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Initial Experience with Spinal Cord Stimulation (SCS) for the Treatment of Advanced Heart Failure
The 14th Annual Scientific Meeting prevalence of SDB in this cohort of ICD pts ranged from 40% to 49.3% (18.9% S) and was significantly influenced by pts gender.
213 Inadequate Self-Care Practices in Patients with Implantable Devices: Implications for Remote Monitoring Lisa D. Rathman1, Roy S. Small1, J. Thomas Heywood2, John A. Andriulli3, W.H. Wilson Tang4; 1Heart Failure Clinic, The Heart Group/Lancaster Heart and Stroke Foundation, Lancaster, PA; 2Scripps Clinic Torrey Pines, La Jolla, CA; 3UMDNJ, Voorhees, NJ; 4Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH Background: Self-care behavior refers to decisions and actions that an individual can take to cope with a medical condition or to improve his or her health and is essential to successful heart failure (HF) management. The Self-Care of HF Index (SCHFI) is a tool that can quantify a patient’s (pt’s) behavior and decision-making process as it relates to maintaining health (maintenance) and response to symptoms (management). We sought to examine self-care behaviors in pts with cardiac resynchronization (CRT-D) devices and defibrillators (ICD). Methods: As part of the large, multi-center OptiVol Care Pathway study, self-care practices were evaluated at baseline using the SCHFI questionnaire. Adequate self-care is defined by a standardized score O70 when using SCHFI. Results: In the analysis cohort of 1540 subjects (mean age 68 6 12 years, 73% male, 50% CRT-D, 50% ICD), baseline self-care maintenance scores from 1520 SCHFI surveys were low (mean 64 6 15), with 69% of pts having below adequate scores. Interestingly 75% of pts were very or extremely confident in their own ability to relieve their symptoms (sx), 60% reported that they ‘‘always’’ or ‘‘frequently’’ weighed themselves and 75% reported taking prescribed medications. However, only 29% of pts requested low-sodium items when eating out or visiting others. In the subset of 630 pts (41%) who reported sx of worsening HF (trouble breathing or ankle swelling) during the previous month, self-care management was poor (53 6 25), with 76% of pts having below adequate scores. Across all responses, only 50% quickly recognized their sx, and 31% of pts were either ‘‘not likely’’ or ‘‘somewhat likely’’ to call a provider for guidance in the setting of HF sx. Conclusion: Although most pts were confident in their ability to relieve their sx, baseline SCHFI data in this cohort of pts with implantable devices demonstrated that self-care remained inadequate. Pts were frequently slow to recognize decompensation and oftentimes did not seek medical advice for treatment. These findings show improvement is needed in self-care practices. Whether remote monitoring of diagnostic data from implanted devices may help improve self-care practices and in turn potentially reduce heart failure events will be explored in the OptiVol Care Pathway study.
214 Initial Experience with Spinal Cord Stimulation (SCS) for the Treatment of Advanced Heart Failure Siller Jesus2, Kenneth M. Alo2, Guillermo Torre-Amione1,2; 1The Methodist DeBakey Heart & Vascular Center & Instituto de Cardiologia y Medicina Vascular, Cardiology; Tec de Monterrey, Houston, TX & Monterrey Mexico; 2 Instituto de Cardiologia y Medicina Vascular, Tec de Monterrey, Monterrey, Mexico SCS consists on the implantation of an electrode in the epidural space connected to a power source that can be activated to pulse, frequency and time. The use of SCS in cardiovascular conditions has been limited to the treatment of angina and peripheral vascular disease. However, experimental and theoretical work indicates that SCS may
HFSA
S67
prevent cardiac arrhythmias and promote reverse remodeling. Objective: Accordingly, we are conducting a feasibility non-randomized study in patients with CHF ischemic or non-ischemic that were in NYHA class III-IV. Methods: Two leads were implanted in each patient (T1-T3 and T9-T12). Parameters of activation were: stimulation frequency of 50 Hz, pulse width 200 msec with bipolar stimulation and output current amplitude set at 90% of initial parasthesias. Stimulation was programmed for 2hrs three times a day Results: Characteristics of the initial study cohort are shown in table A.1. All implants were successfully performed without worsening SOB, edema or angina. There were no episodes of bleeding or infection. Patients were discharged within 24 hrs with programming of the device prior to discharge. All patients reported symptomatic improvements. Six-minute walk test improved as shown in Figure A.2. No demonstrable echo changes were observed at 3 months. Conclusion: This initial experience indicates that it is possible to implant SCS in patients with advanced heart failure and supports the concept of conducting further clinical studies to test the safety and efficacy of SCS for CHF.
215 Exercise Training Improves Heart Rate Variability in Older Patients with Heart Failure. A Randomized, Controlled, Single-Blinded Study Khalil Murad1, Elsayed Z. Soliman1, Timothy M. Morgan1, David M. Fitzgerald2, Joel D. Eggebeen2, David C. Goff1, Dalane W. Kitzman2; 1Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC; 2Internal Medicine/Section of Cardiology, Wake Forest University School of Medicine, Winston-Salem, NC Background: Autonomic dysfunction, as measured by reduced heart rate variability (HRV), is commonly seen in older patients with heart failure (HF), and it is associated with poor outcome. In other patient populations, exercise training (ET) has been shown to improve HRV. Therefore, we examined the effect of ET on HRV in older patients with chronic HF. Method: Sixty six patients (36% males), age 69 6 5 years, with NYHA class II-III HF (36 patients with HF with preserved ejection fraction (EF), and 30 patients with reduced EF) were randomly assigned to supervised aerobic ET 3 times a week for 16 weeks (ET group, N 5 31) versus attention control (AC group, N 5 35). Using a 10-minute ECG recording, two short term HRV parameters (the standard deviation of all normal RR intervals (SDNN) and the root mean square of successive differences in normal RR intervals (RMSSD)) were measured at baseline and after completion of ET. Analysis of Covariance was used to compare changes in HRV between the study groups. Results: At baseline, there were no significant differences in demographic or clinical characteristics In the ET compared to the AC. At follow up, ET had a significantly greater increase in HRV parameters than AC. SDNN changed from 31.6 6 21.0 to 47.0 6 36.5 in ET vs from 30.2 6 17.7 to 32.6 6 15.4 in AC, (P 5 0.002). RMSSD changed from 24.7 6 24.7 to 42.3 6 48.3 in ET vs from 20.4 6 15.5 to 22.1 6 15.9 in AC, (P 5 0.006). There was no significant gender difference in the response to ET. There was a trend toward greater increase in SDNN in patients with reduced compared to preserved EF, (P 5 0.063). Conclusion: Exercise training increases HRV in older patients with HF. This effect is possibly greater in those with reduced EF.
216 The Effects of Short Term Beta-Blockade on Exercise Capacity and Left Ventricular Function in Elderly Patients with Heart Failure Milica Dekleva1, Hans Dirk Dungen2, Simone Incrot2, Tomas Rau3, Svetlana Apostolovic4, Fimm Waagstein4; 1Cardiology, University Clinical Centar Zvezdara, Belgrade, Serbia; 2University Clinical Hospital Cherite, Berlin, Germany; 3 University Clinical Center, Hamburg, Germany; 4University Clinical Center, Nis, Serbia Exercise capacity is correlated with overall cardiac beta receptors density, but effects of ß blockers on exercise ability and capacity in elderly patients with HF remains unclear. In present study we estimated the impact of ß blockers therapy on cardiopulmonary functional capacity and LV function in elderly patients with HF. Methods: Thirty consecutive patients aged over 65 with clinical existence of systolic HF treated with ß blockers during 8 weeks. All patients were in NYHA class II-III. Cardiopulmonary exercise testing (CPET) were performed according to a submaximal test protocol before therapy and after 12 week follow up. Left atrium dimensions (LA), LV volumes (EDV/bsa, ESV/bsa) and ejection fraction (LVEF), filling velocities (E and A) and annular s and e wave were obtained by Doppler echocardiography. Results: Heart rate after ß blockers up titration was significantly decreased at rest and during exercise (p ! 0.001), but systolic blood pressure only during exercise (p ! 0.05). Changes of heart rate at rest and during CPET were closely correlated (p ! 0.001).There were significant rise of LVEF (p 5 0.003) longitudinal LV function (s) (p 5 0.006) with modest decrease of LV stiffness (p 5 0.027) and level of LV filling pressure, (E/e) (p 5 0.044). Significant decrease of respiratory exchange ratio (RER) at maximal oxygen consumption (peak VO2) was found after therapy (p 5 0.001).Symptoms of breathlessness were reduced at the end of the test after therapy (Borg score) (p 5 0.001).Close correlations were found between LV diastolic dysfunction and exercise cardiopulmonary variables ie peak VO2 and LA dimension (r 5 0.375, p 5 0.049), maximal loading time of exercise and LV stiffness index (r 5 0.399, p 5 0.039), and between e and VE/VCO2 slope (r 5 e 0.449, p 5 0.019). Conclusion: In eldrely patients with HF ß blockers significantly decrease heart rate and blood pressdure at rest and during exercise and impoved LV systolic
213 Inadequate Self-Care Practices in Patients with Implantable Devices: Implications for Remote Monitoring Lisa D. Rathman1, Roy S. Small1, J. Thomas Heywood2, John A. Andriulli3, W.H. Wilson Tang4; 1Heart Failure Clinic, The Heart Group/Lancaster Heart and Stroke Foundation, Lancaster, PA; 2Scripps Clinic Torrey Pines, La Jolla, CA; 3UMDNJ, Voorhees, NJ; 4Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH Background: Self-care behavior refers to decisions and actions that an individual can take to cope with a medical condition or to improve his or her health and is essential to successful heart failure (HF) management. The Self-Care of HF Index (SCHFI) is a tool that can quantify a patient’s (pt’s) behavior and decision-making process as it relates to maintaining health (maintenance) and response to symptoms (management). We sought to examine self-care behaviors in pts with cardiac resynchronization (CRT-D) devices and defibrillators (ICD). Methods: As part of the large, multi-center OptiVol Care Pathway study, self-care practices were evaluated at baseline using the SCHFI questionnaire. Adequate self-care is defined by a standardized score O70 when using SCHFI. Results: In the analysis cohort of 1540 subjects (mean age 68 6 12 years, 73% male, 50% CRT-D, 50% ICD), baseline self-care maintenance scores from 1520 SCHFI surveys were low (mean 64 6 15), with 69% of pts having below adequate scores. Interestingly 75% of pts were very or extremely confident in their own ability to relieve their symptoms (sx), 60% reported that they ‘‘always’’ or ‘‘frequently’’ weighed themselves and 75% reported taking prescribed medications. However, only 29% of pts requested low-sodium items when eating out or visiting others. In the subset of 630 pts (41%) who reported sx of worsening HF (trouble breathing or ankle swelling) during the previous month, self-care management was poor (53 6 25), with 76% of pts having below adequate scores. Across all responses, only 50% quickly recognized their sx, and 31% of pts were either ‘‘not likely’’ or ‘‘somewhat likely’’ to call a provider for guidance in the setting of HF sx. Conclusion: Although most pts were confident in their ability to relieve their sx, baseline SCHFI data in this cohort of pts with implantable devices demonstrated that self-care remained inadequate. Pts were frequently slow to recognize decompensation and oftentimes did not seek medical advice for treatment. These findings show improvement is needed in self-care practices. Whether remote monitoring of diagnostic data from implanted devices may help improve self-care practices and in turn potentially reduce heart failure events will be explored in the OptiVol Care Pathway study.
214 Initial Experience with Spinal Cord Stimulation (SCS) for the Treatment of Advanced Heart Failure Siller Jesus2, Kenneth M. Alo2, Guillermo Torre-Amione1,2; 1The Methodist DeBakey Heart & Vascular Center & Instituto de Cardiologia y Medicina Vascular, Cardiology; Tec de Monterrey, Houston, TX & Monterrey Mexico; 2 Instituto de Cardiologia y Medicina Vascular, Tec de Monterrey, Monterrey, Mexico SCS consists on the implantation of an electrode in the epidural space connected to a power source that can be activated to pulse, frequency and time. The use of SCS in cardiovascular conditions has been limited to the treatment of angina and peripheral vascular disease. However, experimental and theoretical work indicates that SCS may
HFSA
S67
prevent cardiac arrhythmias and promote reverse remodeling. Objective: Accordingly, we are conducting a feasibility non-randomized study in patients with CHF ischemic or non-ischemic that were in NYHA class III-IV. Methods: Two leads were implanted in each patient (T1-T3 and T9-T12). Parameters of activation were: stimulation frequency of 50 Hz, pulse width 200 msec with bipolar stimulation and output current amplitude set at 90% of initial parasthesias. Stimulation was programmed for 2hrs three times a day Results: Characteristics of the initial study cohort are shown in table A.1. All implants were successfully performed without worsening SOB, edema or angina. There were no episodes of bleeding or infection. Patients were discharged within 24 hrs with programming of the device prior to discharge. All patients reported symptomatic improvements. Six-minute walk test improved as shown in Figure A.2. No demonstrable echo changes were observed at 3 months. Conclusion: This initial experience indicates that it is possible to implant SCS in patients with advanced heart failure and supports the concept of conducting further clinical studies to test the safety and efficacy of SCS for CHF.
215 Exercise Training Improves Heart Rate Variability in Older Patients with Heart Failure. A Randomized, Controlled, Single-Blinded Study Khalil Murad1, Elsayed Z. Soliman1, Timothy M. Morgan1, David M. Fitzgerald2, Joel D. Eggebeen2, David C. Goff1, Dalane W. Kitzman2; 1Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC; 2Internal Medicine/Section of Cardiology, Wake Forest University School of Medicine, Winston-Salem, NC Background: Autonomic dysfunction, as measured by reduced heart rate variability (HRV), is commonly seen in older patients with heart failure (HF), and it is associated with poor outcome. In other patient populations, exercise training (ET) has been shown to improve HRV. Therefore, we examined the effect of ET on HRV in older patients with chronic HF. Method: Sixty six patients (36% males), age 69 6 5 years, with NYHA class II-III HF (36 patients with HF with preserved ejection fraction (EF), and 30 patients with reduced EF) were randomly assigned to supervised aerobic ET 3 times a week for 16 weeks (ET group, N 5 31) versus attention control (AC group, N 5 35). Using a 10-minute ECG recording, two short term HRV parameters (the standard deviation of all normal RR intervals (SDNN) and the root mean square of successive differences in normal RR intervals (RMSSD)) were measured at baseline and after completion of ET. Analysis of Covariance was used to compare changes in HRV between the study groups. Results: At baseline, there were no significant differences in demographic or clinical characteristics In the ET compared to the AC. At follow up, ET had a significantly greater increase in HRV parameters than AC. SDNN changed from 31.6 6 21.0 to 47.0 6 36.5 in ET vs from 30.2 6 17.7 to 32.6 6 15.4 in AC, (P 5 0.002). RMSSD changed from 24.7 6 24.7 to 42.3 6 48.3 in ET vs from 20.4 6 15.5 to 22.1 6 15.9 in AC, (P 5 0.006). There was no significant gender difference in the response to ET. There was a trend toward greater increase in SDNN in patients with reduced compared to preserved EF, (P 5 0.063). Conclusion: Exercise training increases HRV in older patients with HF. This effect is possibly greater in those with reduced EF.
216 The Effects of Short Term Beta-Blockade on Exercise Capacity and Left Ventricular Function in Elderly Patients with Heart Failure Milica Dekleva1, Hans Dirk Dungen2, Simone Incrot2, Tomas Rau3, Svetlana Apostolovic4, Fimm Waagstein4; 1Cardiology, University Clinical Centar Zvezdara, Belgrade, Serbia; 2University Clinical Hospital Cherite, Berlin, Germany; 3 University Clinical Center, Hamburg, Germany; 4University Clinical Center, Nis, Serbia Exercise capacity is correlated with overall cardiac beta receptors density, but effects of ß blockers on exercise ability and capacity in elderly patients with HF remains unclear. In present study we estimated the impact of ß blockers therapy on cardiopulmonary functional capacity and LV function in elderly patients with HF. Methods: Thirty consecutive patients aged over 65 with clinical existence of systolic HF treated with ß blockers during 8 weeks. All patients were in NYHA class II-III. Cardiopulmonary exercise testing (CPET) were performed according to a submaximal test protocol before therapy and after 12 week follow up. Left atrium dimensions (LA), LV volumes (EDV/bsa, ESV/bsa) and ejection fraction (LVEF), filling velocities (E and A) and annular s and e wave were obtained by Doppler echocardiography. Results: Heart rate after ß blockers up titration was significantly decreased at rest and during exercise (p ! 0.001), but systolic blood pressure only during exercise (p ! 0.05). Changes of heart rate at rest and during CPET were closely correlated (p ! 0.001).There were significant rise of LVEF (p 5 0.003) longitudinal LV function (s) (p 5 0.006) with modest decrease of LV stiffness (p 5 0.027) and level of LV filling pressure, (E/e) (p 5 0.044). Significant decrease of respiratory exchange ratio (RER) at maximal oxygen consumption (peak VO2) was found after therapy (p 5 0.001).Symptoms of breathlessness were reduced at the end of the test after therapy (Borg score) (p 5 0.001).Close correlations were found between LV diastolic dysfunction and exercise cardiopulmonary variables ie peak VO2 and LA dimension (r 5 0.375, p 5 0.049), maximal loading time of exercise and LV stiffness index (r 5 0.399, p 5 0.039), and between e and VE/VCO2 slope (r 5 e 0.449, p 5 0.019). Conclusion: In eldrely patients with HF ß blockers significantly decrease heart rate and blood pressdure at rest and during exercise and impoved LV systolic