Outcomes of novel pacing technologies with right ventricular pacing as a primary strategy for patient undergoing transvenous permanent pacing regardless of pacing indication

Background

Right ventricular pacing (RVP) may cause electrical and mechanical desynchrony leading to impaired left ventricular ejection fraction (LVEF). We investigated the outcomes of RVP with His bundle pacing (HBP) and left bundle branch pacing (LBBP) for patients requiring a de novo permeant pacemaker (PPM) irrespective of baseline pacing indication.

Methods and results

Systematic review of randomized clinical trials and observational studies comparing HBP or LBP with RVP for de novo PPM implantation between 01 January 2013 and 17 November 2020 using MEDLINE and Embase. Two independent reviewers extracted the data and assessed the risk of bias of included studies. Random and fixed effects meta-analyses of the effect of pacing technology on study outcomes (all-cause mortality, heart failure hospitalization (HFH), left ventricular ejection fraction, QRS duration, lead revision, atrial fibrillation and procedure and pacing metrics) were performed. Overall, 7 studies were included. HBP compared with RVP was associated with decreased mortality (risk ratio [RR] 0.76, 95% CI 0.59 to 0.98), preservation of LVEF (mean difference [MD] 1.2, 95% CI −1.37 to 3.8 vs. −5.22, 95% CI: −6.94 to −3.51), increased procedure duration (MD 15.17 min, 95% CI: 11.27 to 19.07) and more lead revisions (RR 6.30, 95% CI: 2.31 to 17.19). LBBP compared with RVP was associated with shorter paced QRS durations (MD 5.6 ms, 95% CI −6.4 to 17.6) vs. (51.0 ms, 95% CI 39.2 to 62.9) and increased procedure durations (MD 37.78 min, 95% CI: 20.04 to 55.51).

Conclusion

Of the limited studies published, this meta-analysis found that HBP and LBBP were superior to RVP in maintaining physiological ventricular activation as an initial pacing strategy. Well conducted comparative studies are required to understand the impact of such novel pacing strategies on clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

1420Peripheral edema and headache associated with amlodipine treatment: a meta-analysis of randomized, placebo-controlled trials

Background

Use of amlodipine for treatment of arterial hypertension (AH) and stabile angina pectoris (SAP) is sometimes limited by occurrence of peripheral edema and headache.

Purpose

As these side effects (SE) occur also on placebo in clinical trials, we aimed to explore the true magnitude of this phenomenon by determining the rate and placebo-adjusted rate of these SE.

Methods

We performed a meta-analysis by including all randomized, placebo-controlled trials reporting edema and headache with amlodipine in patients with AH and SAP. Placebo-adjusted rate (%) was determined as follows: (SE amlodipine % − SE placebo %)/SE amlodipine %. Electronic databases PubMed, Web of Science, and Cochrane library were systematically searched for eligible trials published until July 2018. Diseases such as heart failure, severe renal or hepatic disease were not considered. Furthermore, in most of the trials, a wash-out period took place before the study medication was given.

Results

Data from 7,226 patients of 22 trials were analyzed. In most of the analyzed trials, duration of follow up was comparable, and lasted about 8 weeks. All studies were graded as high quality according to Jadad score. Rate of edema was higher on amlodipine compared with placebo (16.6 vs 6.2%, RR: 2.9, 95% CI: 2.5–3.36, p<0.0001). The placebo-adjusted rate was 63%, indicating that 37% of edema cases were unrelated to amlodipine. Treatment with low/medium doses (2.5–5 mg) resulted in lower rates of edema (RR: 2.01, 95% CI: 1.41–2.88, p=0.0001) compared with high dose (10 mg) (RR: 3.08, 95% CI 2.62–3.6, p<0.0001, p for interaction=0.03). For each 5-mmHg reduction in BP one could expect lower rates of edema using a low/medium compared with high dose of amlodipine (3.2 vs. 12.2%). Headache was reduced using amlodipine compared with placebo (7.9 vs 10.9%, RR: 0.77, 95% CI: 0.65–0.90, p=0.002) and was driven by use of low/medium doses (RR: 0.52, 95% CI: 0.40–0.69, p<0.ehz748.00661 versus RR: 0.92, 95%-CI: 0.74–1.15, p=0.45, for high doses, p for interaction =0.002). According to a data from six studies administration of renin-angiotensin-inhibitors as add-on therapy to low/medium dose of amlodipine, resulted in higher BP reduction with equivalent rates of edema in comparison with amlodipine monotherapy (p for interaction = 0.23), which may be advantageous in obtaining guideline-recommended target BP values.

Conclusion

Patients on amlodipine exhibit a dose-dependent 3-fold increased risk of peripheral edema compared with placebo. Of note, up to one third of edema cases on amlodipine might not be induced by amlodipine. Headache is reduced on amlodipine treatment, mainly driven by use of this drug at low/medium doses potentially related to better blood pressure control. Amlodipine used at appropriate doses express the best risk-benefit ratio concerning edema and prevention of headache, thus maintaining treatment adherence, alone or in combination with other drugs.

Acknowledgement/Funding

None

Carotid atherosclerotic plaque progression and change in plaque composition over time: a 5-year follow-up study using serial CT angiography

BACKGROUND AND PURPOSE

Serial in vivo imaging of atherosclerosis is important for understanding plaque progression and is potentially useful in predicting cardiovascular events and monitoring treatment efficacy. This prospective study aims to quantify temporal changes in carotid atherosclerotic plaque volume and plaque composition using MDCTA.

MATERIALS AND METHODS

In 109 patients with TIA or ischemic stroke, serial MDCTA of the carotid arteries was performed after 5.3 ± 0.7 years. The carotid bifurcation was semiautomatically registered for paired baseline follow-up datasets. Outer vessel wall and lumen boundaries were defined using semiautomated segmentation tools. Plaque component volumes were measured using HU thresholds. Annual changes in plaque volume and plaque component proportions were calculated.

RESULTS

One-hundred-ninety-three carotid arteries were analyzed. Plaque volume decreased in 31% and increased in 69% of vessels (range -5.6-10.1%/year). Overall, plaque volume increased 1.2% per year (95% CI, 0.8-1.6, P ≤ .001). Plaque composition changed significantly from BL (fibrous 66.4%, lipid 28.8%, calcifications 4.8%): fibrous tissue decreased by 1.5%, lipid decreased by 1.8%, and calcification increased by 3.3% (P < .001). Intraobserver reproducibility of all volume and proportion measurements was good (ICC 0.78-1.00) and interobserver reproducibility was moderate (ICC 0.76-0.99).

CONCLUSIONS

Changes in carotid plaque burden and plaque composition can be quantified by using serial MDCTA. Plaque burden development is a heterogeneous and slow process.