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Improving ICD Guideline Utilization in a Community Based Cardiology Practice
The 12th Annual Scientific Meeting coupling interval (AECI). Prolongation of AECI and remodelling result in left atrial dysfunction with increased risk for heart failure. Methods: The study group consisted of 158 male patients without medical history, divided in three age groups: I: 21e40; II: 41e60 and III: 61e80 years. The AECI in ms was determined by measuring the time interval between the onset of the p-wave on the electrocardiogram and the onset of atrial contraction on tissue Doppler imaging at the interatrial septal wall and at both atrial lateral walls and roofs. Results: Left and right AECI increase with age. At the septal wall AECI is 57ms in group I, 60ms in II and 67ms in III. At the lateral wall left AECI is 60ms in group I, 63ms in II and 72ms in III; at the lateral wall right AECI is 51ms in group I, 54ms in II and 57ms in III. At the roof left AECI measures 66ms in group I, 70ms in II and 78ms in III. At the roof right AECI is 24ms in group I, 26ms in II, 27ms in III. In all age groups left AECI is the shortest at the septum, longer at the lateral wall and the longest at the roof. Right AECI is the longest at the septum, less longer at the lateral wall and the shortest at the roof. In group III with a left atrial diameter more than 4.5 cm, we noted a supplementary prolongation of AECI. Intra-atrial asynchrony increases with age both at right and left atrium. Also interatrial asynchrony shows a progressive increase with age. The onset of mechanical atrial systole is 42ms delayed at the roof of the left atrium in group I, 44ms in II and 50ms in III. When left atrium diameter exceeds 4.5 cm, the increase of interatrial asynchrony is also influenced by the size of the left atrium. Conclusions: Ageing leads to remodelling of atrial myocardium, to a progressive prolongation of the AECI and an increase of intra-and interatrial asynchrony, resulting in a substrate for atrial dysfunction and a higher risk for heart failure. Trying to maintain a short AECI, if necessary with medical or pacing therapy, is of primordial importance in prevention of atrial arrhythmias, thrombo-embolic events and heart failure.
Post-MI-sheduled day of discharge Echocardiogram 6 weeks Stress Nuclear 6 weeks Office visit immediately after above
HFSA
S61
Post CABG/PCI-scheduled day of discharge Echocardiogram 3 months Optional Stress test 3 months Office visit with PA/CNP 6 weeks Office visit with physician 3 months
Results: 6000 cardiac catheterization patient charts were reviewed. 311 (5.1%) nonimplanted patients met guideline criteria for ICD, varying from 5 to 61 patients per physician. Each physician received a list of their patients who met ICD criteria, but were not implanted. The ICD implant rate increased from 23/month in 2006 to 30/ month (30% increase) in the 6 months following chart review and program initiation. Practice size and specialties within the practice remained constant. Conclusions: The implementation of standardized discharge plans by a community-based cardiology practice improves the delivery of quality care, potentially reducing variations in guideline adherence.
194 Over Utilization of ICDs? Results from a Large Multi-Subspecialty Cardiology Clinic Cheryl L. Myers1, Brian Ramza1; 1Cardiovascular Consultants, Kansas City, MO
192 Differences in Electrical and Mechanical Dyssynchrony as Quantified by Phase Analysis of Gated SPECT Imaging in Patients with Mild-Moderate Left Ventricular Dysfunction Mark A. Trimble1, Allen Atchley1, Zainab Samad1, Linda K. Shaw2, Robert Pagnanelli1, Ji Chen3, Ernest V. Garcia3, Ami E. Iskandrian4, Salvador BorgesNeto1,2, Eric J. Velazquez1,2; 1Duke Medical Center, Durham, NC; 2Duke Clinical Research Institute, Durham, NC; 3Emory University, Atlanta, GA; 4University of Alabama at Birmingham, Birmingham, AL Background: Cardiac resynchronization therapy (CRT) is approved for patients with heart failure, prolonged QRS duration, and ejection fraction # 35%. Mechanical dyssynchrony may better predict which patients will benefit from CRT. Data suggests that patients with mild-moderate left ventricular (LV) dysfunction have significant dyssynchrony and may benefit from CRT. The relationship between QRS duration and mechanical dyssynchrony in patients with mild-moderate LV dysfunction is not known. Methods: A novel method to quantify dyssynchrony using phase analysis of gated SPECT imaging has been developed. A Fourier analysis method converts regional LV myocardial counts into a continuous thickening function. The standard deviation of the LV phases (phase SD) and histogram bandwidth are quantitative indices describing mechanical dyssynchrony. We utilized this method to compare the degree of dyssynchrony in patients with mild-moderate LV dysfunction (ejection fraction 35e50%) and normal QRS duration (n 5 73) with those with prolonged QRS duration (n 5 20), to describe the relationship between QRS duration and mechanical dyssynchrony, and to determine the prevalence of significant dyssynchrony in these cohorts of patients. Results: Patients with mild-to-moderate LV dysfunction who have prolonged QRS duration have higher degrees of dyssynchrony as quantified by phase SD (49 6 18 vs. 35 6 15 , p 5 0.002) and bandwidth (138 6 42 vs. 107 6 54 , p 5 0.014) than those patients with normal QRS duration. However there are weak correlations between QRS duration and phase SD (r 5 0.28) as well as with histogram bandwidth (r 5 0.20). The prevalence of significant dyssynchrony (phase SD $ 43 ) was 65% in patients with prolonged QRS duration as compared to 29% in patients with normal QRS duration. Conclusions: This is the first study on the relationship between electrical and mechanical dyssynchrony in patients with mild-moderate LV dysfunction. Although patients with prolonged QRS duration have higher degrees of dyssynchrony, there are weak relationships between electrical dyssynchrony as determined by QRS duration and SPECT derived indices of mechanical dyssynchrony in this cohort of patients.
Introduction: Studies have suggested there may be over utilization of prophylactic implantable cardiac defibrillators (ICD) in heart failure patients. Data from the MADIT II and SCDHeFT studies suggest a significant rate of sudden cardiac arrest (SCA) in those pts without ICDs. We have recently reported successful implementation of an electronic medical record (EMR) tool for screening patients at risk for SCA in a cardiology practice following over 40,000 patients. We now report on the incidence of events following successful screening. Hypothesis: This evaluation of patients with ICDs will determine whether a correlation exists between time to first therapy and EF, time to first therapy for ICD versus CRT-D, and ischemia and appropriate ICD therapy. Data would suggest that sicker population of patients (ie lower EF, ischemia, and heart failure class) would have more therapy. Methods: This study was a retrospective chart review of 112 patients that received an ICD with or without cardiac resynchronization therapy (CRT-D) for primary prevention in 2005e2006. Patient records were reviewed for ejection fraction (EF), left ventricular end diastolic diameter (LVEDD), ischemia, and CRT-D indications. Device interrogations were reviewed for first appropriate therapy versus implant date. Results: Appropriate ICD therapy was identified in 31/112 patients of which 33% received therapy within 1 year. There was a direct correlation between time to first therapy (TFT) and diminishing EF (Graph 1, p 5 0.01). Non-ischemic patients received significantly more ICD therapy (p 5 0.04). The TFT was earlier for those patients receiving CRT-D versus ICD (Graph 2, p 5 0.02). There was no statistically significant correlation between TFT and LVEDD.
Conclusions: The results emphasize the need for detection of SCA risk. Based on these results, screening tools within EMR systems should focus on ischemia evaluation and CRT-D indications because of more therapies and shorter time to treatment in this group.
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Improving ICD Guideline Utilization in a Community Based Cardiology Practice F. Kevin Hackett1, Caitlin E. Hackett1, Brian J. Fisher1, Thomas P. Archer1; 1 Columbus Cardiology Consultants, Columbus, OH
Development of Mechanical Dyssynchrony in a Chronic Systolic Heart Failure Canine Model Is Not Associated with Development of Electrical Dyssynchrony Jih-Min Lin1, Renee Gerhart3, Phillip Falkner3, Rodolphe P. Katra4, Kimberly A. Oleson3, Jiunn-Lee Lin2; 1Interanl Medicine, Keelung General Hospital, Executive Yuan, Keelung, Taiwan; 2Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; 3Medtronic Physiological Reaearch Laboratory, Medtronic, Minneapolis, MN; 4Medtronic Cardiac Rhythm Disease Management, Medtronic, Minneapolis, MN
Introduction: ACC/AHA guidelines have established implantable cardioverter defibrillator (ICD) therapy as a Class I guideline for preventing sudden cardiac arrest. In our 11 person cardiology practice, the use of ICDs decreased by 29% in 2006 versus 2005, while the number of patients seen remained stable. We sought to understand the impact of a simple quality improvement plan to increase identification of patients at risk for sudden cardiac arrest. Methods: We initiated a manual chart review of cardiac catheterization patients from the previous 3 years, and standardized discharge plans for coronary artery disease patients who were Post-MI, Post CABG, or Post PCI (Table 1). Practice staff and physicians were educated on current ICD guidelines. The monthly ICD implant rates for the 6 months following these steps were compared with the monthly implant rates in 2006.
Introduction: The presence of cardiac electrical and mechanical dyssynchrony (ED and MD) aggravates hemodynamic impairment in chronic heart failure (HF) patients. However, the relationship between ED and MD, as HF develops, remains poorly understood. Methods: We investigated the evolution of ED and MD in a canine model of systolic HF (n 5 8) as HF was induced via multi-vessel microsphere embolizations. Stable HF endpoint was achieved as LV ejection fraction reached !35%, as determined by echo. QRS wave duration, a measure of total ventricular activation
Post-MI-sheduled day of discharge Echocardiogram 6 weeks Stress Nuclear 6 weeks Office visit immediately after above
HFSA
S61
Post CABG/PCI-scheduled day of discharge Echocardiogram 3 months Optional Stress test 3 months Office visit with PA/CNP 6 weeks Office visit with physician 3 months
Results: 6000 cardiac catheterization patient charts were reviewed. 311 (5.1%) nonimplanted patients met guideline criteria for ICD, varying from 5 to 61 patients per physician. Each physician received a list of their patients who met ICD criteria, but were not implanted. The ICD implant rate increased from 23/month in 2006 to 30/ month (30% increase) in the 6 months following chart review and program initiation. Practice size and specialties within the practice remained constant. Conclusions: The implementation of standardized discharge plans by a community-based cardiology practice improves the delivery of quality care, potentially reducing variations in guideline adherence.
194 Over Utilization of ICDs? Results from a Large Multi-Subspecialty Cardiology Clinic Cheryl L. Myers1, Brian Ramza1; 1Cardiovascular Consultants, Kansas City, MO
192 Differences in Electrical and Mechanical Dyssynchrony as Quantified by Phase Analysis of Gated SPECT Imaging in Patients with Mild-Moderate Left Ventricular Dysfunction Mark A. Trimble1, Allen Atchley1, Zainab Samad1, Linda K. Shaw2, Robert Pagnanelli1, Ji Chen3, Ernest V. Garcia3, Ami E. Iskandrian4, Salvador BorgesNeto1,2, Eric J. Velazquez1,2; 1Duke Medical Center, Durham, NC; 2Duke Clinical Research Institute, Durham, NC; 3Emory University, Atlanta, GA; 4University of Alabama at Birmingham, Birmingham, AL Background: Cardiac resynchronization therapy (CRT) is approved for patients with heart failure, prolonged QRS duration, and ejection fraction # 35%. Mechanical dyssynchrony may better predict which patients will benefit from CRT. Data suggests that patients with mild-moderate left ventricular (LV) dysfunction have significant dyssynchrony and may benefit from CRT. The relationship between QRS duration and mechanical dyssynchrony in patients with mild-moderate LV dysfunction is not known. Methods: A novel method to quantify dyssynchrony using phase analysis of gated SPECT imaging has been developed. A Fourier analysis method converts regional LV myocardial counts into a continuous thickening function. The standard deviation of the LV phases (phase SD) and histogram bandwidth are quantitative indices describing mechanical dyssynchrony. We utilized this method to compare the degree of dyssynchrony in patients with mild-moderate LV dysfunction (ejection fraction 35e50%) and normal QRS duration (n 5 73) with those with prolonged QRS duration (n 5 20), to describe the relationship between QRS duration and mechanical dyssynchrony, and to determine the prevalence of significant dyssynchrony in these cohorts of patients. Results: Patients with mild-to-moderate LV dysfunction who have prolonged QRS duration have higher degrees of dyssynchrony as quantified by phase SD (49 6 18 vs. 35 6 15 , p 5 0.002) and bandwidth (138 6 42 vs. 107 6 54 , p 5 0.014) than those patients with normal QRS duration. However there are weak correlations between QRS duration and phase SD (r 5 0.28) as well as with histogram bandwidth (r 5 0.20). The prevalence of significant dyssynchrony (phase SD $ 43 ) was 65% in patients with prolonged QRS duration as compared to 29% in patients with normal QRS duration. Conclusions: This is the first study on the relationship between electrical and mechanical dyssynchrony in patients with mild-moderate LV dysfunction. Although patients with prolonged QRS duration have higher degrees of dyssynchrony, there are weak relationships between electrical dyssynchrony as determined by QRS duration and SPECT derived indices of mechanical dyssynchrony in this cohort of patients.
Introduction: Studies have suggested there may be over utilization of prophylactic implantable cardiac defibrillators (ICD) in heart failure patients. Data from the MADIT II and SCDHeFT studies suggest a significant rate of sudden cardiac arrest (SCA) in those pts without ICDs. We have recently reported successful implementation of an electronic medical record (EMR) tool for screening patients at risk for SCA in a cardiology practice following over 40,000 patients. We now report on the incidence of events following successful screening. Hypothesis: This evaluation of patients with ICDs will determine whether a correlation exists between time to first therapy and EF, time to first therapy for ICD versus CRT-D, and ischemia and appropriate ICD therapy. Data would suggest that sicker population of patients (ie lower EF, ischemia, and heart failure class) would have more therapy. Methods: This study was a retrospective chart review of 112 patients that received an ICD with or without cardiac resynchronization therapy (CRT-D) for primary prevention in 2005e2006. Patient records were reviewed for ejection fraction (EF), left ventricular end diastolic diameter (LVEDD), ischemia, and CRT-D indications. Device interrogations were reviewed for first appropriate therapy versus implant date. Results: Appropriate ICD therapy was identified in 31/112 patients of which 33% received therapy within 1 year. There was a direct correlation between time to first therapy (TFT) and diminishing EF (Graph 1, p 5 0.01). Non-ischemic patients received significantly more ICD therapy (p 5 0.04). The TFT was earlier for those patients receiving CRT-D versus ICD (Graph 2, p 5 0.02). There was no statistically significant correlation between TFT and LVEDD.
Conclusions: The results emphasize the need for detection of SCA risk. Based on these results, screening tools within EMR systems should focus on ischemia evaluation and CRT-D indications because of more therapies and shorter time to treatment in this group.
193
195
Improving ICD Guideline Utilization in a Community Based Cardiology Practice F. Kevin Hackett1, Caitlin E. Hackett1, Brian J. Fisher1, Thomas P. Archer1; 1 Columbus Cardiology Consultants, Columbus, OH
Development of Mechanical Dyssynchrony in a Chronic Systolic Heart Failure Canine Model Is Not Associated with Development of Electrical Dyssynchrony Jih-Min Lin1, Renee Gerhart3, Phillip Falkner3, Rodolphe P. Katra4, Kimberly A. Oleson3, Jiunn-Lee Lin2; 1Interanl Medicine, Keelung General Hospital, Executive Yuan, Keelung, Taiwan; 2Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; 3Medtronic Physiological Reaearch Laboratory, Medtronic, Minneapolis, MN; 4Medtronic Cardiac Rhythm Disease Management, Medtronic, Minneapolis, MN
Introduction: ACC/AHA guidelines have established implantable cardioverter defibrillator (ICD) therapy as a Class I guideline for preventing sudden cardiac arrest. In our 11 person cardiology practice, the use of ICDs decreased by 29% in 2006 versus 2005, while the number of patients seen remained stable. We sought to understand the impact of a simple quality improvement plan to increase identification of patients at risk for sudden cardiac arrest. Methods: We initiated a manual chart review of cardiac catheterization patients from the previous 3 years, and standardized discharge plans for coronary artery disease patients who were Post-MI, Post CABG, or Post PCI (Table 1). Practice staff and physicians were educated on current ICD guidelines. The monthly ICD implant rates for the 6 months following these steps were compared with the monthly implant rates in 2006.
Introduction: The presence of cardiac electrical and mechanical dyssynchrony (ED and MD) aggravates hemodynamic impairment in chronic heart failure (HF) patients. However, the relationship between ED and MD, as HF develops, remains poorly understood. Methods: We investigated the evolution of ED and MD in a canine model of systolic HF (n 5 8) as HF was induced via multi-vessel microsphere embolizations. Stable HF endpoint was achieved as LV ejection fraction reached !35%, as determined by echo. QRS wave duration, a measure of total ventricular activation