The role of the Wearable Cardiac Defibrillator (WCD) in protecting ischemic cardiomyopathy (ICM) and nonischemic cardiomyopathy (NICM) patients at risk for sudden cardiac arrest (SCA) who are not immediate candidates for the implantable cardiac defibrillator (ICD)

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without audS3 (p=0.0055). DevS3 had a stronger stratification power with a hazard ratio of 5.6 (p<0.0001). DevS3 can also better predict patients with ADHFs with a sensitivity and specificity of 71% and 67%, respectively (p<0.0001).TagedPTEn

S3 heart sound amplitudes measured by accelerometer reflect auscultated S3 heart sound volume grades TAGEDPJOHN BOEHMER, ROY GARDNER, JAGMEET SINGH, BRANISLAV STANCAK, DEVI NAIR, MICHAEL CAO, CHRISTOPHER SCHULZE, PRAMODSINGH THAKURTAGEDN Background: The third heart sound (S3) is regarded as one of the earliest signs of heart failure (HF) and is typically assessed via auscultation clinically. The embedded accelerometer sensor in implantable devices can pick up the mechanical vibration caused by S3. We compared the device-measured S3 amplitude (devS3) to auscultated S3 volume grades (audS3). Methods: In the MultiSENSE study, ambulatory HF patients implanted with a CRT-D were enrolled and followed up for 1 year. DevS3 amplitude was trended daily. Clinicians were asked to auscultate for S3 intensity on a graded scale (None/Low/Moderate/ Loud) at baseline and each regular follow-up. Clinicians were blinded to the devS3 data at the time of assessment. We compared devS3 on the day of assessment in patients with different level of audS3 intensity. ANOVA test was used to compare the mean S3 amplitudes among groups and unpaired t-tests for between-group comparison. Conclusion: This demonstrates that device-measured S3 amplitude reflects auscultated S3 heart sound volume grades. Since device-measured S3 is an objective measure on a continuous scale as opposed to auscultation which is subjectively categorized, it could avoid interobserver auscultation variability and enables monitoring of this clinical variables in ambulatory HF patients. Result: A total of 5211 auscultation reports were obtained from the 900 patients in the study. AudS3 intensity was None in 4709, Low in 391, Moderate in 108, and Loud in 3 reports (moderate and loud were combined for this analysis). Figure represents the devS3 amplitude (mean § standard error) on the day of the follow-up as a function of the audS3 grades reported, the mean devS3 values for None, Low, and Moderate/Loud audS3 was 0.96 § 0.01 mG, 1.02 § 0.02 mG, and 1.27§ 0.06 mG respectively. Both ANOVA test and unpaired tests between groups were significant and remained significant after adjusting for repeated measures.TagedPTEn

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Shared decision-making about end-of-life care compared among implantable cardioverter defibrillator patients with and without heart failure: a national cohort study TAGEDPJESSICA HARMON, DEBRA MOSERTAGEDN Background: Authors of expert guidelines and consensus statements recommend that decisions at the end-of-life be discussed before and after implantation of an implantable cardioverter defibrillator (ICD), and include promotion of shared decision making. The degree to which these guidelines are followed for patients with and without heart failure (HF) is undocumented in the literature. The purpose of this study was to compare experiences, attitudes, and knowledge about the ICD at end-of-life between ICD recipients with and without HF to determine how well patients could participate in end-of-life decisions. Methods: Utilizing a national registry in Sweden of all ICD recipients (n=5355), the End-of-Life and Implantable Cardioverter Defibrillator Questionnaire (EOL-ICDQ) was sent out and 3,067 recipients participated. This survey also included a measure of anxiety and depression (HADS). Conclusion: Initially we assumed that participants with HF would have more knowledge about end-of-life care due to their shortened life expectancy, however, we found this was not true. In order to better prepare patients with HF and an ICD for the end-of-life, shared decision making and open lines of communication between providers, patients, and their families should be encouraged. The role of the Wearable Cardiac Defibrillator (WCD) in protecting ischemic cardiomyopathy (ICM) and nonischemic cardiomyopathy (NICM) patients at risk for sudden cardiac arrest (SCA) who are not immediate candidates for the implantable cardiac defibrillator (ICD) TAGEDPKATHLEEN KING-DAILEYTAGEDN Background: There are >30,000 deaths in the United States annually due to sudden cardiac death (SCD). SCD from a ventricular tachyarrhythmia (VT) is a significant contributor to mortality in patients with heart disease. If defibrillation therapy is delivered within minutes of the patient’s collapse, this renders the highest probability of surviving life-threatening VT. The WCD is a temporary, non-surgical device, designed for patients who are at risk for SCA but are not appropriate candidates for ICD implantation at the present time. The WCD allows providers time to assess their long-term arrhythmic risk and make appropriate plans for those patients at a perceived risk, who may show clinical improvement after being medically optimized. Post-MI patients with heart failure are at 4 6 times greater risk of SCA in the first 30 days post-MI. The rate of sustained ventricular tachyarrhythmia (SVT) by three months was 3% among patients with ICM and in congenital/inherited heart disease, and 1% among NICM patients. The WEARIT-II registry demonstrated a high rate of SVT at three months in at risk patients who were not eligible for an ICD, suggesting that wearing the WCD can be safely used to protect patients during this period of risk assessment. Methods: Between October 1, 2015 and September 30, 2017, the patients who used the WCD were included in this retrospective chart review. All patients with ICM and NICM that met the criteria for WCD were included. The number of subjects in the database determined the sample size pragmatically over a two-year period of time. Data was entered into an Excel spreadsheet for Windows. Descriptive statistics were conducted to describe the sample demographics. Frequency and percentages were calculated for nominal data and means were calculated for continuous data. Conclusion: Patients who are at risk for SCA are patients who have had a cardiac arrest due to ventricular fibrillation (VF) or sustained ventricular tachycardia (SVT), those with familial or inherited condition with sudden cardiac arrest risk, myocardial infarction with an ejection fraction (EF) of less than or equal to 35%, dilated

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cardiomyopathy (including NICM), with an EF of less than or equal to 35%, ICD explanations, and other conditions with high risk of ventricular tachycardia (VT) or VF are candidates for the WCD. The sample of data was from 186 patients. However, more patients were likely candidates but may not have been considered due to lack of awareness or provider preference of the WCD. Of those patients, four received a living saving shock from the WCD. Two were ICM and two were NICM. Of the sample population, there was a much smaller group of woman than men protected with the WCD. Recognizing at risk patients for SCA can be challenging. There is considerable controversy regarding the use of the WCD in the short term for cardiomyopathy patients. The use of the WCD has shown to be lifesaving in both the ICM and NICM patients in protecting them from SCA. However, the risk assessment among patients with NICM is less straightforward that’s for patients with ICM. The WCD is a therapeutic option, listed along with implantable cardioverter defibrillators (ICDs), in the ACC/AHA/ESC Guidelines for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. It is also a Class I recommendation in the International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates. Result: The PinnacleHealth CardioVascular Institute enrolled 186 patients with ischemic (N= 60, 32.3%), and nonischemic (n= 126, 67.7 %) cardiomyopathies prescribed the WCD between October 1, 2015 through September 30 2017. Clinical data, arrhythmic events, and ejection fractions were captured. The median age was 62-years-old; there were 58 female patients (31%) and 128 male patients (69%), the median ejection fraction was 25%. Four patients received appropriate WCD shock. Two patients were NICM (2%) and two patients were ICM (4%). Of the two ICM there was one VT and one VF arrest. Of the NICM they were both shocked for VF arrests. Long-term effect of patiromer for hyperkalemia treatment in patients with chronic kidney disease, heart failure, and ejection fraction >40% on RAAS inhibitors TAGEDPBERTRAM PITT, ANDREW KO, MARTHA MAYO, DAHLIA GARZA, SUSAN ARTHUR, LAINSCAK MITJATAGEDN Background: Patients with heart failure and chronic kidney disease (CKD) on RAAS inhibitors have a high risk of hyperkalemia, which can increase risk of mortality and lead to RAAS inhibitor dose reduction or discontinuation. Patiromer, a sodium-free nonabsorbed K+-binding polymer that exchanges calcium for K+, is approved for the treatment of hyperkalemia. Previously, we showed that patiromer reduced mean serum K+ over 52 weeks in a small (n=26) subgroup of patients with heart failure with reduced ejection fraction (40%) in the AMETHYST-DN study. Methods: Patients with CKD, type 2 diabetes mellitus, and hyperkalemia (baseline serum K+ >5.0 to <6.0 mEq/L) were randomized to patiromer starting doses of 8.4 33.6 g/d, divided twice daily. All patients remained on RAAS inhibitors during study treatment. Changes in mean serum K+ from baseline through 52 weeks were evaluated in the subgroup of patients with heart failure and EF >40%. Conclusion: Patiromer decreased serum K+ through 52 weeks in patients with hyperkalemia, chronic kidney disease, and heart failure with EF>40%, all of whom were taking RAAS inhibitors. These posthoc results require prospective evaluation, but suggest that patiromer allows control of hyperkalemia in heart failure patients with EF >40% on RAAS inhibitors. Result: Overall, 55 out of 306 randomized patients had heart failure with EF >40% (100% Caucasian, 75% male, 69% 65 years of age). Mean (SD) EF was 48 (7)% and mean (SD) eGFR was 41 (13) mL/min/ 1.73 m2 at baseline. All patients had hypertension (mean BP 155/ 83 mm Hg). Mean serum K+ was reduced to <5.0 mEq/L at the first post-baseline visit (day 3) through 52 weeks (Table). From baseline to 52 weeks, mean (SE) eGFR increased by 6 (3) mL/min/1.73 m2 and mean (SE) SBP/DBP decreased by 22 (3)/ 9 (2) mm Hg. Forty-two

(76%) patients reported 1 adverse event (AE); hypomagnesemia (9.1%) was the most common AE (none severe). Three patients had serum K+ <3.5 mEq/L. TagedPEn

Implementation challenges of conducting a heart failure palliative care intervention pilot trial in the deep south TAGEDPRACHEL WELLS, NICHOLAS J. DIONNE-ODOM J, SALPY PAMBOUKIAN, JOSE TALLAJ, ANDRES AZUERO, KONA KEEBLER, DEBORAH EJEM, ELIZABETH KVALE, KEITH SWETZ, KAREN STEINHAUSER, REAGAN DURANT, ALAN KONO, MARIE BAKITASTAGEDN Background: We translated and tested ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends Comprehensive Heart care for Patients and Caregivers), an early heart failure (HF) palliative care (PC) telehealth intervention, to determine implementation and access challenges in medically-underserved/rural HF patient and caregiver dyads Methods: ENABLE CHF-PC was piloted in North- and Southeast U.S. sites (4/1/14-8/31/15). Eligibility criteria included: Class III/IV or Stage C/D HF and age 50 years. Intervention components were in-person PC consultation, nurse coach phone sessions (patients: 6 sessions; caregivers: 4 sessions), monthly phone check-ins. Measures included quality of life (QOL), physical/mental health, symptom, and burden outcomes at baseline, 12, and 24 weeks. Feasibility determined by intervention and measurement completion. Conclusion: Lessons learned from pilot-testing ENABLE CHF-PC facilitated refinement of strategies to recruit and retain literacy-challenged advanced HF dyads, which have been incorporated in an ongoing efficacy trial of ENABLE CHF-PC. Result: Patients (n = 61; NE = 32; SE = 29) and caregivers (n = 48; NE =29; SE =19) were enrolled. HF patients were 70.6 years, NYHA Class IIIa/b (70.5%), mostly male (50.8%), and white (80.3%); caregivers were 64.9 years, mostly female (81.3%), and white (83.3%). Intervention sessions averaged 50 minutes per patient and 46 minutes per caregiver. There were between-site differences in completing pc consultation (NE = 44% vs. SE = 20%), patient sessions (NE = 94% vs. SE = 41 %) and measurements (NE = 72% vs. SE = 38%, P = .008). Additional challenges in the SE were recruitment/retention, participants' comprehension of non-hospice palliative care, keeping appointments for