Atrial Fibrillation in Congestive Heart Failure: Impact on Clinical Presentation, Course and Outcomes



The 11th Annual Scientific Meeting wall blue to red tissue Doppler color change after the QRS complex to the posterior wall red to blue change at peak inward motion. End systolic volume (ESV) was measured by biplane Simpsons method and reverse remodeling was defined as $ 15% reduction in ESV. Results: To date, 125 patients (70% ischemic) have been enrolled; 76 have completed 3 month echo and 83 have completed 3 month clinical follow up. Of these, 40 patients (53%) had reverse remodeling. SPWMD could be measured in 80% of patients using standard M-mode and 96% of patients using Doppler color enhanced M-mode. The mean color M-mode SPWMD was 224 msec þ/- 124 msec. SPWMD tended to correlate with change in ESV at 3 mo (r 5 0.21, p 5 0.07). However, by receiver operating characteristics (ROC) analysis, the area under the ROC curve (AUC) for SPWMD in predicting reverse remodeling was not different from the line of no information (AUC 5 0.60; p 5 0.11). Optimal SPWMD was 215 ms with sensitivity of 66% and specificity of 60%. QRS duration had slightly superior predictive value (AUC 5 0.66, p 5 0.01). When patients with atrial fibrillation were excluded (n 5 38), the predictive value of QRS improved (AUC 5 0.80, p ! 0.0001) but not SPWMD (AUC 5 0.61, p 5 0.18). SPWMD did not correlate (r ! 0.2, p O 0.05 for all) with clinical measures of ‘‘CRT response’’ (DMLHFQ, D6MW distance or D peak VO2). Conclusions: The addition of tissue Doppler color to standard Mmode improves the feasibility of obtaining SPWMD. However, SPWMD was not predictive of response to CRT as defined by reverse remodeling or by improvement in symptoms or exercise performance.

194 Atrial Fibrillation in Congestive Heart Failure: Impact on Clinical Presentation, Course and Outcomes Ambika Bhaskaran1, Robert M. Siegel1, Ashok Garg1, Barbara Barker1, Therese Sargent1, Jennifer Vermillion1, James R. Romo1; 1Cardiovascular Research, Advanced Cardiac Specialists, Phoenix, AZ Atrial fibrillation (AF) and HF are major health concerns in an aging population in the United States. Both often co-exist and set off a vicious circle where the presence of one promotes the development of the other. Recent studies suggest AF may be an independent predictor of mortality in patients with advanced HF. We studied our HF Registry experience to evaluate the impact of AF on clinical presentation, course and 1-year outcomes. From 1/04 to 12/06, 70 patients presented with HF (LVEF ! 40%) and AF. Compared to patients in sinus rhythm (AF-), AFþ patients were older (mean age 69 vs 66; p 5 0.008), more likely to have an ischemic etiology (79% vs 72%; p 5 0.01), HTN (74% vs 63%; p 5 0.002) or prior stroke (34% vs 14%; p 5 0.027). AFþ were more symptomatic (52% vs 41% in NYHA Class III-IV; p 5 0.028). Noninvasive evaluation showed AFþ had worse LV systolic function (LVEF 29% vs 32%; p 5 0.017) and significantly greater LV end-diastolic (LVIDd 6.4 cm vs 6.0 cm; p ! 0.0001) dimensions. The incidence of $ moderate mitral regurgitation (51% vs 39%; p 5 0.000), elevated PA pressures (47 mmHg vs 40 mmHg; p 5 0.002) and LA enlargement (47 cm vs 41 mm; p 5 0.001) were significantly greater in the AFþ group. Patients with AFþ were more likely to receive diuretics (89% vs 71%; p 5 0.003), digoxin (77% vs 55%; p 5 0.001) and nesiritide (5.7% vs 1.4%; p 5 0.05). Patients received optimized medical, invasive and EP therapies. At 1-year follow up, resolution of AF was seen in 76%. This coincided with improvement in NYHA class (from 2.7 to 1.9), LV systolic function (mean LVEF 38%), and PA pressures (41 mmHg). LA enlargement remained stable (47 mm). At 1-year follow-up, patients in the AFþ group had more hospitalizations (27.1% vs 6.8%; p 5 0.08) and deaths from HF (8.6% vs 1.5%; p 5 0.045). Conclusions: (1) The presence of AF in HF patients is associated with significantly higher co-morbidities. (2) Patients are more symptomatic and demonstrate lower functional class. (3) Non-invasive evaluation demonstrates significantly worse hemodynamic parameters. (4) This is associated with significantly higher hospitalizations and mortality. (5) Effective restoration of sinus rhythm, with optimal therapeutic measures produce significant improvement in almost all parameters. Our series demonstrates that AF is an important factor in the course and progression of HF. Early diagnosis and treatment may help reduce morbidity and mortality associated with HF.

195 Comparative Adherence to Guidelines for Utilization of Implantable Cardiac Defibrillators and Cardiac Resynchronization Pacemakers by Heart Failure Clinicians and General Cardiologists Hannah Asghar1, Peter S. Rahko1; 1University of Wisconsin School of Medicine and Public Health, Madison, WI Device therapy indications for patients with heart failure (HF) and an ejection fraction (EF) # 35% have expanded due to new evidence-based studies. We compared adherence to recently published guidelines for the use of the implantable cardiac defibrillator (ICD) and the biventricular pacemaker (BiV) in a HF clinic and general cardiology clinic (CV). Methods: Records of 563 patients with an EF # 35% and symptomatic HF were abstracted for patients seen in the clinics during 2005 and early 2006. The entire course of HF care was reviewed and adherence to all guidelines for ICDs and BiV pacing from the current ACC/AHA HF guidelines determined. Results: There were 324 HF clinic (73% male, age 59 6 14 years, EF 23 6 7%) and 239 CV (67% male, age 67 6 15* years, EF 26 6 6*) patients, *5 p ! 0.0001 vs HF clinic. An ischemic etiology was more common in CV than HF patients: 63% vs 43%, p ! 0.0001. There were 145 patients in HF clinic and 94 patients in CV clinic with a QRS $ 120 ms. There were 67 HF and 38 CV patients with

HFSA

S131

a history of severe ventricular arrhythmia qualifying for secondary prevention; others were evaluated for primary prevention. Use of devices is shown below, analyzed by Chi-squared analysis. Conclusions: In this single center study HF clinicians used significantly more ICDs but use of BiV pacemakers was similar. For both groups guideline adherence was high (range 78-86%). A significant minority of patients improve confirming the concept that medical therapy should be maximized prior to device decisions.

BiV Pacer (QRS $ 120 ms)

ICD HF clinic Device in or planned Refused Not offered Not appropriate HF improved, not indicated ICD only P value

CV

HF clinic

CV

47% 3% 14% 3% 12% 20%

36% 5% 19% 2% 20% 17%

54% 33% 3% 4% 18% 22% 2% 2% 22% 34% e e 0.002

0.29

196 Phase Analysis of Gated SPECT Perfusion Imaging Can Quantify Left Ventricular Mechanical Dyssynchrony Mark A. Trimble1,4, Eric J. Velazquez1,4, Ami E. Iskandrian2, Ji Chen3, Ernest V. Garcia3, Emily F. Honeycutt4, Salvador Borges-Neto1,4; 1Duke University Medical Center, Durham, NC; 2University of Alabama at Birmingham, Birmingham, AL; 3 Emory University, Atlanta, GA; 4Duke Clinical Research Institute, Durham, NC Introduction: Cardiac resynchronization therapy (CRT) is used to treat patients with advanced heart failure. However, 30% of patients do not respond when QRS duration is used to define dyssynchrony. More precise methods to quantify dyssynchrony are needed. We report the ability of a novel nuclear technique to quantify mechanical dyssynchrony in subjects expected on average to have increased levels of dyssynchrony including subjects with left ventricular dysfunction, conduction delays, and paced rhythms. Hypothesis: Phase analysis of gated SPECT imaging can quantify left ventricular mechanical dyssynchrony. Methods: A count based method is used to extract regional systolic wall thickening amplitude and phase from gated SPECT images. Five indices describing the phase dispersion of the left ventricular regional onset of mechanical contraction are calculated including peak phase, phase SD, bandwidth, skewness, and kurtosis. These indices were determined in subjects with left ventricular dysfunction (n 5 120), left bundle branch block (LBBB, n 5 33), right bundle branch block (RBBB, n 5 19), and paced rhythm (n 5 23) and compared to normal controls (n 5 157). Results: Table 1 provides the mean for all phase indices. Phase SD, bandwidth, skewness, and kurtosis were significantly different from normal controls in subjects with left ventricular dysfunction, LBBB, RBBB, and paced rhythms (all p values ! .001). Peak phase was significantly different from normal controls only in subjects with paced rhythms (p 5 .001). Conclusion: Phase analysis of gated SPECT perfusion images permits detection and quantification of left ventricular mechanical dyssynchrony and may prove useful in the evaluation of patients for CRT. Table 1. Phase Analysis Indices

Peak Phase Phase SD Bandwidth Skewness Kurtosis

Normal

LV-Dysfunction

LBBB

RBBB

Paced

134.8 15.7 42.0 4.6 22.4

130.8 47.8 147.0 2.7 8.8

138.6 28.7 87.6 2.9 9.9

138.6 28.1 79.1 3.3 12.5

118.6 30.8 94.1 2.9 10.2

Table 1 presents the mean values for the phase analysis indices in all the cohorts studied.

197 Association between Atrial and Ventricular Tachyarrhythmias, Intrathoracic Impedance and Heart Failure Decompensation in CRT-D Patients William Wickemeyer1, Robin Germany2, Bobbi Hoppe3, John Andriulli4, Peter Brady5, Roy Small6, Wilson Tang7, Melody LaBeau8, Shantanu Sarkar8; 1Iowa Heart Center; 2University of Oklahoma; 3North Memorial Hospital; 4Cooper Heart Institute; 5Mayo Clinic; 6Lancaster Heart; 7Cleveland Clinic; 8Medtronic, Inc. Background: The relationship between heart failure (HF) decompensation and atrial and ventricular tachyarrhythmias is not well understood. We examined the association between atrial arrhythmias (AT/AF, including both fibrillation and flutter), ventricular arrhythmias (VT/VF) and intrathoracic impedance, an index of worsening heart failure, in a population of CRT-D patients. Methods: The OFISSER clinical trial was a multi-center (n 5 7) US patient registry that included 326 patients (70 6 11 yrs, 76% Male, EF 5 25 6 8%) with at least 6 months experience with