School of Medicine, Catholic University of Valencia San Vicente Mártir, Valencia, Spain
| | - Fabian Sanchis-Gomar
- Department of Physiology, Faculty of Medicine, University of Valencia and INCLIVA Biomedical Research Institute, Valencia, Spain; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA.
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7
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Salden OAE, van Stipdonk AMW, den Ruijter HM, Cramer MJ, Kloosterman M, Rienstra M, Maass AH, Prinzen FW, Vernooy K, Meine M. Heart Size Corrected Electrical Dyssynchrony and Its Impact on Sex-Specific Response to Cardiac Resynchronization Therapy. Circ Arrhythm Electrophysiol 2020; 14:e008452. [PMID: 33296227 DOI: 10.1161/circep.120.008452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Women are less likely to receive cardiac resynchronization therapy, yet, they are more responsive to the therapy and respond at shorter QRS duration. The present study hypothesized that a relatively larger left ventricular (LV) electrical dyssynchrony in smaller hearts contributes to the better cardiac resynchronization therapy response in women. For this, the vectorcardiography-derived QRS area is used, since it allows for a more detailed quantification of electrical dyssynchrony compared with conventional electrocardiographic markers. METHODS Data from a multicenter registry of 725 cardiac resynchronization therapy patients (median follow-up, 4.2 years [interquartile range, 2.7-6.1]) were analyzed. Baseline electrical dyssynchrony was evaluated using the QRS area and the corrected QRS area for heart size using the LV end-diastolic volume (QRSarea/LVEDV). Impact of the QRSarea/LVEDV ratio on the association between sex and LV reverse remodeling (LV end-systolic volume change) and sex and the composite outcome of all-cause mortality, LV assist device implantation, or heart transplantation was assessed. RESULTS At baseline, women (n=228) displayed larger electrical dyssynchrony than men (QRS area, 132±55 versus 123±58 μVs; P=0.043), which was even more pronounced for the QRSarea/LVEDV ratio (0.76±0.46 versus 0.57±0.34 μVs/mL; P<0.001). After multivariable analyses, female sex was associated with LV end-systolic volume change (β=0.12; P=0.003) and a lower occurrence of the composite outcome (hazard ratio, 0.59 [0.42-0.85]; P=0.004). A part of the female advantage regarding reverse remodeling was attributed to the larger QRSarea/LVEDV ratio in women (25-fold change in β from 0.12 to 0.09). The larger QRSarea/LVEDV ratio did not contribute to the better survival observed in women. In both volumetric responders and nonresponders, female sex remained strongly associated with a lower risk of the composite outcome (adjusted hazard ratio, 0.59 [0.36-0.97]; P=0.036; and 0.55 [0.33-0.90]; P=0.018, respectively). CONCLUSIONS Greater electrical dyssynchrony in smaller hearts contributes, in part, to more reverse remodeling observed in women after cardiac resynchronization therapy, but this does not explain their better long-term outcomes.
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Affiliation(s)
- Odette A E Salden
- Department of Cardiology (O.A.E.S., M.J.C., M.M.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | | | - Hester M den Ruijter
- Laboratory of Experimental Cardiology (H.M.d.R.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Maarten Jan Cramer
- Department of Cardiology (O.A.E.S., M.J.C., M.M.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Mariëlle Kloosterman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands (M.K., M.R., A.H.M.)
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands (M.K., M.R., A.H.M.)
| | - Alexander H Maass
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands (M.K., M.R., A.H.M.)
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht, the Netherlands (F.W.P.)
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center, the Netherlands (A.M.W.v.S., K.V.)
| | - Mathias Meine
- Department of Cardiology (O.A.E.S., M.J.C., M.M.), University Medical Center Utrecht, Utrecht University, the Netherlands
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Combination of Left Ventricular End-Diastolic Diameter and QRS Duration Strongly Predicts Good Response to and Prognosis of Cardiac Resynchronization Therapy. Cardiol Res Pract 2020; 2020:1257578. [PMID: 32411441 PMCID: PMC7201746 DOI: 10.1155/2020/1257578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/26/2019] [Indexed: 11/17/2022] Open
Abstract
Background Approximately 20–40% of recipients of cardiac resynchronization therapy (CRT) do not respond to it based on the current patient selection criteria. The purpose of this study was to identify baseline parameters that can predict CRT response and to evaluate the effect of those predictive parameters on long-term prognosis. Methods This was a retrospective, nonrandomized, noncontrolled cohort study. Patients who received CRT in our centre were divided into responders and nonresponders by the definition of CRT response (an increase in left ventricular ejection fraction (LVEF) of ≥5% and improvement of ≥1 New York Heart Association (NYHA) class from baseline to the 6-month follow-up). Results Of the 101 patients, 68 were responders and 33 were nonresponders. Left ventricular end-diastolic diameter (LVEDD; OR: 0.88, 95% CI: 0.81–0.95, P=0.001) and QRS duration (OR: 1.07, 95% CI: 1.04–1.10, P < 0.001) were independent predictors of CRT response. The combination of LVEDD and QRS duration was more valuable for predicting CRT response (AUC 0.836; 95% CI: 0.76–0.91; P < 0.001). Moreover, the combination of LVEDD ≤ 71 mm and QRS duration ≥ 170 ms had a low incidence of all-cause mortality, HF hospitalisation, and the composite endpoint. In addition, baseline LVEDD had a positive correlation with QRS duration (R=0.199, P=0.046). Responders to CRT had better LV reverse remodeling. Conclusion The combination of LVEDD and QRS duration provided more robust prediction of CRT response. Moreover, the combination of LVEDD ≤ 71 mm and QRS duration ≥ 170 ms was associated with a low incidence of all-cause mortality, HF hospitalisation, and the composite endpoint. Our results may be useful to provide individualized patient selection for CRT.
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Leyva F, Qiu T, Zegard A, McNulty D, Evison F, Ray D, Gasparini M. Sex-Specific Differences in Survival and Heart Failure Hospitalization After Cardiac Resynchronization Therapy With or Without Defibrillation. J Am Heart Assoc 2019; 8:e013485. [PMID: 31718445 PMCID: PMC6915284 DOI: 10.1161/jaha.119.013485] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Women are underrepresented in cardiac resynchronization therapy (CRT) trials. Some studies suggest that women fare better than men after CRT. We sought to explore clinical outcomes in women and men undergoing CRT‐defibrillation or CRT‐pacing in real‐world clinical practice. Methods and Results A national database (Hospital Episode Statistics for England) was used to quantify clinical outcomes in 43 730 patients (women: 10 890 [24.9%]; men: 32 840 [75.1%]) undergoing CRT over 7.6 years, (median follow‐up 2.2 years, interquartile range, 1–4 years). In analysis of the total population, the primary end point of total mortality (adjusted hazard ratio [aHR], 0.73; 95% CI, 0.69–0.76) and the secondary end point of total mortality or heart failure hospitalization (aHR, 0.79, 95% CI 0.75–0.82) were lower in women, independent of known confounders. Total mortality (aHR, 0.73; 95% CI, 0.70–0.76) and total mortality or heart failure hospitalization (aHR, 0.79; 95% CI, 0.75–0.82) were lower for CRT‐defibrillation than for CRT‐pacing. In analyses of patients with (aHR, 0.89; 95% CI, 0.80–0.98) or without (aHR, 0.70; 95% CI, 0.66–0.73) a myocardial infarction, women had a lower total mortality. In sex‐specific analyses, total mortality was lower after CRT‐defibrillation in women (aHR, 0.83; P=0.013) and men (aHR, 0.69; P<0.001). Conclusions Compared with men, women lived longer and were less likely to be hospitalized for heart failure after CRT. In both sexes, CRT‐defibrillation was superior to CRT‐pacing with respect to survival and heart failure hospitalization. The longest survival after CRT was observed in women without a history of myocardial infarction.
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Affiliation(s)
- Francisco Leyva
- Aston Medical Research Institute Aston Medical School Aston University Birmingham United Kingdom
| | - Tian Qiu
- Quality and Outcomes Research Unit Queen Elizabeth Hospital Birmingham United Kingdom
| | - Abbasin Zegard
- Aston Medical Research Institute Aston Medical School Aston University Birmingham United Kingdom
| | - David McNulty
- Quality and Outcomes Research Unit Queen Elizabeth Hospital Birmingham United Kingdom
| | - Felicity Evison
- Quality and Outcomes Research Unit Queen Elizabeth Hospital Birmingham United Kingdom
| | - Daniel Ray
- NHS Digital and Farr Institute London United Kingdom
| | - Maurizio Gasparini
- Electrophysiology and Pacing Unit Humanitas Research Hospital IRCCS Rozzano-Milano Italy
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10
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Beela AS, Duchenne J, Petrescu A, Ünlü S, Penicka M, Aakhus S, Winter S, Aarones M, Stefanidis E, Fehske W, Willems R, Szulik M, Kukulski T, Faber L, Ciarka A, Neskovic AN, Stankovic I, Voigt JU. Sex-specific difference in outcome after cardiac resynchronization therapy. Eur Heart J Cardiovasc Imaging 2019; 20:504-511. [DOI: 10.1093/ehjci/jey231] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/22/2018] [Indexed: 01/06/2023] Open
Affiliation(s)
- Ahmed S Beela
- Department of Cardiovascular Diseases, University Hospitals Leuven, University of Leuven, Herestraat 49, Leuven, Belgium
- Department of Cardiovascular Diseases, Faculty of Medicine, Suez Canal University, km 4.5 Ring road, Ismailia, Egypt
| | - Jürgen Duchenne
- Department of Cardiovascular Diseases, University Hospitals Leuven, University of Leuven, Herestraat 49, Leuven, Belgium
| | - Aniela Petrescu
- Department of Cardiovascular Diseases, University Hospitals Leuven, University of Leuven, Herestraat 49, Leuven, Belgium
| | - Serkan Ünlü
- Department of Cardiovascular Diseases, University Hospitals Leuven, University of Leuven, Herestraat 49, Leuven, Belgium
| | - Martin Penicka
- Department of Cardiology, Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Svend Aakhus
- Department of Circulation and Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, Clinic of Cardiology, St. Olavs Hospital, Trondheim, Norway
| | - Stefan Winter
- Department of Internal Medicine and Cardiology, Klinik für Innere Medizin und Kardiologie, St. Vinzenz Hospital, Cologne, Germany
| | - Marit Aarones
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Evangelos Stefanidis
- Department of Circulation and Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, Clinic of Cardiology, St. Olavs Hospital, Trondheim, Norway
| | - Wolfgang Fehske
- Department of Internal Medicine and Cardiology, Klinik für Innere Medizin und Kardiologie, St. Vinzenz Hospital, Cologne, Germany
| | - Rik Willems
- Department of Cardiovascular Diseases, University Hospitals Leuven, University of Leuven, Herestraat 49, Leuven, Belgium
| | - Mariola Szulik
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Silesian University of Medicine, Zabrze, Poland
| | - Tomasz Kukulski
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Silesian University of Medicine, Zabrze, Poland
| | - Lothar Faber
- Department of Cardiology, Heart and Diabetes Centre of North-Rhine Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Agnieszka Ciarka
- Department of Cardiovascular Diseases, University Hospitals Leuven, University of Leuven, Herestraat 49, Leuven, Belgium
| | - Aleksandar N Neskovic
- Department of Cardiology, Faculty of Medicine, Clinical Hospital Centre Zemun, University of Belgrade, Belgrade, Serbia
| | - Ivan Stankovic
- Department of Cardiology, Faculty of Medicine, Clinical Hospital Centre Zemun, University of Belgrade, Belgrade, Serbia
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven, University of Leuven, Herestraat 49, Leuven, Belgium
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Sieniewicz BJ, Gould J, Porter B, Sidhu BS, Teall T, Webb J, Carr-White G, Rinaldi CA. Understanding non-response to cardiac resynchronisation therapy: common problems and potential solutions. Heart Fail Rev 2019; 24:41-54. [PMID: 30143910 PMCID: PMC6313376 DOI: 10.1007/s10741-018-9734-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Heart failure is a complex clinical syndrome associated with a significant morbidity and mortality burden. Reductions in left ventricular (LV) function trigger adaptive mechanisms, leading to structural changes within the LV and the potential development of dyssynchronous ventricular activation. This is the substrate targeted during cardiac resynchronisation therapy (CRT); however, around 30-50% of patients do not experience benefit from this treatment. Non-response occurs as a result of pre-implant, peri-implant and post implant factors but the technical constraints of traditional, transvenous epicardial CRT mean they can be challenging to overcome. In an effort to improve response, novel alternative methods of CRT delivery have been developed and of these endocardial pacing, where the LV is stimulated from inside the LV cavity, appears the most promising.
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Affiliation(s)
- Benjamin J Sieniewicz
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK.
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.
| | - Justin Gould
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Bradley Porter
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Baldeep S Sidhu
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Thomas Teall
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Jessica Webb
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Gerarld Carr-White
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Christopher A Rinaldi
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
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12
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Enina TN, Kuznetsov VA, Soldatova AM, Petelina TI, Krinochkin DV, Rychkov AY, Nochrina OY. Gender in cardiac resynchronisation therapy. J Cardiovasc Thorac Res 2018; 10:197-202. [PMID: 30680077 PMCID: PMC6335983 DOI: 10.15171/jcvtr.2018.34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 05/11/2018] [Indexed: 12/27/2022] Open
Abstract
Introduction:
Gender differences in cardiac resynchronisation therapy (CRT) response are
not clear enough. This study aimed to assess gender influence on systemic inflammation,
neurohormonal activation, fibrosis in patients with congestive heart failure (CHF) and CRT.
Methods: We compared group I (61 men) and group II (16 women) of patients undergoing
CRT. Plasma levels of Nt-proBNP, interleukin (IL)-1β, IL-6, IL-10, tumor necrosis factor alpha
(TNF-α), C-reactive protein, galectin-3 (Gal-3), metalloproteinase-9 (MMP-9), tissue inhibitors
of metalloproteinase 1 and 4 (TIMP-1, TIMP-4), ratio MMP-9/TIMP-1, MMP-9/TIMP-4 were
measured. According to dynamics of left ventricular end-systolic volume patients were classified
into non-responders, responders, super-responders.
Results: Women more likely had left bundle branch block (81.3 vs 47.5%, P = 0.016), were more
super-responders (66.7 vs 30.5%). Both groups showed decrease of IL-6 (P < 0.05), TNF-α
(P < 0.001; P < 0.05), NT-proBNP (P = 0.001; P < 0.05), Gal-3 (P < 0.05). In women there was
decrease of IL-6 by 44.4 vs 23.5% in men (PP = 0.029), TNF-α by 41.4 vs 30.9%, NT-proBNP by 73.3
vs 46% (P = 0.002), Gal-3 by 82.3 vs 64.9% (P < 0.05). Group I also showed decrease of IL-10 by
34.2% (P < 0.05). Group dynamics of TIMP-1 was opposite: men showed tendency to reduction of
TIMP-1 (P = 0.054), women showed increase of TIMP-1 (P < 0.05). Besides, men showed decrease
of MMP-9 (P < 0.05) and ratio MMP-9/TIMP-4 (P < 0.05).
Conclusion: The best response to CRT is associated with female gender explained by greater
decrease of neurohormonal activation, systemic inflammation and fibrosis. The revealed opposite
dynamics of TIMP-1 in the groups can demonstrate the existence of gender features of matrix
metalloproteinase system activity and their tissue inhibitors.
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Affiliation(s)
- Tatiana N Enina
- Scientific researcher in Instrumental Laboratory of Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk, Russia
| | - Vadim A Kuznetsov
- Director of Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk, Russia
| | - Anna M Soldatova
- Scientific researcher in Instrumental Laboratory of Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk, Russia
| | - Tatiana I Petelina
- Scientific researcher in Instrumental Laboratory of Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk, Russia
| | - Dmitriy V Krinochkin
- Scientific researcher in Instrumental Laboratory of Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk, Russia
| | - Alexander Yu Rychkov
- Scientific researcher in Instrumental Laboratory of Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk, Russia
| | - Olga Yu Nochrina
- Scientific researcher in Instrumental Laboratory of Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk, Russia
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Prophylactic implantable cardioverter defibrillator in heart failure: the growing evidence for all or Primum non nocere for some? Heart Fail Rev 2018; 22:305-316. [PMID: 28229272 DOI: 10.1007/s10741-017-9602-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Heart failure (HF) is a common health problem and has reached epidemic in many western countries. Despite the current era of HF treatment, the risk of sudden cardiac death (SCD) in HF remains significant. Implantable cardioverter defibrillator (ICD) support has been shown to reduce the risk of SCD in patients with HF and impaired left ventricular function. Prophylactic ICD implantation in HF patients seems a logical step to reduce mortality through a reduction in SCD. However, ICD implantation is an invasive procedure, and both short- and long-term complications can occur. This needs to be carefully considered when evaluating the risk-benefit ratio of ICD implantation for individual patients. As the severity of HF increases, the proportion of SCD compared with HF-related deaths decreases. The challenge lies in identifying patients with HF who are at significant risk of SCD and who would most benefit from an ICD in addition to other anti-arrhythmic strategies. This review offers insight on the applicability and practicability of ICD for this growing population.
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Carnlöf C, Insulander P, Jensen-Urstad M, Iwarzon M, Gadler F. Atrio-ventricular junction ablation and pacemaker treatment: a comparison between men and women. SCAND CARDIOVASC J 2018. [DOI: 10.1080/14017431.2018.1446549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Carina Carnlöf
- Heart and Vascular Theme, Karolinska Institute of Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Per Insulander
- Heart and Vascular Theme, Karolinska Institute of Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Jensen-Urstad
- Heart and Vascular Theme, Karolinska Institute of Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Iwarzon
- Department of Neurobiology, Care Sciences and Society, Karolinska Institute of Medicine, Huddinge, Sweden
| | - Fredrik Gadler
- Heart and Vascular Theme, Karolinska Institute of Medicine, Karolinska University Hospital, Stockholm, Sweden
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15
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Raeisi-Giglou P, Volgman AS, Patel H, Campbell S, Villablanca A, Hsich E. Advances in Cardiovascular Health in Women over the Past Decade: Guideline Recommendations for Practice. J Womens Health (Larchmt) 2018; 27:128-139. [PMID: 28714810 PMCID: PMC5815443 DOI: 10.1089/jwh.2016.6316] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular disease (CVD) remains the number one cause of death in women. It is estimated that 44 million women in the United States are either living with or at risk for heart disease. This article highlights the recent significant progress made in improving care, clinical decision-making, and policy implications for women with CVD. We provide our perspective supported by evidence-based advances in cardiovascular research and clinical care guidelines in seven areas: (1) primary CVD prevention and community heart care, (2) secondary prevention of CVD, (3) stroke, (4) heart failure and cardiomyopathies, (5) ischemia with nonobstructive coronary artery disease, (6) spontaneous coronary artery dissection, and (7) arrhythmias and device therapies. Advances in these fields have improved the lives of women living with and at risk for heart disease. With increase awareness, partnership with national organizations, sex-specific research, and changes in policy, the morbidity and mortality of CVD in women can be further reduced.
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Affiliation(s)
| | - Annabelle Santos Volgman
- Rush Heart Center for Women Division of Cardiology, Rush University Medical Center, Chicago, Illinois
| | - Hena Patel
- Rush Heart Center for Women Division of Cardiology, Rush University Medical Center, Chicago, Illinois
| | | | - Amparo Villablanca
- Women's Cardiovascular Medicine Program, Division of Cardiovascular Medicine, University of California, Davis, Davis, California
| | - Eileen Hsich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
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16
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Li X, Yang D, Kusumoto F, Shen WK, Mulpuru S, Zhou S, Liang J, Wu G, Yang M, Liu JQ, Friedman PA, Cha YM. Predictors and outcomes of cardiac resynchronization therapy extended to the second generator. Heart Rhythm 2017; 14:1793-1800. [DOI: 10.1016/j.hrthm.2017.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Indexed: 10/18/2022]
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Han Z, Chen Z, Lan R, Di W, Li X, Yu H, Ji W, Zhang X, Xu B, Xu W. Sex-specific mortality differences in heart failure patients with ischemia receiving cardiac resynchronization therapy. PLoS One 2017; 12:e0180513. [PMID: 28683134 PMCID: PMC5500352 DOI: 10.1371/journal.pone.0180513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 06/18/2017] [Indexed: 01/01/2023] Open
Abstract
Background Recent studies have reported prognosis differences between male and female heart failure patients following cardiac resynchronization therapy (CRT). However, the potential clinical factors that underpin these differences remain to be elucidated. Methods A meta-analysis was performed to investigate the factors that characterize sex-specific differences following CRT. This analysis involved searching the Medline (Pubmed source) and Embase databases in the period from January 1980 to September 2016. Results Fifty-eight studies involving 33445 patients (23.08% of whom were women) were analyzed as part of this study. Only patients receiving CRT with follow-up greater than six months were included in our analysis. Compared with males, females exhibited a reduction of 33% (hazard ratio, 0.67; 95% confidence interval, 0.62–0.73; P < 0.0001) and 42% (hazard ratio, 0.58; 95% confidence interval, 0.46–0.74; P = 0.003) in all-cause mortality and heart failure hospitalization or heart failure, respectively. Following a stratified analysis of all-cause mortality, we observed that ischemic causes (p = 0.03) were likely to account for most of the sex-specific differences in relation to CRT. Conclusion These data suggest that women have a reduced risk of all-cause mortality and heart failure hospitalization or heart failure following CRT. Based on the results from the stratified analysis, we observed more optimal outcomes for females with ischemic heart disease. Thus, ischemia are likely to play a role in sex-related differences associated with CRT in heart failure patients. Further studies are required to determine other indications and the potential mechanisms that might be associated with sex-specific CRT outcomes.
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Affiliation(s)
- Zhonglin Han
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Zheng Chen
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Rongfang Lan
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Wencheng Di
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Xiaohong Li
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Hongsong Yu
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Wenqing Ji
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Xinlin Zhang
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Biao Xu
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Wei Xu
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
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18
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Yin FH, Fan CL, Guo YY, Zhu H, Wang ZL. The impact of gender difference on clinical and echocardiographic outcomes in patients with heart failure after cardiac resynchronization therapy: A systematic review and meta-analysis. PLoS One 2017; 12:e0176248. [PMID: 28453545 PMCID: PMC5409183 DOI: 10.1371/journal.pone.0176248] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 04/07/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cardiac resynchronization therapy(CRT) has been recommended as a standard treatment for patients with advanced heart failure. However, some studies have reported different clinical and echocardiographic outcomes between male and female patients who received CRT. This Meta-analysis is to determine whether gender difference has any significant impact on clinical and echocardiographic outcomes in patients with heart failure after CRT. METHODS AND RESULTS PubMed, Embase, and the Cochrane library database were searched. A total of 149,259 patients in 11 studies were identified. Our analysis demonstrated that women showed lower all-cause mortality than men after CRT (odds ratio[OR] 0.50, 95% confidence interval [CI] 0.36 to 0.70). No significant difference was observed in the increment of New York Heart Association (NYHA) functional class(standard mean difference[SMD] -0.07,95% CI -0.15 to 0.01), 6-minitue walk distance (6-MWD) (SMD -0.05, 95% CI -0.07 to 0.17), and quality of life (QoL) (SMD -0.10, 95% CI -0.23 to 0.03). With respect to the echocardiographic parameters, women exhibited statistically significant improvement in left ventricular ejection fraction (LVEF) (SMD 0.25,95% CI 0.07 to 0.43), and decrement of left ventricular end diastolic diameter (LVEDD) (SMD -0.27, 95% CI -0.39 to -0.25) as compared with men. No significant difference was observed in left ventricular end diastolic volume (LVEDV) (SMD -0.08, 95% CI -0.28 to 0.08) and left ventricular end systolic volume (LVESV) (SMD -0.16, 95% CI -0.40 to 0.09) between men and women. CONCLUSION Women seem to obtain greater benefits from CRT both in clinical and echocardiographic outcomes compared with men. But as this gender superiority could be observed only during long-term follow-up periods, further studies are needed to elucidate exact reasons for this phenomenon.
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Affiliation(s)
- Fa-Hui Yin
- The First Medical Clinical College of Lanzhou University, Lanzhou, Gansu, China
| | - Chun-Lei Fan
- The First Medical Clinical College of Lanzhou University, Lanzhou, Gansu, China
| | - Ya-Ya Guo
- The First Medical Clinical College of Lanzhou University, Lanzhou, Gansu, China
| | - Hai Zhu
- Department of Cardiology, Gansu Province People’s Hospital, Lanzhou, Gansu, China
| | - Zhi-Lu Wang
- Department of Cardiology, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- * E-mail:
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20
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Harvey RE, Coffman KE, Miller VM. Women-specific factors to consider in risk, diagnosis and treatment of cardiovascular disease. ACTA ACUST UNITED AC 2015; 11:239-257. [PMID: 25776297 DOI: 10.2217/whe.14.64] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In the era of individualized medicine, gaps in knowledge remain about sex-specific risk factors, diagnostic and treatment options that might reduce mortality from cardiovascular disease (CVD) and improve outcomes for both women and men. In this review, contributions of biological mechanisms involving the sex chromosomes and the sex hormones on the cardiovascular system will be discussed in relationship to the female-specific risk factors for CVD: hypertensive disorders of pregnancy, menopause and use of hormonal therapies for contraception and menopausal symptoms. Additionally, sex-specific factors to consider in the differential diagnosis and treatment of four prevalent CVDs (hypertension, stroke, coronary artery disease and congestive heart failure) will be reviewed with emphasis on areas where additional research is needed.
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Affiliation(s)
- Ronée E Harvey
- Department of Physiology & Biomedical, Engineering, Medical Sciences 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Kirsten E Coffman
- Department of Physiology & Biomedical, Engineering, Medical Sciences 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Virginia M Miller
- Department of Physiology & Biomedical, Engineering, Medical Sciences 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.,Department of Surgery, Medical Sciences, 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
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Abstract
The benefits of cardiac resynchronization therapy (CRT) on the outcomes of patients with heart failure are unquestionable. Women are under-represented in all CRT studies. Most of the available data show that CRT produces a greater clinical benefit in women than men. In several studies, women have left bundle branch block more frequently than men. Women have a remarkably high (90%) CRT response over a wide range of QRS lengths (130-175 milliseconds). Use of a QRS duration of 150 milliseconds as the threshold for CRT prescription may deny a life-saving therapy to many women likely to benefit from CRT.
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Affiliation(s)
- Maria Rosa Costanzo
- Advocate Heart Institute, Edward Heart Hospital, 4th Floor, 801 South Washington Street, Naperville, IL 60566, USA.
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Abstract
Cardiac resynchronisation therapy (CRT) is an effective intervention for appropriately selected patients with heart failure, but exactly how it works is uncertain. Recent data suggest that much, or perhaps most, of the benefits of CRT are not delivered by re-coordinating left ventricular dyssynchrony. Atrio-ventricular resynchronization, reduction in mitral regurgitation and prevention of bradycardia are other potential mechanisms of benefit that will vary from one patient to the next and over time. Because there is no single therapeutic target, it is unlikely that any single measure will accurately predict benefit. The only clinical characteristic that appears to be a useful predictor of the benefits of CRT is a QRS duration of >140 ms. Many new approaches are being developed to try to improve the effectiveness of and extend the indications for CRT. These include smart pacing algorithms, better pacing-site targeting, new sensors, multipoint pacing, remote device monitoring and leadless endocardial pacing. Whether CRT is effective in patients with atrial fibrillation or whether adding a defibrillator function to CRT improves prognosis awaits further evidence.
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Narasimha D, Curtis AB. Sex Differences in Utilisation and Response to Implantable Device Therapy. Arrhythm Electrophysiol Rev 2015; 4:129-35. [PMID: 26835114 PMCID: PMC4711527 DOI: 10.15420/aer.2015.04.02.129] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 08/12/2015] [Indexed: 12/21/2022] Open
Abstract
Multiple studies have demonstrated that implantable cardioverter-defibrillators (ICDs) and cardiac resynchronisation therapy (CRT) provide significant mortality and morbidity benefits to eligible patients irrespective of gender. However, female patients are less likely to receive this life-saving therapy and are significantly under-represented in cardiac device trials. Various performance improvement programmes have proved that this gender disparity can be reduced and these therapies should be offered to all eligible patients regardless of sex. Efforts should be made to enrol more women in clinical trials and sex-specific analysis in medical device clinical studies should be encouraged. In this article we review the data on sex differences in clinical outcomes with ICDs and CRT and explore the reasons for this sex-based disparity.
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Affiliation(s)
- Deepika Narasimha
- Department of Medicine, University at Buffalo, Buffalo, New York, US
| | - Anne B Curtis
- Department of Medicine, University at Buffalo, Buffalo, New York, US
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Comparative Effectiveness of Cardiac Resynchronization Therapy Defibrillators Versus Standard Implantable Defibrillators in Medicare Patients. Am J Cardiol 2015; 116:79-84. [PMID: 25933736 DOI: 10.1016/j.amjcard.2015.03.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/26/2015] [Accepted: 03/26/2015] [Indexed: 11/21/2022]
Abstract
Previous analyses have shown that there is lower mortality with cardiac resynchronization therapy defibrillators (CRT-D) in patients with left bundle branch block (LBBB) but demonstrated mixed results in patients without LBBB. We evaluated the comparative effectiveness of CRT-D versus standard implantable defibrillators (ICDs) separately in patients with LBBB and right bundle branch block (RBBB) using Medicare claims data. Medicare records from CRT-D and ICD recipients from 2002 to 2009 that were followed up for up to 48 months were analyzed. We used propensity scores to match patients with ICD to those with CRT-D. In LBBB, 1:1 matching with replacement resulted in 54,218 patients with CRT-D and 20,763 with ICD, and in RBBB, 1:1 matching resulted in 7,298 patients with CRT-D and 7,298 with ICD. In LBBB, CRT-D had a 12% lower risk of heart failure hospitalization or death (hazard ratio [HR] 0.88, 95% confidence interval 0.86 to 0.90) and 5% lower death risk (HR 0.95, 0.92 to 0.97) compared with ICD. In RBBB, CRT-D had a 15% higher risk of heart failure hospitalization or death (HR 1.15, 1.10 to 1.20) and 13% higher death risk (HR 1.13, 1.07 to 1.18). Sensitivity analysis revealed that accounting for covariates not captured in the Medicare database may lead to increased benefit with CRT-D in LBBB and no difference in RBBB. In conclusion, in a large Medicare population, CRT-D was associated with lower mortality in LBBB but higher mortality in RBBB. The absence of certain covariates, in particular those that determine treatment selection, may affect the results of comparative effectiveness studies using claims data.
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Mehta NK, Abraham WT, Maytin M. ICD and CRT use in ischemic heart disease in women. Curr Atheroscler Rep 2015; 17:512. [PMID: 25921310 DOI: 10.1007/s11883-015-0512-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Although the role of implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) in improving outcomes in ischemic cardiomyopathy (ICM) has been described, the data regarding gender-based survival outcomes are limited. There is a higher preponderance of non-ischemic cardiomyopathy (NICM) in women, and most of the ICM literature is derived from sub-study analysis. This review summarizes the current body of literature on prognosis, pathophysiology, and the present clinical practice for device implantation in women with ICM.
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Affiliation(s)
- Nishaki Kiran Mehta
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, 43220, USA,
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Herz ND, Engeda J, Zusterzeel R, Sanders WE, O'Callaghan KM, Strauss DG, Jacobs SB, Selzman KA, Piña IL, Caños DA. Sex differences in device therapy for heart failure: utilization, outcomes, and adverse events. J Womens Health (Larchmt) 2015; 24:261-71. [PMID: 25793483 DOI: 10.1089/jwh.2014.4980] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Multiple studies of heart failure patients demonstrated significant improvement in exercise capacity, quality of life, cardiac left ventricular function, and survival from cardiac resynchronization therapy (CRT), but the underenrollment of women in these studies is notable. Etiological and pathophysiological differences may result in different outcomes in response to this treatment by sex. The observed disproportionate representation of women suggests that many women with heart failure either do not meet current clinical criteria to receive CRT in trials or are not properly recruited and maintained in these studies. METHODS We performed a systematic literature review through May 2014 of clinical trials and registries of CRT use that stratified outcomes by sex or reported percent women included. One-hundred eighty-three studies contained sex-specific information. RESULTS Ninety percent of the studies evaluated included ≤ 35% women. Fifty-six articles included effectiveness data that reported response with regard to specific outcome parameters. When compared with men, women exhibited more dramatic improvement in specific parameters. In the studies reporting hazard ratios for hospitalization or death, women generally had greater benefit from CRT. CONCLUSIONS Our review confirms women are markedly underrepresented in CRT trials, and when a CRT device is implanted, women have a therapeutic response that is equivalent to or better than in men, while there is no difference in adverse events reported by sex.
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Affiliation(s)
- Naomi D Herz
- Center for Devices and Radiological Health, United States Food and Drug Administration , Silver Spring, Maryland
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27
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Cipriani M, Ammirati E, Landolina M, Oliva F, Ghio S, Rordorf R, Lunati M. Cumulative analysis on 4802 patients confirming that women benefit more than men from cardiac resynchronization therapy. Int J Cardiol 2015; 182:454-6. [DOI: 10.1016/j.ijcard.2015.01.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 01/07/2015] [Accepted: 01/09/2015] [Indexed: 11/27/2022]
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28
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Zusterzeel R, Spatz ES, Curtis JP, Sanders WE, Selzman KA, Piña IL, Bao H, Ponirakis A, Varosy PD, Masoudi FA, Caños DA, Strauss DG. Cardiac resynchronization therapy in women versus men: observational comparative effectiveness study from the National Cardiovascular Data Registry. Circ Cardiovasc Qual Outcomes 2015; 8:S4-11. [PMID: 25714821 DOI: 10.1161/circoutcomes.114.001548] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Women have been under-represented in trials of cardiac resynchronization therapy-defibrillators (CRT-D). Previous studies suggest that women benefit from CRT-D at shorter QRS duration than men and that there may be no benefit of CRT-D in patients without left bundle branch block (LBBB) regardless of patient sex. METHODS AND RESULTS We compared sex-specific death risk in 75 079 patients with New York Heart Association class III or IV heart failure, reduced left ventricular ejection fraction, and prolonged QRS duration (≥120 ms) receiving either CRT-D or implantable cardioverter defibrillator in subgroups according to QRS morphology and 10-ms increments in QRS duration. We applied propensity score weighting to control for differences between treatments. Among patients with LBBB, women receiving CRT-D had a lower relative death risk than those receiving an implantable cardioverter-defibrillator (absolute difference, 11%; hazard ratio=0.74 [95% confidence interval, 0.68-0.81]). In men, the lower mortality with CRT-D versus implantable cardioverter defibrillator was less pronounced (absolute difference, 9%; hazard ratio=0.84 [0.79-0.89]; sex×device interaction P=0.025). In those without LBBB, the mortality difference was modest and did not differ between women and men (absolute difference, 3%; hazard ratio=0.88 [0.79-0.97] in women and absolute difference, 2%; hazard ratio=0.95 [0.91-0.998] in men; interaction P=0.17). In subgroups according to QRS duration, CRT-D was associated with better survival in both sexes with LBBB and QRS ≥130 ms, whereas there was no clear relation between QRS duration and survival in patients without LBBB regardless of patient sex. CONCLUSIONS In a large real-world population CRT-D was associated with a lower mortality risk in both sexes with LBBB, although more pronounced among women. Only among those with LBBB, both sexes had better survival with longer QRS duration. The mortality differences in patients without LBBB were attenuated in both sexes.
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Affiliation(s)
- Robbert Zusterzeel
- From the Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (R.Z., W.E.S., K.A.S., I.L.P., D.A.C., D.G.S.); Yale School of Medicine, New Haven, CT (E.S.S., J.P.C., H.B.); American College of Cardiology Foundation, Washington, DC (A.P.); VA Eastern Colorado Health Care System, University of Colorado, Denver (P.D.V.); Colorado Cardiovascular Outcomes Research Group, Denver (P.D.V.); and University of Colorado Anschutz Medical Campus, Aurora (F.A.M.)
| | - Erica S Spatz
- From the Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (R.Z., W.E.S., K.A.S., I.L.P., D.A.C., D.G.S.); Yale School of Medicine, New Haven, CT (E.S.S., J.P.C., H.B.); American College of Cardiology Foundation, Washington, DC (A.P.); VA Eastern Colorado Health Care System, University of Colorado, Denver (P.D.V.); Colorado Cardiovascular Outcomes Research Group, Denver (P.D.V.); and University of Colorado Anschutz Medical Campus, Aurora (F.A.M.)
| | - Jeptha P Curtis
- From the Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (R.Z., W.E.S., K.A.S., I.L.P., D.A.C., D.G.S.); Yale School of Medicine, New Haven, CT (E.S.S., J.P.C., H.B.); American College of Cardiology Foundation, Washington, DC (A.P.); VA Eastern Colorado Health Care System, University of Colorado, Denver (P.D.V.); Colorado Cardiovascular Outcomes Research Group, Denver (P.D.V.); and University of Colorado Anschutz Medical Campus, Aurora (F.A.M.)
| | - William E Sanders
- From the Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (R.Z., W.E.S., K.A.S., I.L.P., D.A.C., D.G.S.); Yale School of Medicine, New Haven, CT (E.S.S., J.P.C., H.B.); American College of Cardiology Foundation, Washington, DC (A.P.); VA Eastern Colorado Health Care System, University of Colorado, Denver (P.D.V.); Colorado Cardiovascular Outcomes Research Group, Denver (P.D.V.); and University of Colorado Anschutz Medical Campus, Aurora (F.A.M.)
| | - Kimberly A Selzman
- From the Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (R.Z., W.E.S., K.A.S., I.L.P., D.A.C., D.G.S.); Yale School of Medicine, New Haven, CT (E.S.S., J.P.C., H.B.); American College of Cardiology Foundation, Washington, DC (A.P.); VA Eastern Colorado Health Care System, University of Colorado, Denver (P.D.V.); Colorado Cardiovascular Outcomes Research Group, Denver (P.D.V.); and University of Colorado Anschutz Medical Campus, Aurora (F.A.M.)
| | - Ileana L Piña
- From the Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (R.Z., W.E.S., K.A.S., I.L.P., D.A.C., D.G.S.); Yale School of Medicine, New Haven, CT (E.S.S., J.P.C., H.B.); American College of Cardiology Foundation, Washington, DC (A.P.); VA Eastern Colorado Health Care System, University of Colorado, Denver (P.D.V.); Colorado Cardiovascular Outcomes Research Group, Denver (P.D.V.); and University of Colorado Anschutz Medical Campus, Aurora (F.A.M.)
| | - Haikun Bao
- From the Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (R.Z., W.E.S., K.A.S., I.L.P., D.A.C., D.G.S.); Yale School of Medicine, New Haven, CT (E.S.S., J.P.C., H.B.); American College of Cardiology Foundation, Washington, DC (A.P.); VA Eastern Colorado Health Care System, University of Colorado, Denver (P.D.V.); Colorado Cardiovascular Outcomes Research Group, Denver (P.D.V.); and University of Colorado Anschutz Medical Campus, Aurora (F.A.M.)
| | - Angelo Ponirakis
- From the Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (R.Z., W.E.S., K.A.S., I.L.P., D.A.C., D.G.S.); Yale School of Medicine, New Haven, CT (E.S.S., J.P.C., H.B.); American College of Cardiology Foundation, Washington, DC (A.P.); VA Eastern Colorado Health Care System, University of Colorado, Denver (P.D.V.); Colorado Cardiovascular Outcomes Research Group, Denver (P.D.V.); and University of Colorado Anschutz Medical Campus, Aurora (F.A.M.)
| | - Paul D Varosy
- From the Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (R.Z., W.E.S., K.A.S., I.L.P., D.A.C., D.G.S.); Yale School of Medicine, New Haven, CT (E.S.S., J.P.C., H.B.); American College of Cardiology Foundation, Washington, DC (A.P.); VA Eastern Colorado Health Care System, University of Colorado, Denver (P.D.V.); Colorado Cardiovascular Outcomes Research Group, Denver (P.D.V.); and University of Colorado Anschutz Medical Campus, Aurora (F.A.M.)
| | - Frederick A Masoudi
- From the Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (R.Z., W.E.S., K.A.S., I.L.P., D.A.C., D.G.S.); Yale School of Medicine, New Haven, CT (E.S.S., J.P.C., H.B.); American College of Cardiology Foundation, Washington, DC (A.P.); VA Eastern Colorado Health Care System, University of Colorado, Denver (P.D.V.); Colorado Cardiovascular Outcomes Research Group, Denver (P.D.V.); and University of Colorado Anschutz Medical Campus, Aurora (F.A.M.)
| | - Daniel A Caños
- From the Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (R.Z., W.E.S., K.A.S., I.L.P., D.A.C., D.G.S.); Yale School of Medicine, New Haven, CT (E.S.S., J.P.C., H.B.); American College of Cardiology Foundation, Washington, DC (A.P.); VA Eastern Colorado Health Care System, University of Colorado, Denver (P.D.V.); Colorado Cardiovascular Outcomes Research Group, Denver (P.D.V.); and University of Colorado Anschutz Medical Campus, Aurora (F.A.M.)
| | - David G Strauss
- From the Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (R.Z., W.E.S., K.A.S., I.L.P., D.A.C., D.G.S.); Yale School of Medicine, New Haven, CT (E.S.S., J.P.C., H.B.); American College of Cardiology Foundation, Washington, DC (A.P.); VA Eastern Colorado Health Care System, University of Colorado, Denver (P.D.V.); Colorado Cardiovascular Outcomes Research Group, Denver (P.D.V.); and University of Colorado Anschutz Medical Campus, Aurora (F.A.M.).
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Cheng YJ, Zhang J, Li WJ, Lin XX, Zeng WT, Tang K, Tang AL, He JG, Xu Q, Mei MY, Zheng DD, Dong YG, Ma H, Wu SH. More Favorable Response to Cardiac Resynchronization Therapy in Women Than in Men. Circ Arrhythm Electrophysiol 2014; 7:807-15. [PMID: 25146838 DOI: 10.1161/circep.113.001786] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background—
Data on sex difference in response to cardiac resynchronization therapy (CRT) remain controversial. We conducted a meta-analysis to summarize all published studies to determine whether sex-based differences in response to CRT exist.
Methods and Results—
We performed a literature search using MEDLINE (source PubMed; January 1966 to March 2014) and EMBASE (January 1980 to March 2014) with no restrictions. Pooled effect estimates were obtained by using random-effects meta-analysis. Seventy-two studies involving 33 434 patients were identified. Overall, female patients had better outcomes from CRT compared with male patients, with a significant 33% reduction in the risk of death from any cause (hazard ratio, 0.67; 95% confidence interval, 0.61–0.74;
P
<0.001), 20% reduction in death or hospitalization for heart failure (hazard ratio, 0.80; 95% confidence interval, 0.71–0.90;
P
<0.001), 41% reduction in cardiac death (hazard ratio, 0.59; 95% confidence interval, 0.42–0.84;
P
<0.001), and 41% reduction in ventricular arrhythmias or sudden cardiac death (hazard ratio, 0.59; 95% confidence interval, 0.49–0.70;
P
<0.001). These more favorable responses to CRT in women were consistently associated with greater echocardiographic evidence of reverse cardiac remodeling in women than in men.
Conclusions—
Women obtained greater reductions in the risk of death from any cause, cardiac cause, death or hospitalization for heart failure, and ventricular arrhythmias or sudden cardiac death with CRT therapy compared with men, with consistently greater echocardiographic evidence of reverse cardiac remodeling in women than in men. Further studies are needed to investigate the exact reasons for these results and determine whether indications for CRT in women should be different from men.
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Affiliation(s)
- Yun-Jiu Cheng
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
| | - Jing Zhang
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
| | - Wei-Jie Li
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
| | - Xiao-Xiong Lin
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
| | - Wu-Tao Zeng
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
| | - Kai Tang
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
| | - An-li Tang
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
| | - Jian-Gui He
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
| | - Qing Xu
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
| | - Mei-Yi Mei
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
| | - Dong-Dan Zheng
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
| | - Yu-Gang Dong
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
| | - Hong Ma
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
| | - Su-Hua Wu
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Y.J.C., J.Z., W.J.L., X.X.L., W.T.Z., K.T., A.L.T., J.G.H., Q.X., W.Y.M., D.D.Z., Y.G.D., H.M., S.H.W.); and Department of Cardiology, Liuzhou Municipal Liutie Central Hospital, Liuzhou, China (J.Z.)
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Cipriani M, Landolina M, Oliva F, Ghio S, Vargiu S, Rordorf R, Raineri C, Ammirati E, Petracci B, Campo C, Bisetti S, Lunati M. Women with nonischemic cardiomyopathy have a favorable prognosis and a better left ventricular remodeling than men after cardiac resynchronization therapy. J Cardiovasc Med (Hagerstown) 2014; 17:291-8. [PMID: 25222077 DOI: 10.2459/jcm.0000000000000187] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Cardiac resynchronization therapy (CRT) is a well established therapy in heart failure patients who are on optimal medical therapy and have reduced left ventricular ejection fraction (LVEF) and wide QRS complexes. Although women and patients with nonischemic cardiomyopathy are under-represented in CRT trials and registries, there is evidence that these two groups of patients can benefit more from CRT. The aim of our analysis was to investigate the impact of female sex on mortality in a population that included a high percentage of patients (61%) with nonischemic cardiomyopathy. METHODS We analyzed data on 507 consecutive patients (20% women) who received CRT at two Italian Heart Transplant centers and were followed up for a maximum of 48 months. RESULTS After multivariate adjustment, women showed a trend toward better survival with regard to all-cause mortality [hazard ratio (HR) 0.32, confidence interval (CI) 0.10-1.04; P = 0.059]. However, this benefit was limited to nonischemic patients with regard to all-cause mortality (HR 0.20, CI 0.05-0.87, P = 0.032) and cardiovascular mortality (HR 0.14, CI 0.02-1.05, P = 0.056). CONCLUSION Female CRT recipients, at mid-term, have a favorable prognosis than male patients and this benefit appears to be more evident in nonischemic patients. Thus, we strongly believe that the apparent under-utilization of CRT in females is an anomaly that should be corrected.
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Affiliation(s)
- Manlio Cipriani
- a'A De Gasperis' Cardiac Department, Niguarda Ca' Granda, Granda Hospital, Milan bCardiac Department, Policlinico San Matteo, Pavia cMedtronic Clinical Research Institute dMedtronic Italia S.p.A., Milano, Italy
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Zusterzeel R, Curtis JP, Caños DA, Sanders WE, Selzman KA, Piña IL, Spatz ES, Bao H, Ponirakis A, Varosy PD, Masoudi FA, Strauss DG. Sex-Specific Mortality Risk by QRS Morphology and Duration in Patients Receiving CRT. J Am Coll Cardiol 2014; 64:887-94. [DOI: 10.1016/j.jacc.2014.06.1162] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 05/20/2014] [Accepted: 06/03/2014] [Indexed: 10/24/2022]
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Gottlieb C, Klugherz B. Gender disparity in response to CRT: here's the skinny. Heart Rhythm 2014; 11:1148-9. [PMID: 24801900 DOI: 10.1016/j.hrthm.2014.04.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Indexed: 11/27/2022]
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Varma N, Manne M, Nguyen D, He J, Niebauer M, Tchou P. Probability and magnitude of response to cardiac resynchronization therapy according to QRS duration and gender in nonischemic cardiomyopathy and LBBB. Heart Rhythm 2014; 11:1139-47. [PMID: 24704570 DOI: 10.1016/j.hrthm.2014.04.001] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND QRS morphology and QRS duration (QRSd) determine cardiac resynchronization therapy (CRT) candidate selection but criteria require refinement. OBJECTIVE To assess CRT effect according to QRSd, treated by dichotomization vs a continuous function, and modulation by gender. METHODS Patients selected were those with New York Heart Association class III/IV heart failure and with left bundle branch block and nonischemic cardiomyopathy (to test "pure" CRT effect) with pre- and postimplant echocardiographic evaluations. Positive response was defined as increased left ventricular ejection fraction (LVEF) post-CRT. RESULTS In 212 patients (LVEF 19% ± 7.1%; QRSd 160 ± 23 ms; 105 (49.5%) women), CRT increased LVEF to 30% ± 15% (P < .001) during a median follow-up of 2 years. Positive response occurred in 150 of 212 (71%) patients. Genders did not differ for QRSd, pharmacotherapy, and comorbidities, but response to CRT among women was greater: incidence 84% (88 of 105) in women vs 58% (62 of 107) in men (P < .001); increase in LVEF 15% ± 14% vs 7.2% ± 13%, respectively (P < .001). Overall, the response rate was 58% when QRSd <150 ms and 76% when QRSd ≥150 ms (P = .009). This probability differed between genders: 86% in women vs 36% in men (P < .001) when QRSd <150 ms and 83% vs 69%, respectively, when QRSd ≥150 ms (P = .05). Thus, female response rates remained high whether QRSd was <150 ms or ≥150 ms (86% vs 83%; P = .77) but differed in men (36% vs 69%; P < .001). With QRSd as a continuum, the CRT-response relationship was nonlinear and significantly different between genders. Female superiority at shorter QRSd inverted with prolongation >180 ms. CONCLUSION The QRSd-CRT response relationship in patients with heart failure and with left bundle branch block and nonischemic cardiomyopathy is better described by a sex-specific continuous function and not by dichotomization by 150 ms, which excludes a large proportion of women with potentially favorable outcome.
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Affiliation(s)
- Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Mahesh Manne
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dat Nguyen
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jiayan He
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Mark Niebauer
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick Tchou
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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Killu AM, Grupper A, Friedman PA, Powell BD, Asirvatham SJ, Espinosa RE, Luria D, Rozen G, Buber J, Lee YH, Webster T, Brooke KL, Hodge DO, Wiste HJ, Glikson M, Cha YM. Predictors and outcomes of "super-response" to cardiac resynchronization therapy. J Card Fail 2014; 20:379-86. [PMID: 24632340 DOI: 10.1016/j.cardfail.2014.03.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 01/28/2014] [Accepted: 03/04/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) has been shown to improve heart failure (HF) symptoms and survival. We hypothesized that a greater improvement in left-ventricular ejection fraction (LVEF) after CRT is associated with greater survival benefit. METHODS AND RESULTS In 693 patients across 2 international centers, the improvement in LVEF after CRT was determined. Patients were grouped as non-/modest-, moderate-, or super-responders to CRT, defined as an absolute change in LVEF of ≤5%, 6-15%, and >15%, respectively. Changes in New York Heart Association (NYHA) functional class and left ventricular end-diastolic dimension (LVEDD) were assessed for each group. There were 395 non-/modest-, 186 moderate-, and 112 super-responders. Super-responders were more likely to be female and to have nonischemic cardiomyopathy, lower creatinine, and lower pulmonary artery systolic pressure than non-/modest- and moderate-responders. Super-responders were also more likely to have lower LVEF than non-/modest-responders. There was no difference in NYHA functional class, mitral regurgitation grade, or tricuspid regurgitation grade between groups. Improvement in NYHA functional class (-0.9 ± 0.9 vs -0.4 ± 0.8 [P < .001] and -0.6 ± 0.8 [P = .02]) and LVEDD (-8.7 ± 9.9 mm vs -0.5 ± 5.0 and -2.4 ± 5.8 mm [P < .001 for both]) was greatest in super-responders. Kaplan-Meier survival analysis revealed that super-responders achieved better survival compared with non-/modest- (P < .001) and moderate-responders (P = .049). CONCLUSIONS Improvement in HF symptoms and survival after CRT is proportionate to the degree of improvement in LV systolic function. Super-response is more likely in women, those with nonischemic substrate, and those with lower pulmonary artery systolic pressure.
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Affiliation(s)
- Ammar M Killu
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Avishay Grupper
- Davidai Arrhythmia Center, Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Brian D Powell
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Raul E Espinosa
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - David Luria
- Davidai Arrhythmia Center, Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Guy Rozen
- Davidai Arrhythmia Center, Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Jonathan Buber
- Davidai Arrhythmia Center, Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Ying-Hsiang Lee
- Cardiovascular Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Tracy Webster
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Kelly L Brooke
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - David O Hodge
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Heather J Wiste
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Michael Glikson
- Davidai Arrhythmia Center, Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Yong-Mei Cha
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
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Schuchert A, Muto C, Maounis T, Frank R, Ella RO, Polauck A, Padeletti L. Gender-related safety and efficacy of cardiac resynchronization therapy. Clin Cardiol 2013; 36:683-90. [PMID: 24105909 DOI: 10.1002/clc.22203] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 08/01/2013] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an established therapy for patients with chronic heart failure (CHF) and a broad QRS complex. Gender-related safety and efficacy data are necessary for informed patient decision-making for female patients with CHF. The aim of the study was to assess the effects of gender on the outcome of CRT in highly symptomatic heart failure patients. HYPOTHESIS Gender may have an effect on the outcome of heart failure patients undergoing cardiac resynchronisation therapy. METHODS The study analyzed the 2-year follow-up of 393 New York Heart Association (NYHA) class III/IV patients with a class I CRT indication enrolled in the Management of Atrial Fibrillation Suppression in AF-HF Comorbidity Therapy (MASCOT) study. RESULTS In female patients (n = 82), compared with male patients (n = 311), CHF was more often due to dilated cardiomyopathy (74% vs 44%, respectively; P < 0.0001). Females also had a more impaired quality-of-life score and a smaller left ventricular end-diastolic diameter (LVEDD). Women were less likely than men to have received a CRT defibrillator (35% vs 61%, respectively; P < 0.0001). After 2 years, the devices had delivered more biventricular pacing in women than in men (96% ± 13% vs 94% ± 13%, respectively; P < 0.0004). Women had a greater reduction in LVEDD than did men (-8.2 mm ± 11.1 mm vs -1.1 mm ± 22.1 mm, respectively; P < 0.02). Both genders improved similarly in NYHA functional class. Women reported greater improvement than men in quality-of-life score (-21.1 ± 26.5 vs -16.2 ± 22.1, respectively; P < 0.0001). After adjustment for cardiovascular history, women had lower all-cause mortality (P = 0.0007), less cardiac death (P = 0.04), and fewer hospitalizations for worsening heart failure (P = 0.01). CONCLUSIONS Females exhibited a better response to CRT than did males. Because females have such impressive benefits from CRT, improved screening and advocacy for CRT implantation in women should be considered.
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Loring Z, Caños DA, Selzman K, Herz ND, Silverman H, MaCurdy TE, Worrall CM, Kelman J, Ritchey ME, Piña IL, Strauss DG. Left bundle branch block predicts better survival in women than men receiving cardiac resynchronization therapy: long-term follow-up of ∼ 145,000 patients. JACC-HEART FAILURE 2013; 1:237-44. [PMID: 24621876 DOI: 10.1016/j.jchf.2013.03.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 03/04/2013] [Accepted: 03/06/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The goal of this study was to test the hypothesis that in recipients of cardiac resynchronization therapy defibrillators (CRT-D), conventional left bundle branch block (LBBB) diagnosis predicts better survival in women than in men. BACKGROUND New York Heart Association class I and II patients without LBBB do not benefit from CRT-D, and women have better survival after CRT-D than men. Separate analysis suggests that QRS duration thresholds for LBBB diagnosis differ according to sex, and conventional LBBB electrocardiographic criteria are falsely positive in men more frequently than in women. METHODS We analyzed Medicare records from 144,642 CRT-D recipients between 2002 and 2008 that were followed up for up to 90 months. Medicare billing data were used to determine age, sex, race, and comorbidities. Hazard ratios (HRs) were calculated to assess if conventional LBBB diagnosis had different prognostic significance according to sex. RESULTS In univariate analysis, LBBB was associated with a 31% reduction in death in women (HR: 0.69 [95% confidence interval (CI): 0.67 to 0.71]) but only a 16% reduction in death in men (HR: 0.84 [95% CI: 0.82 to 0.85]). In multivariable analyses controlling for comorbidities, LBBB was associated with a 26% reduction in death in women (HR: 0.74 [95% CI: 0.71 to 0.77]) and a 15% reduction in death in men (HR: 0.85 [95% CI: 0.83 to 0.87]). A significant interaction (p < 0.0001) between sex and LBBB was seen. CONCLUSIONS LBBB diagnosis is associated with greater survival in women than in men receiving CRT-D, and this discrepancy is not explained by differences in measured comorbidities. Possible explanations for this difference include that LBBB may have different prognostic significance according to sex or that LBBB diagnosis is more often false-positive in men compared with women.
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Affiliation(s)
- Zak Loring
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland; Duke University School of Medicine, Durham, North Carolina
| | - Daniel A Caños
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland
| | - Kimberly Selzman
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland; Division of Cardiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Naomi D Herz
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland
| | | | | | | | - Jeffrey Kelman
- Centers for Medicare & Medicaid Services, Baltimore, Maryland
| | - Mary E Ritchey
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland
| | - Ileana L Piña
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland; Division of Cardiology, Albert Einstein College of Medicine, Bronx, New York
| | - David G Strauss
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland.
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Ståhlberg M, Lund LH, Zabarovskaja S, Gadler F, Braunschweig F, Linde C. Cardiac resynchronization therapy: a breakthrough in heart failure management. J Intern Med 2012; 272:330-43. [PMID: 22882554 DOI: 10.1111/j.1365-2796.2012.02580.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Heart failure is now considered an epidemic. In patients with heart failure, electrical and mechanical dyssynchrony, evident primarily as prolongation of the QRS-complex on the surface electrocardiogram, is associated with detrimental effects on the cardiovascular system at several levels. In the past 10 years, studies have demonstrated that by stimulating both cardiac ventricles simultaneously, or almost simultaneously [cardiac resynchronization therapy (CRT)], the adverse effects of dyssynchrony can be overcome. Here, we provide a comprehensive overview of different aspects of CRT including the rationale behind and evidence for efficacy of the therapy. Issues with regard to gender effects and patient follow-up as well as a number of unresolved concerns will also be discussed.
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Affiliation(s)
- M Ståhlberg
- Department of Cardiology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
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Ellenbogen KA, Huizar JF. Foreseeing Super-Response to Cardiac Resynchronization Therapy. J Am Coll Cardiol 2012; 59:2374-7. [DOI: 10.1016/j.jacc.2011.11.074] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 11/03/2011] [Accepted: 11/08/2011] [Indexed: 10/28/2022]
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