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Heart Failure Trending by Multiple-Vector Impedance
The 11th Annual Scientific Meeting with pacemakers was compared to those without pacemakers. Results: A total of 36 (age 68 6 9 years, 92% male) had permanent pacemakers and were included. Of these, AL form was present in 20 (56%), senile in 12 (33%), and familial in 4 (11%). All had restrictive physiology (EF 47% 6 16%), with increased septal thickness ($ 15 mm) in 23 (65%). Pacemakers were implanted prior to a diagnosis of CA in 23 (64%, 13 6 14 months). A total of 24 (66%) had atrial fibrillation. Pacing indication was sinus node dysfunction in 20 (55%) and high grade AV block in 16 (45%). No difference in pacing indications or incidence of atrial fibrillation was observed between subtypes of CA (AL and transthyretin), p O 0.05 for all. During mean follow-up of 27 6 42 months, survival at one year from diagnosis was 58% in CA patients with pacemakers vs. 50% in CA patients without pacemakers (p 5 0.36). Conclusions: Sinus node and conduction system disease are not uncommon in CA and frequently precedes definitive diagnosis of CA. No significant differences in conduction system disease were observed in subtypes of CA. Survival of CA patients with and without permanent pacemakers is similar, suggesting that the presence of sinus node dysfunction and conduction system disease in CA is not associated with worse prognosis.
188 Heart Failure Trending by Multiple-Vector Impedance Dirar Khoury1, Mihir Naware2, Jeff Siou2, Dan Gutfinger2, Neal Eigler2, Malin Ohlander2, Nils Holmstrom2, Miriam Rademaker3, Chris Charles3, Richard Troughton3, Dorin Panescu2; 1The Methodist Hospital, Houston, TX; 2School of Medicine and Health Science, Christchurch, New Zealand; 3St. Jude Medical, Inc.
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beta-blockers. In African American (AA) patients, the addition of fixed dose isosorbide dinitrate and hydralazine (ISDN/H) to standard medical therapy increases survival in advanced HF (A-HeFT Investigators). Current practice guidelines support the addition of ISDN/H to standard HF medications in AA patients with symptomatic systolic dysfunction. Cardiac resynchronization therapy (CRT) should be considered only if patients remain symptomatic from HF despite OMT. We looked at the utilization of OMT in AA patients with HF referred for CRT at a single, urban teaching institution. Methods: We conducted a retrospective chart review of 216 patients referred for CRT from Nov 2004 (date of A-HeFT publication) to Jan 2007, in order to determine the utilization of OMT at the time of CRT referral. Individuals were classified by self-identified race. Results: Medication information was available in 192 patients. Of these, 48 (25%) were AA, 53 (27.6%) were Caucasian, 81 (42.2%) were Hispanic, and 10 (5.2%) were other or unidentified. Of the 48 AA patients referred for CRT, utilization of medications was as follows: 89.6% betablocker, 70.8% ACEI, 22.9% ARB, 62.5% aldosterone antagonist, 6.7% fixed dose ISDN/H, 0% individual components ISDN/H, and 12.5% individual components isosorbide mononitrate and hydralazine (ISMN/H). AA patients were more likely to be on aldosterone antagonists than Caucasians or Hispanics. The percent of patients on each HF drug at the time of CRT is shown in Figure 1. Conclusions: Despite current evidence-based guidelines regarding optimal medical therapy in patients with HF, less than 1 in 10 AA patients were on fixed-dose or individual components of ISDN/H at the time of referral for CRT. Potential reasons for underutilization of these medications should be explored, as studies demonstrate that adherence to practice guidelines can have a substantial impact on HF survival and readmission rates.
Introduction: Impedance (Z) utilizing a RVcoil-Can vector is a useful sensor for monitoring pulmonary edema secondary to congestive heart failure (CHF). Several physiologic variables affect the Z sensitivity. We hypothesized that using a LV lead to measure Z improves sensitivity to CHF onset. Methods: Biventricular ICDs (Promote RF e St. Jude Medical) were implanted in 16 dogs and 5 sheep. Standard RA, RV and LV leads were used, with the ICD Can placed in the left pectoral region. Continuous RV pacing (230-250 bpm) was applied over several weeks to induce CHF. Z was measured every hour along 4 transthoracic: LVring-Can (LV-Can), RVcoil-Can (RVc-Can), RVring-Can (RV-Can), RAring-Can (RA-Can) and 2 intracardiac vectors: LVring-RAring (LV-RA), and RVring-LVring (RV-LV). Daily means were trended. In dogs, LV end-diastolic volume (LVEDV), LV ejection fraction (LVEF), LV end-diastolic pressure (LVEDP) and left atrial (LA) volume were measured every 2 weeks. In N 5 10 animals, LAP was measured daily using an implantable sensor (HeartPOD e St. Jude Medical). Results: All animals developed CHF after 2-4 weeks of pacing from baseline as evidenced by deterioration in hemodynamics (LVEF, 52 vs. 34%; LVEDV, 65 vs. 97 ml; LVEDP, 7 vs. 16 mmHg; LAV, 17 vs. 33 ml; LAP, 7 vs. 26 mmHg), symptoms, or autopsy. All impedance vectors decreased during CHF: LV-Can, 17 6 9%; RV-LV, 15 6 8%; LV-RA, 12 6 6%; RV-Can, 12 6 8%; RVc-Can, 8 6 6%; RA-Can, 5 6 6% (Fig). The LV lead improved impedance sensitivity to CHF, with LV-Can highly sensitive compared to RV-Can, RVc-Can or RA-Can (P ! 0.05). Z changes in RV-LV and LV-RA vectors were also significant as compared to RVc-Can or RA-Can (P ! 0.05). In a linear regression model, LV-Can Z correlated well with LAP trends (r2 5 0.73, N 5 10), while RV-Can and RVc-Can Zs were less correlated (r2 5 0.43 and r2 5 0.52). Conclusions: We observed a marked decrease in the Z in all vectors after CHF onset. The addition of left-side vectors improved Z sensitivity and correlated well with LAP trends. The use of Z for HF monitoring deserves further investigation.
190 The Relationship of Systolic Synchrony and Cardiac Remodeling in Patients with a Narrow QRS Complex Daniel Haithcock1, Kevin Jackson1, Patrick Hranitzky1, Francis R. Gilliam1, Eric J. Velazquez1; 1Cardiology, Duke University Medical Center, Durham, NC
189 Optimization of Medical Therapy in African-American Patients with Heart Failure Referred for Cardiac Resynchronization Therapy Muhammad R. Sardar1, Anna Kezerashvili1, Marie Galvao1, Simon W. Maybaum1, Kamini Trivedi2, Jooyoung Julia Shin1; 1Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY; 2NitroMed, Inc., Lexington, MA Background: Heart failure (HF) remains a national epidemic. Optimal medical therapy (OMT) for HF includes ACE-inhibitors (ACEI), aldosterone antagonists, and
Introduction: Despite data demonstrating cardiac resynchronization therapy (CRT) improves morbidity and mortality in selected patients with advanced cardiomyopathy, 40% of patients do not symptomatically improve with CRT. Systolic asynchrony as measured by Tissue Doppler Imaging has emerged as a predictor of ventricular remodeling and clinical response to CRT. We investigated the effects of CRT on echocardiographic parameters of remodeling in systolic heart failure patients with and without prolonged QRS and with and without systolic asynchrony. Methods: All patients undergoing echocardiography with analysis of ventricular asynchrony were enrolled in the Duke Cardiac Synchrony Database. A cohort of individuals with QRS ! 120ms were identified and compared to patients in the database with QRS O 120ms. Serial echocardiographic data was further stratified based on whether or not the patients received cardiac resynchronization therapy. Results: Baseline clinical data is described in Table 1. Figure 1 demonstrates the changes in EF and ventricular volumes among the groups. Patients with QRS ! 120ms and evidence of asynchrony demonstrated significant volume reductions and improvement in ejection function, while patients with similar QRS duration without asynchrony did not. Conclusions: Patients with asynchrony and a narrow QRS who received CRT had significantly greater changes in echocardiographic parameters and demonstrated a similar degree of ventricular reverse remodeling as patients with prolonged QRS duration who were treated with CRT. Correlation with heart failure functional improvement and validation in larger populations are needed prior to expanding CRT indications beyond current guidelines.
188 Heart Failure Trending by Multiple-Vector Impedance Dirar Khoury1, Mihir Naware2, Jeff Siou2, Dan Gutfinger2, Neal Eigler2, Malin Ohlander2, Nils Holmstrom2, Miriam Rademaker3, Chris Charles3, Richard Troughton3, Dorin Panescu2; 1The Methodist Hospital, Houston, TX; 2School of Medicine and Health Science, Christchurch, New Zealand; 3St. Jude Medical, Inc.
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beta-blockers. In African American (AA) patients, the addition of fixed dose isosorbide dinitrate and hydralazine (ISDN/H) to standard medical therapy increases survival in advanced HF (A-HeFT Investigators). Current practice guidelines support the addition of ISDN/H to standard HF medications in AA patients with symptomatic systolic dysfunction. Cardiac resynchronization therapy (CRT) should be considered only if patients remain symptomatic from HF despite OMT. We looked at the utilization of OMT in AA patients with HF referred for CRT at a single, urban teaching institution. Methods: We conducted a retrospective chart review of 216 patients referred for CRT from Nov 2004 (date of A-HeFT publication) to Jan 2007, in order to determine the utilization of OMT at the time of CRT referral. Individuals were classified by self-identified race. Results: Medication information was available in 192 patients. Of these, 48 (25%) were AA, 53 (27.6%) were Caucasian, 81 (42.2%) were Hispanic, and 10 (5.2%) were other or unidentified. Of the 48 AA patients referred for CRT, utilization of medications was as follows: 89.6% betablocker, 70.8% ACEI, 22.9% ARB, 62.5% aldosterone antagonist, 6.7% fixed dose ISDN/H, 0% individual components ISDN/H, and 12.5% individual components isosorbide mononitrate and hydralazine (ISMN/H). AA patients were more likely to be on aldosterone antagonists than Caucasians or Hispanics. The percent of patients on each HF drug at the time of CRT is shown in Figure 1. Conclusions: Despite current evidence-based guidelines regarding optimal medical therapy in patients with HF, less than 1 in 10 AA patients were on fixed-dose or individual components of ISDN/H at the time of referral for CRT. Potential reasons for underutilization of these medications should be explored, as studies demonstrate that adherence to practice guidelines can have a substantial impact on HF survival and readmission rates.
Introduction: Impedance (Z) utilizing a RVcoil-Can vector is a useful sensor for monitoring pulmonary edema secondary to congestive heart failure (CHF). Several physiologic variables affect the Z sensitivity. We hypothesized that using a LV lead to measure Z improves sensitivity to CHF onset. Methods: Biventricular ICDs (Promote RF e St. Jude Medical) were implanted in 16 dogs and 5 sheep. Standard RA, RV and LV leads were used, with the ICD Can placed in the left pectoral region. Continuous RV pacing (230-250 bpm) was applied over several weeks to induce CHF. Z was measured every hour along 4 transthoracic: LVring-Can (LV-Can), RVcoil-Can (RVc-Can), RVring-Can (RV-Can), RAring-Can (RA-Can) and 2 intracardiac vectors: LVring-RAring (LV-RA), and RVring-LVring (RV-LV). Daily means were trended. In dogs, LV end-diastolic volume (LVEDV), LV ejection fraction (LVEF), LV end-diastolic pressure (LVEDP) and left atrial (LA) volume were measured every 2 weeks. In N 5 10 animals, LAP was measured daily using an implantable sensor (HeartPOD e St. Jude Medical). Results: All animals developed CHF after 2-4 weeks of pacing from baseline as evidenced by deterioration in hemodynamics (LVEF, 52 vs. 34%; LVEDV, 65 vs. 97 ml; LVEDP, 7 vs. 16 mmHg; LAV, 17 vs. 33 ml; LAP, 7 vs. 26 mmHg), symptoms, or autopsy. All impedance vectors decreased during CHF: LV-Can, 17 6 9%; RV-LV, 15 6 8%; LV-RA, 12 6 6%; RV-Can, 12 6 8%; RVc-Can, 8 6 6%; RA-Can, 5 6 6% (Fig). The LV lead improved impedance sensitivity to CHF, with LV-Can highly sensitive compared to RV-Can, RVc-Can or RA-Can (P ! 0.05). Z changes in RV-LV and LV-RA vectors were also significant as compared to RVc-Can or RA-Can (P ! 0.05). In a linear regression model, LV-Can Z correlated well with LAP trends (r2 5 0.73, N 5 10), while RV-Can and RVc-Can Zs were less correlated (r2 5 0.43 and r2 5 0.52). Conclusions: We observed a marked decrease in the Z in all vectors after CHF onset. The addition of left-side vectors improved Z sensitivity and correlated well with LAP trends. The use of Z for HF monitoring deserves further investigation.
190 The Relationship of Systolic Synchrony and Cardiac Remodeling in Patients with a Narrow QRS Complex Daniel Haithcock1, Kevin Jackson1, Patrick Hranitzky1, Francis R. Gilliam1, Eric J. Velazquez1; 1Cardiology, Duke University Medical Center, Durham, NC
189 Optimization of Medical Therapy in African-American Patients with Heart Failure Referred for Cardiac Resynchronization Therapy Muhammad R. Sardar1, Anna Kezerashvili1, Marie Galvao1, Simon W. Maybaum1, Kamini Trivedi2, Jooyoung Julia Shin1; 1Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY; 2NitroMed, Inc., Lexington, MA Background: Heart failure (HF) remains a national epidemic. Optimal medical therapy (OMT) for HF includes ACE-inhibitors (ACEI), aldosterone antagonists, and
Introduction: Despite data demonstrating cardiac resynchronization therapy (CRT) improves morbidity and mortality in selected patients with advanced cardiomyopathy, 40% of patients do not symptomatically improve with CRT. Systolic asynchrony as measured by Tissue Doppler Imaging has emerged as a predictor of ventricular remodeling and clinical response to CRT. We investigated the effects of CRT on echocardiographic parameters of remodeling in systolic heart failure patients with and without prolonged QRS and with and without systolic asynchrony. Methods: All patients undergoing echocardiography with analysis of ventricular asynchrony were enrolled in the Duke Cardiac Synchrony Database. A cohort of individuals with QRS ! 120ms were identified and compared to patients in the database with QRS O 120ms. Serial echocardiographic data was further stratified based on whether or not the patients received cardiac resynchronization therapy. Results: Baseline clinical data is described in Table 1. Figure 1 demonstrates the changes in EF and ventricular volumes among the groups. Patients with QRS ! 120ms and evidence of asynchrony demonstrated significant volume reductions and improvement in ejection function, while patients with similar QRS duration without asynchrony did not. Conclusions: Patients with asynchrony and a narrow QRS who received CRT had significantly greater changes in echocardiographic parameters and demonstrated a similar degree of ventricular reverse remodeling as patients with prolonged QRS duration who were treated with CRT. Correlation with heart failure functional improvement and validation in larger populations are needed prior to expanding CRT indications beyond current guidelines.