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Wong KYK, Hughes DA, Debski M, Latt N, Assaf O, Abdelrahman A, Taylor R, Allgar V, McNeill L, Howard S, Wong SYS, Jones R, Cassidy CJ, Seed A, Galasko G, Clark A, Wilson D, Davis GK, Montasem A, Lang CC, Kalra PR, Campbell R, Lip GYH, Cleland JGF. Effectiveness of out-patient based acute heart failure care: a pilot randomised controlled trial. Acta Cardiol 2023; 78:828-837. [PMID: 37694719 DOI: 10.1080/00015385.2023.2197834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVES Acute heart failure (AHF) hospitalisation is associated with 10% mortality. Outpatient based management (OPM) of AHF appeared effective in observational studies. We conducted a pilot randomised controlled trial (RCT) comparing OPM with standard inpatient care (IPM). METHODS We randomised patients with AHF, considered to need IV diuretic treatment for ≥2 days, to IPM or OPM. We recorded all-cause mortality, and the number of days alive and out-of-hospital (DAOH). Quality of life, mental well-being and Hope scores were assessed. Mean NHS cost savings and 95% central range (CR) were calculated from bootstrap analysis. Follow-up: 60 days. RESULTS Eleven patients were randomised to IPM and 13 to OPM. There was no statistically significant difference in all-cause mortality during the index episode (1/11 vs 0/13) and up to 60 days follow-up (2/11 vs 2/13) [p = .86]. The OPM group accrued more DAOH {47 [36,51] vs 59 [41,60], p = .13}. Two patients randomised to IPM (vs 6 OPM) were readmitted [p = .31]. Hope scores increased more with OPM within 30 days but dropped to lower levels than IPM by 60 days. More out-patients had increased total well-being scores by 60 days (p = .04). OPM was associated with mean cost savings of £2658 (95% CR 460-4857) per patient. CONCLUSIONS Patients with acute HF randomised to OPM accrued more days alive out of hospital (albeit not statistically significantly in this small pilot study). OPM is favoured by patients and carers and is associated with improved mental well-being and cost savings.
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Affiliation(s)
- K Y K Wong
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - D A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - M Debski
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - N Latt
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - O Assaf
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - A Abdelrahman
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - R Taylor
- Research and Development Department, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - V Allgar
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
| | - L McNeill
- Accountant, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - S Howard
- Financial Information And Costing Manager, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - S Y S Wong
- Department of Care of the Older Person, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - R Jones
- Public Involvement Group, Research and Development Department, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - C J Cassidy
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - A Seed
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - G Galasko
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - A Clark
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
| | - D Wilson
- Department of Cardiology, Worcestershire Royal Hospital (Worcestershire Acute Hospital NHS Trust), Worcester, UK
| | - G K Davis
- Cardiorespiratory Research Centre, Edge Hill University Medical School, Ormskirk, UK
| | - A Montasem
- Institute of Life Course and Medical Sciences, School of Dental Sciences, Liverpool University Dental Hospital, University of Liverpool, Liverpool, UK
| | - C C Lang
- Department of Cardiology, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - P R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - R Campbell
- Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - G Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - J G F Cleland
- Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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Abdelrahman A, Debski M, More R, Eichhofer J, Patel B. One-year outcomes of percutaneous coronary intervention in native coronary arteries versus bypass grafts in patients with prior coronary artery bypass graft surgery. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Patients with prior coronary artery bypass graft (CABG) surgery often require percutaneous coronary intervention (PCI). Data are still limited in regards to the outcomes of native versus graft PCI after CABG.
Methods
We performed a retrospective study in a tertiary reference cardiac centre of consecutive patients who underwent PCI after CABG. The data were collected for patients who underwent either native or graft PCI from January 2008 to December 2018. Major adverse cardiac events (MACE) included death or myocardial infarction (MI) or revascularization. All outcomes were assessed at 1-year after each index procedure.
Results
A total of 445 PCI were performed in 410 patients (209 had native PCI and 201 had graft PCI). The groups of patients with native vessel PCI and graft PCI were statistically comparable regarding their baseline characteristics. In multivariable Cox regression graft PCI relative to native PCI was an independent risk factor for MACE (hazard ratio [HR] 1.818, 95% confidence interval [CI] 1.148–2.878).
Conclusion
Compared with native coronary PCI, bypass graft PCI was significantly associated with higher incidence of MACE at 1-year and this was mainly driven by MI and revascularization.
MACE outcomes
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- A Abdelrahman
- Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - M Debski
- Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - R More
- Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - J Eichhofer
- Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - B Patel
- Blackpool Victoria Hospital, Blackpool, United Kingdom
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Debski M, Howard L, Black P, Goode A, Cassidy C, Seed A. Real world experience with heart failure risk status generated by cardiac resynchronisation therapy defibrillators: high heart failure risk status incidence, causes and timing of remote transmissions. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Proactive patient monitoring is of paramount importance in effective management of heart failure (HF) patients. Cardiac implantable electronic devices (CIEDs) used in HF patients are able to derive long-term trends in physiologic parameters and provide timely warning to clinicians. Little is known, however, on the real-world experience with device-generated HF risk-stratifying algorithms.
Purpose
Heart Failure Risk Score (HFRS) takes into account nine parameters and is calculated automatically based on long-term clinical trends. Remote transmissions provide information on the risk of HF event in next 30 days categorized as low, medium or high based on a maximum daily risk status in prior 30 days. We aimed to evaluate the ability of HFRS to alert HF specialists on the actual HF risk status.
Methods
The prospective registry included all patients with CIEDs featuring integrated Heart Failure Risk Score (HFRS) followed via Medtronic CareLink remote monitoring system and enabled for Co-management (CM) from May 2015 to August 2019 in a tertiary centre. High HFRS does not trigger automatic alert transmission. Study follow-up spanned between start of CM and last transmission in 2019. Inclusion criteria were CRT-D in situ, active Home Monitor, switched on OptiVol 2.0 remote alert and transmission data available on CareLink following study period completion. Transmissions were scheduled 3-monthly.
Results
Out of 229 consecutive patients, 132 met study criteria. Mean age was 74±10 years, 18% were female. Median follow-up duration was 2.7 years (IQR 1.3). Total number of transmissions was 2652, median per patient was 18 (IQR 13); scheduled, unscheduled and care alerts constituted 42%, 44% and 14%, respectively. One third of transmissions were automatically sent for CM review. There were 398 high HFRS episodes. OptiVol fluid index was below the threshold throughout 128 (32%) episodes. Missed episodes (not transmitted within 30 days from the final day of high HFRS) amounted to 130 (33%) and the reasons behind this included OptiVol alerting before the first day of high HFRS or persistently elevated when HFRS changed from low/medium to high (52%), low OptiVol index during the episode (38%) or other (10%). Median duration of high HFRS was 7 days (IQR 12, range, 1–187). Among timely picked-up high HFRS episodes, 38% were transmitted during the relevant episode and 62% afterwards with median delay of 10 days (IQR 15) from the last day of high HFRS; 21% of transmissions showing high HFRS were not highlighted for CM review which correlated with low OptiVol index, P<0.001. The factors contributing to high HFRS included: raised OptiVol (60%), patient activity (83%), AT/AF (46%), ventricular rate (VR) during AF (6%), % of VP (40%), shocks (2%), treated VT/VF (2%), night VR (72%) and HR variability (34%).
Conclusions
In a real-world clinical setting high HFRS was frequently under-reported. The investigation into clinical implications is warranted.
Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Our department has benefited from unrestricted grants from Boston Scientific and Medtronic Inc during the last 5 years.
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Affiliation(s)
- M Debski
- Blackpool Teaching Hospitals NHS Trust, Lancashire Cardiac Centre, Blackpool, United Kingdom
| | - L Howard
- Blackpool Teaching Hospitals NHS Trust, Lancashire Cardiac Centre, Blackpool, United Kingdom
| | - P Black
- Blackpool Teaching Hospitals NHS Trust, Lancashire Cardiac Centre, Blackpool, United Kingdom
| | - A Goode
- Blackpool Teaching Hospitals NHS Trust, Lancashire Cardiac Centre, Blackpool, United Kingdom
| | - C Cassidy
- Blackpool Teaching Hospitals NHS Trust, Lancashire Cardiac Centre, Blackpool, United Kingdom
| | - A Seed
- Blackpool Teaching Hospitals NHS Trust, Lancashire Cardiac Centre, Blackpool, United Kingdom
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Boczar K, Zabek A, Slawuta A, Debski M, Gajek J, Lelakowski J, Malecka B. Optimal programming of cardiac resynchronisation therapy with His bundle pacing based on aortic velocity time integral in patients with congestive heart failure and permanent atrial fibrillation. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Cardiac resynchronisation therapy (CRT) in patients with permanent atrial fibrillation (AF) is usually less effective than in sinus rhythm patients. Recent evidence has shown that His bundle pacing (HBP) might be a valuable alternative to conventional pacing systems resulting in more physiologic electrical activation of the heart. Currently, there is a need to identify the optimal way of CRT + HBP programming in patients with congestive heart failure (CHF) and permanent AF to achieve high cardiac output and improve physical capacity and survival.
Purpose
The aim of this study was to evaluate the impact of CRT + HBP programming on cardiac output in the early post-operative measurements.
Methods
We included consecutive patients with: 1. permanent AF, 2. CHF in NYHA class III-IV, 3. bundle branch block with QRS >130 ms or QRS <130 ms and high expected requirement of ventricular pacing, 4. severely reduced left ventricular ejection fraction (LVEF) ≤35%, 5. CHF refractory to optimal medical therapy, 6. implanted CRT + HBP. All patients gave informed consent for CRT + HBP implantation and optimization of device programming.
During the early post-operative phase, we aimed to optimize CRT + HBP settings in order to achieve the highest cardiac output assessed by repeated echocardiographic measurements of aortic velocity time integral at various pacing programs (Table 1). Then, we selected the optimal pacing settings of CRT + HBP for each individual patient.
Results
Study included 17 consecutive patients aged 71.5±6.3 years, 12 were male. Mean LVEF was 24% and median NYHA class was III. The most efficacious method of pacing in terms of aortic VTI was HBP combined with left ventricular pacing (LV) which resulted in median VTI of 22.5. HBP + LV was superior to right ventricular pacing (RV): VTI of 22.5 vs 18.5, P=0.003 and outperformed biventricular pacing: VTI 22.5 vs 18.7, P=0.019. Detailed results are shown in Figure 1.
Conclusion
His bundle pacing coupled with LV pacing proved to be the most advantageous pacing program setting with regard to cardiac output and it performed significantly better than RV pacing only or biventricular pacing. Our observation supports the use of His bundle pacing in CRT systems in patients with CHF and permanent AF.
Figure 1
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- K Boczar
- John Paul II Hospital, Department of Electrocardiology, Krakow, Poland
| | - A Zabek
- John Paul II Hospital, Department of Electrocardiology, Krakow, Poland
| | - A Slawuta
- Klodzko County Hospital, Department of Cardiology, Klodzko, Poland
| | - M Debski
- John Paul II Hospital, Department of Electrocardiology, Krakow, Poland
| | - J Gajek
- Wroclaw Medical University, Department of Clinical Nursing, Wroclaw, Poland
| | - J Lelakowski
- John Paul II Hospital, Institute of Cardiology, Jagiellonian University Medical College. Department of Electrocardiology, Krakow, Poland
| | - B Malecka
- John Paul II Hospital, Institute of Cardiology, Jagiellonian University Medical College. Department of Electrocardiology, Krakow, Poland
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Debski M, Ulman M, Zabek A, Boczar K, Haberka K, Kuniewicz M, Lelakowski J, Malecka B. P6557Permanent atrial fibrillation development in patients with DDD pacemaker -Rrisk factors and association with mortality in long-term. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.1147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
In patients undergoing permanent DDD cardiac pacing, the maintenance of atrial contractility is important to ensure adequate ventricular filling and to guarantee an optimal ventricular ejection capacity. Atrial fibrillation (AF) is a major risk factor for thromboembolic events and is associated with increased cardiovascular and all-cause mortality.
Purpose
To analyse the risk factors for development of permanent AF in patients with DDD pacemaker and determine its association with all-cause mortality in long-term follow-up.
Methods
Retrospectively collected records comprised all consecutive patients who underwent primary DDD pacemaker implantation at single-centre between 1984–2014. Patients who were lost to follow-up after hospital discharge were excluded from analysis. Follow-up was completed on 31st August 2016. Definition of permanent AF was the occurence of AF which persisted until the end of follow-up. Data on patients' survival status and deceased patients' dates of death were collected from the national death registration system. Information of death date was available as of 31st August 2016. The endpoint was all-cause mortality.
Results
We included a total of 3771 patients and 24,432 patient-years of follow-up and exluded 157 (4%) patients who were lost to follow-up after hospital discharge. Mean follow-up was 78±62 months (max. 370 months), 1761 (47%) were female. Paroxysmal AF prior to DDD pacemaker implantation was detected in 1276 patients (34%). During entire follow-up 717 (19%) patients developed permanent AF in a mean period of 55±50 months. Analysis of risk factors for development of permanent AF is presented in Figure. Cox proportional hazards model with time-dependent covariate showed that development of permanent AF significantly increased mortality during follow-up (HR = 1.885, 95% CI, 1.654–2.148, P<0.001; with adjustment for age at implantation and sex: HR = 1.475, 95% CI, 1.294–1.682, P<0.001).
Permanent AF risk factors
Conclusions
Female sex protected against permanent AF development, whereas age at implantation, history of paroxysmal AF and apical position of RV lead increased the risk. Permanent AF was significantly increasing the all-cause mortality, even after adjustment for age at implant and gender.
Acknowledgement/Funding
None
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Affiliation(s)
- M Debski
- John Paul II Hospital, Department of Electrocardiology, Krakow, Poland
| | - M Ulman
- John Paul II Hospital, Department of Electrocardiology, Krakow, Poland
| | - A Zabek
- John Paul II Hospital, Department of Electrocardiology, Krakow, Poland
| | - K Boczar
- John Paul II Hospital, Department of Electrocardiology, Krakow, Poland
| | - K Haberka
- John Paul II Hospital, Department of Electrocardiology, Krakow, Poland
| | - M Kuniewicz
- John Paul II Hospital, Department of Electrocardiology, Krakow, Poland
| | - J Lelakowski
- John Paul II Hospital, Department of Electrocardiology, Krakow, Poland
| | - B Malecka
- John Paul II Hospital, Department of Electrocardiology, Krakow, Poland
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Kalinczuk L, Dabrowski M, Lazarczyk H, Debski M, Pregowski J, Prokop M, Trzcinski A, Proczka M, Szymanski P, Kaczmarska-Dyrda E, Dzielinska Z, Chmielak Z, Demkow M, Hryniewiecki T, Witkowski A. P4273Patterns of an early platelet response after TAVI are equal for various types and sizes of implanted valves, but its magnitude differs across valve diameters. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.p4273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Debski M, Ulman M, Zabek A, Boczar K, Haberka K, Kuniewicz M, Lelakowski J, Malecka B. P1677Analysis of lead dysfunction in long-term follow-up in a large cohort after primary DDD pacemaker implantation. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx502.p1677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Malecka B, Zabek A, Szot W, Boczar K, Debski M, Lelakowski J, Kostkiewicz M. P428Usefulness of SPECT-CT with radioisotope-labeled leukocytes for diagnosis of lead-dependent infective endocarditis. Europace 2017. [DOI: 10.1093/ehjci/eux141.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Debski M, Ulman M, Zabek A, Haberka K, Boczar K, Kuniewicz M, Lelakowski J, Malecka B. P1521Prognostic importance of gender, type of bradyarrhythmia and baseline characteristics on the survival of 3924 consecutive patients with DDD pacemaker. Europace 2017. [DOI: 10.1093/ehjci/eux158.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Norman R, Motta E, Soltyk J, Golba A, Debski M. Arterial and venous hemodynamics in patients with multiple sclerosis. J Neurol Sci 2013. [DOI: 10.1016/j.jns.2013.07.1492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Motta E, Kazibutowska Z, Golba A, Bal A, Debski M, Puz P. Parameters of cerebral blood flow in patients with Parkinson's disease and extrapyramidal syndrome. A transcranial doppler study. J Neurol Sci 2009. [DOI: 10.1016/j.jns.2009.02.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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