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Kutyifa V, Naqvi SY, Brown M, McNitt S, Goldenberg I, Klein H, Moss AJ. Comparison of Long-Term Survival Benefits With Cardiac Resynchronization Therapy in Patients With Mild Heart Failure With Versus Without Diabetes Mellitus (from the Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy [MADIT-CRT]). Am J Cardiol 2018; 121:1567-1574. [PMID: 29625702 DOI: 10.1016/j.amjcard.2018.02.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 02/22/2018] [Accepted: 02/27/2018] [Indexed: 01/09/2023]
Abstract
We have previously shown a reduction in HF events with cardiac resynchronization therapy with defibrillator (CRT-D) in patients with mild heart failure (HF) and diabetes mellitus (DM). It remains unknown whether HF remission in DM patients with CRT-D translates into reduced mortality. The effects of CRT-D versus an implantable cardioverter-defibrillator (ICD) alone to reduce long-term mortality were assessed in patients with left bundle branch block with DM (n = 386) and without DM (n = 982), enrolled in the Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy (MADIT-CRT). We further subdivided DM patients by insulin and noninsulin therapy. Kaplan-Meier survival analyses and multivariate cox proportional hazards regression models were utilized. At the 7-year follow-up, CRT-D was associated with a lower mortality in DM patients compared with ICD alone (21% vs 42%, p = 0.02), similar to non-DM patients (16 vs 24%, p = 0.014). CRT-D was associated with a 41% reduction in the risk of long-term all-cause mortality in DM patients (hazard ratio [HR] 0.59, 95% confidence interval 0.36 to 0.96, p = 0.033) and a similar reduction in non-DM patients (HR 0.69, 95% confidence interval 0.48 to 0.99, p = 0.045, treatment-diabetes interaction p = 0.611). Among DM patients, mortality benefit was evident in insulin-treated patients only (HR 0.40, p = 0.030). Reductions in HF events were present in all groups. In the MADIT-CRT, patients with mild HF with DM derive significant long-term survival benefit from CRT-D, similar to those without DM. The mortality benefit from CRT-D within the DM subgroup seems to be confined to patients with insulin treated diabetes.
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Affiliation(s)
- Valentina Kutyifa
- Cardiology Division, Heart Research Follow-Up Program, University of Rochester Medical Center, Rochester, New York.
| | - Syed Yaseen Naqvi
- Cardiology Division, Heart Research Follow-Up Program, University of Rochester Medical Center, Rochester, New York
| | - Mary Brown
- Cardiology Division, Heart Research Follow-Up Program, University of Rochester Medical Center, Rochester, New York
| | - Scott McNitt
- Cardiology Division, Heart Research Follow-Up Program, University of Rochester Medical Center, Rochester, New York
| | - Ilan Goldenberg
- Cardiology Division, Heart Research Follow-Up Program, University of Rochester Medical Center, Rochester, New York
| | - Helmut Klein
- Cardiology Division, Heart Research Follow-Up Program, University of Rochester Medical Center, Rochester, New York
| | - Arthur J Moss
- Cardiology Division, Heart Research Follow-Up Program, University of Rochester Medical Center, Rochester, New York
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Szepietowska B, Kutyifa V, Ruwald MH, Solomon SD, Ruwald AC, McNitt S, Polonsky B, Thomas S, Moss AJ, Zareba W. Effect of Cardiac Resynchronization Therapy in Patients With Insulin-Treated Diabetes Mellitus. Am J Cardiol 2015; 116:393-9. [PMID: 26048851 DOI: 10.1016/j.amjcard.2015.04.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 04/30/2015] [Accepted: 04/30/2015] [Indexed: 11/28/2022]
Abstract
Diabetes mellitus (DM) modify outcome in patients with heart failure (HF). We aimed to analyze the risk for death, HF alone, combined end point HF/death, and ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with mild HF without DM and in those with DM, further stratified by the presence of insulin treatment. We determined whether cardiac resynchronization therapy with defibrillator (CRT-D) versus implantable cardioverter defibrillator improves clinical outcomes in these 3 subgroups. Cox proportional hazards regression models were used to analyze 1,278 patients with left bundle branch block in the Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy trial. Treatment with CRT-D versus implantable cardioverter defibrillator was associated with 76% risk reduction in all-cause mortality (hazard ratio 0.24; 95% confidence interval 0.08 to 0.74, p = 0.012) in subgroup of diabetic patients treated with insulin only (interaction p = 0.043). Significant risk reduction in HF alone, HF/death, and the VT/VF after CRT-D was observed across investigated groups and similar left ventricular reverse remodeling to CRT-D. In conclusion, patients with mild HF with DM treated with insulin derive significant risk reduction in mortality, in HF, and VT/VF after implantation of CRT-D. Diabetic patients not receiving insulin benefit from CRT-D by reduction of HF events.
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Affiliation(s)
- Barbara Szepietowska
- Department of Medicine, Cardiology, Heart Research Follow up Program, University of Rochester Medical Center, Rochester, New York
| | - Valentina Kutyifa
- Department of Medicine, Cardiology, Heart Research Follow up Program, University of Rochester Medical Center, Rochester, New York
| | - Martin H Ruwald
- Department of Medicine, Cardiology, Heart Research Follow up Program, University of Rochester Medical Center, Rochester, New York; Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark
| | - Scott D Solomon
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anne C Ruwald
- Department of Medicine, Cardiology, Heart Research Follow up Program, University of Rochester Medical Center, Rochester, New York; Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark
| | - Scott McNitt
- Department of Medicine, Cardiology, Heart Research Follow up Program, University of Rochester Medical Center, Rochester, New York
| | - Bronislava Polonsky
- Department of Medicine, Cardiology, Heart Research Follow up Program, University of Rochester Medical Center, Rochester, New York
| | - Sabu Thomas
- Department of Medicine, Cardiology, Heart Research Follow up Program, University of Rochester Medical Center, Rochester, New York
| | - Arthur J Moss
- Department of Medicine, Cardiology, Heart Research Follow up Program, University of Rochester Medical Center, Rochester, New York
| | - Wojciech Zareba
- Department of Medicine, Cardiology, Heart Research Follow up Program, University of Rochester Medical Center, Rochester, New York.
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Abstract
Heart rate variability (HRV) non-invasively assesses the activity of the autonomic nervous system. During the past 30 years, an increasing number of studies have related the imbalance of the autonomic nervous system (as assessed by HRV) to several pathophysiogical conditions, particularly in the setting of cardiovascular disease. Sudden death, coronary artery disease, heart failure, or merely cardiovascular risk factors (smoking, diabetes, hyperlipidemia, and hypertension) are the best-known clinical circumstances that can affect and/or be affected by the autonomic nervous system. Analyses of HRV variables have been proposed as a component of the clinical evaluation for patient risk stratification due to its independent prognostic information. Yet the potential for HRV to be used widely in clinical practice remains to be established.
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Affiliation(s)
- Borejda Xhyheri
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale. University of Bologna, Bologna, Italy
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Gronda E, Padeletti L. Cardiac resynchronization therapy in heart failure diabetic population: a challenging issue. J Cardiovasc Med (Hagerstown) 2011; 12:383-4. [PMID: 21540671 DOI: 10.2459/jcm.0b013e3283468f3a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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