- Email: [email protected]
Progressive Worsening in Device-Based Heart Failure Sensor Measurements are Associated with Sub-Optimal LV Pacing Percentages in CRT-D Patients
The 23rd Annual Scientific Meeting HFSA
S17
Biomarkers/Neurohormones/Cytokines 036 Improved Survival on Palliative Home Inotropes in the Modern Era Behram P. Mody1, Syed Zaid1, Mohammed H. Khan1, Howard A. Cooper1, Chul Ahn2, Wilbert S. Aronow1, Gregg M. Lanier1; 1Westchester Medical Center, Valhalla, NY; 2 University of Texas Southwestern Medical Center, Dallas, TX Introduction: Continuous outpatient intravenous inotrope therapy (COIIT) is a treatment strategy in stage D heart failure as bridge to advanced therapies or palliation. Studies conducted before the era of modern guideline directed medical and device therapy (GDMDT) have demonstrated poor outcomes for palliative COIIT, with survival rates as low as 25% at 1 year. Our objective is to describe the outcomes of patients receiving palliative COIIT in the current era of GDMDT. Hypothesis: Overall survival on palliative COIIT has improved in the era of GDMDT. The choice of inotrope (milrinone or dobutamine) has an impact on survival. Methods: We retrospectively analyzed data from a large US registry of patients receiving COIIT (milrinone or dobutamine) from 2015-17. Patients were included if the indication for COIIT was palliation and excluded if they had incomplete data or <7 days of follow-up. Overall survival at 1 and 2 years was estimated from unadjusted Kaplan-Meier curves. Survival for patients receiving milrinone and dobutamine (overall and for low- and high-doses) was compared using the Log rank statistic. Results: Of 1,149 registry patients receiving COIIT, the indication was palliation in 404 (35%). The mean age was 65 years, and 30% were women. During the study period, 124 (31%) patients died. Estimated survival at 1 and 2 years was 55% and 42% respectively (Figure Panel A). Milrinone was used in 235 (58%) patients and dobutamine in 169 (42%). Compared to patients treated with dobutamine, patients treated with milrinone had greater survival at 1 year (63% vs 43%, p=0.0003) and 2 years (47% vs 34%, p=0.0003). Median survival was estimated at 699 days for milrinone and 247 days for dobutamine (Figure Panel B). The use of high-dose milrinone (0.375 mcg/kg/min) was associated with greater survival than either low-dose milrinone or low- or high-dose dobutamine (Figure Panel C). Conclusion: Survival on palliative COIIT appears to be higher than previously reported, and milrinone use was associated with better survival than dobutamine. Prospective studies of palliative COIIT are urgently needed.
Figure. Survival on Palliative Inotropic Therapy.
038 Progressive Worsening in Device-Based Heart Failure Sensor Measurements are Associated with Sub-Optimal LV Pacing Percentages in CRT-D Patients John P. Boehmer1, Edward J. Schloss2, Michael Cao3, Rezwan Ahmed4, Craig Stolen4, Niraj Varma5; 1Penn State Hershey Medical Center, Hershey, PA; 2The Christ Hospital, Cincinnati, OH; 3Golden Heart Medical, Rosemead, CA; 4Boston Scientific, Saint Paul, MN; 5Cleveland Clinic, Cleveland, OH Background: Lower %LV pacing (<98%) have been associated with significantly worse survival in a cohort of >35000 remotely monitored CRT patients. HeartLogic (HL), a heart failure (HF) composite index and alert algorithm available in both CRTD and ICD devices, aggregates physiologic trends associated with multiple aspects of HF status (e.g. heart sounds, heart rate, thoracic impedance, respiration rate, tidal volume, and activity). HL alerts were recently shown to detect HF events with 70% sensitivity, and identify patients with 10-fold increased risk of worsening HF. Objective: We plan to investigate association between daily % LV pacing and device measured individual heart failure sensors and HeartLogic. Methods: The ALTITUDE database collects de-identified data recorded by the implanted devices from the LATITUDE remote monitoring system. Patients with HeartLogic enabled CRT-D devices and a minimum of 30 days of daily sensor data were included. All days with AF burden were excluded. Each patient day was grouped into 6 groups based on the daily % LV pacing values (<90%, 90-91%, 92-93%, 94-95%, 96-97%, and 98%). For each pacing group, the mean of different device sensors, the HeartLogic index, and the proportion of days in HeartLogic alert were evaluated. Results: Out of 2736 CRT-D patients, 594 met the selection criteria had 248 alerts over 155.13 years. Sub-optimal LV pacing percentages were associated with progressively worse device sensor values (see figure). HeartLogic index reflected significant worsening even for a small reduction in % LV pacing. The proportion of days in HeartLogic alert was about 2x higher with <90% LV pacing (19.08%; 95% CI 18.0-20.19) vs. 98% (11.29%; 95% CI 10.99-11.60; p<0.0001). Further, each individual sensor worsens with sub-optimal compared with optimal LV pacing. Conclusion: Lower %LV pacing is associated with multiple worsening heart failure sensors. This analysis provides strong evidence that the poor survival associated lower %LV pacing is likely caused by worsening heart failure.
039 HeartLogic Performs as Well as NT-proBNP to Rule out Acute Heart Failure at Point of Care John P. Boehmer1, Devi G. Nair2, Gezheng Wen3, Qi An3, Pramodsingh H. Thakur3, Roy S. Gardner4; 1Penn State Hershey Medical Center, Hershey, PA; 2St. Bernards Heart and Vascular Center, Jonesboro, AR; 3Boston Scientific, St. Paul, MN; 4Golden Jubilee National Hospital, Clydebank, United Kingdom Background: The ESC Guidelines recommend the measurement of N-terminal pro Btype natriuretic peptide (NT-proBNP) concentration in all patients who present to emergency rooms with acute dyspnoea and suspected acute decompensated heart failure (HF), with a decision cut-off (NT-proBNP<300pg/mL) for the exclusion of acute decompensated HF (ADHF). HeartLogic is a multisensor algorithm that has been developed and validated to proactively provide alerts for worsening heart failure. Purpose: The purpose of this analysis was to compare the diagnostic accuracy of NT-proBNP and HeartLogic to rule out ADHF in acute settings. Methods: The MultiSENSE study followed 900 HF patients with implanted CRT-Ds for up to 1 year. All hospitalizations were adjudicated by an independent panel of clinicians, and classified as HF or non-HF based on the presenting cause. Optional NT-proBNP tests were conducted when patients were hospitalized. The composite HeartLogic index of the day before each of the hospitalization dates were extracted to differentiate HF and non-HF hospitalizations. By varying the HeartLogic index decision cutoff, a ROC curve was generated to assess the prediction accuracy of HeartLogic and compared to the counterpart performance of NT-proBNP using Hanley and McNeil’s method. Results: Of the total 603 hospitalizations, 76 hospitalizations (52 HF, 24 non-HF) had both valid NT-proBNP measures within 48 hours of admission (71 within 24 hours), and valid HeartLogic for the day before the hospitalization date. Figure 1 illustrates that the HeartLogic -based ROC was similar to the ROC of NT-proBNP (AUC of 0.809 and 0.803, respectively, p=0.932). An exclusion criterion of HeartLogic index <1 achieved the same performance as an NT-proBNP<300pg/ml (sensitivity 0.962, NPV 0.778), and the agreement between the two criteria was 84.2%. Limiting the evaluation to 52 hospitalizations with acute dyspnea (42 HF, 10 non-HF), the performance of HeartLogic and NT-proBNP were similar (p=0.906). Expanding the evaluation of HeartLogic across all 467 hospitalizations with HeartLogic data (89 HF, 378 non-HF), performance was still similar (sensitivity 0.934, NPV 0.876 for the criterion of HeartLogic index <1; AUC of 0.734, p=0.166). Conclusion: HeartLogic showed similar accuracy for differentiating HF and non-HF hospitalizations in the MultiSENSE dataset as NT-proBNP. HeartLogic may be used in the acute setting to exclude acute decompensated heart failure.
S17
Biomarkers/Neurohormones/Cytokines 036 Improved Survival on Palliative Home Inotropes in the Modern Era Behram P. Mody1, Syed Zaid1, Mohammed H. Khan1, Howard A. Cooper1, Chul Ahn2, Wilbert S. Aronow1, Gregg M. Lanier1; 1Westchester Medical Center, Valhalla, NY; 2 University of Texas Southwestern Medical Center, Dallas, TX Introduction: Continuous outpatient intravenous inotrope therapy (COIIT) is a treatment strategy in stage D heart failure as bridge to advanced therapies or palliation. Studies conducted before the era of modern guideline directed medical and device therapy (GDMDT) have demonstrated poor outcomes for palliative COIIT, with survival rates as low as 25% at 1 year. Our objective is to describe the outcomes of patients receiving palliative COIIT in the current era of GDMDT. Hypothesis: Overall survival on palliative COIIT has improved in the era of GDMDT. The choice of inotrope (milrinone or dobutamine) has an impact on survival. Methods: We retrospectively analyzed data from a large US registry of patients receiving COIIT (milrinone or dobutamine) from 2015-17. Patients were included if the indication for COIIT was palliation and excluded if they had incomplete data or <7 days of follow-up. Overall survival at 1 and 2 years was estimated from unadjusted Kaplan-Meier curves. Survival for patients receiving milrinone and dobutamine (overall and for low- and high-doses) was compared using the Log rank statistic. Results: Of 1,149 registry patients receiving COIIT, the indication was palliation in 404 (35%). The mean age was 65 years, and 30% were women. During the study period, 124 (31%) patients died. Estimated survival at 1 and 2 years was 55% and 42% respectively (Figure Panel A). Milrinone was used in 235 (58%) patients and dobutamine in 169 (42%). Compared to patients treated with dobutamine, patients treated with milrinone had greater survival at 1 year (63% vs 43%, p=0.0003) and 2 years (47% vs 34%, p=0.0003). Median survival was estimated at 699 days for milrinone and 247 days for dobutamine (Figure Panel B). The use of high-dose milrinone (0.375 mcg/kg/min) was associated with greater survival than either low-dose milrinone or low- or high-dose dobutamine (Figure Panel C). Conclusion: Survival on palliative COIIT appears to be higher than previously reported, and milrinone use was associated with better survival than dobutamine. Prospective studies of palliative COIIT are urgently needed.
Figure. Survival on Palliative Inotropic Therapy.
038 Progressive Worsening in Device-Based Heart Failure Sensor Measurements are Associated with Sub-Optimal LV Pacing Percentages in CRT-D Patients John P. Boehmer1, Edward J. Schloss2, Michael Cao3, Rezwan Ahmed4, Craig Stolen4, Niraj Varma5; 1Penn State Hershey Medical Center, Hershey, PA; 2The Christ Hospital, Cincinnati, OH; 3Golden Heart Medical, Rosemead, CA; 4Boston Scientific, Saint Paul, MN; 5Cleveland Clinic, Cleveland, OH Background: Lower %LV pacing (<98%) have been associated with significantly worse survival in a cohort of >35000 remotely monitored CRT patients. HeartLogic (HL), a heart failure (HF) composite index and alert algorithm available in both CRTD and ICD devices, aggregates physiologic trends associated with multiple aspects of HF status (e.g. heart sounds, heart rate, thoracic impedance, respiration rate, tidal volume, and activity). HL alerts were recently shown to detect HF events with 70% sensitivity, and identify patients with 10-fold increased risk of worsening HF. Objective: We plan to investigate association between daily % LV pacing and device measured individual heart failure sensors and HeartLogic. Methods: The ALTITUDE database collects de-identified data recorded by the implanted devices from the LATITUDE remote monitoring system. Patients with HeartLogic enabled CRT-D devices and a minimum of 30 days of daily sensor data were included. All days with AF burden were excluded. Each patient day was grouped into 6 groups based on the daily % LV pacing values (<90%, 90-91%, 92-93%, 94-95%, 96-97%, and 98%). For each pacing group, the mean of different device sensors, the HeartLogic index, and the proportion of days in HeartLogic alert were evaluated. Results: Out of 2736 CRT-D patients, 594 met the selection criteria had 248 alerts over 155.13 years. Sub-optimal LV pacing percentages were associated with progressively worse device sensor values (see figure). HeartLogic index reflected significant worsening even for a small reduction in % LV pacing. The proportion of days in HeartLogic alert was about 2x higher with <90% LV pacing (19.08%; 95% CI 18.0-20.19) vs. 98% (11.29%; 95% CI 10.99-11.60; p<0.0001). Further, each individual sensor worsens with sub-optimal compared with optimal LV pacing. Conclusion: Lower %LV pacing is associated with multiple worsening heart failure sensors. This analysis provides strong evidence that the poor survival associated lower %LV pacing is likely caused by worsening heart failure.
039 HeartLogic Performs as Well as NT-proBNP to Rule out Acute Heart Failure at Point of Care John P. Boehmer1, Devi G. Nair2, Gezheng Wen3, Qi An3, Pramodsingh H. Thakur3, Roy S. Gardner4; 1Penn State Hershey Medical Center, Hershey, PA; 2St. Bernards Heart and Vascular Center, Jonesboro, AR; 3Boston Scientific, St. Paul, MN; 4Golden Jubilee National Hospital, Clydebank, United Kingdom Background: The ESC Guidelines recommend the measurement of N-terminal pro Btype natriuretic peptide (NT-proBNP) concentration in all patients who present to emergency rooms with acute dyspnoea and suspected acute decompensated heart failure (HF), with a decision cut-off (NT-proBNP<300pg/mL) for the exclusion of acute decompensated HF (ADHF). HeartLogic is a multisensor algorithm that has been developed and validated to proactively provide alerts for worsening heart failure. Purpose: The purpose of this analysis was to compare the diagnostic accuracy of NT-proBNP and HeartLogic to rule out ADHF in acute settings. Methods: The MultiSENSE study followed 900 HF patients with implanted CRT-Ds for up to 1 year. All hospitalizations were adjudicated by an independent panel of clinicians, and classified as HF or non-HF based on the presenting cause. Optional NT-proBNP tests were conducted when patients were hospitalized. The composite HeartLogic index of the day before each of the hospitalization dates were extracted to differentiate HF and non-HF hospitalizations. By varying the HeartLogic index decision cutoff, a ROC curve was generated to assess the prediction accuracy of HeartLogic and compared to the counterpart performance of NT-proBNP using Hanley and McNeil’s method. Results: Of the total 603 hospitalizations, 76 hospitalizations (52 HF, 24 non-HF) had both valid NT-proBNP measures within 48 hours of admission (71 within 24 hours), and valid HeartLogic for the day before the hospitalization date. Figure 1 illustrates that the HeartLogic -based ROC was similar to the ROC of NT-proBNP (AUC of 0.809 and 0.803, respectively, p=0.932). An exclusion criterion of HeartLogic index <1 achieved the same performance as an NT-proBNP<300pg/ml (sensitivity 0.962, NPV 0.778), and the agreement between the two criteria was 84.2%. Limiting the evaluation to 52 hospitalizations with acute dyspnea (42 HF, 10 non-HF), the performance of HeartLogic and NT-proBNP were similar (p=0.906). Expanding the evaluation of HeartLogic across all 467 hospitalizations with HeartLogic data (89 HF, 378 non-HF), performance was still similar (sensitivity 0.934, NPV 0.876 for the criterion of HeartLogic index <1; AUC of 0.734, p=0.166). Conclusion: HeartLogic showed similar accuracy for differentiating HF and non-HF hospitalizations in the MultiSENSE dataset as NT-proBNP. HeartLogic may be used in the acute setting to exclude acute decompensated heart failure.