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Underuse of Primary Prevention Implantable Cardioverter Defibrillator in Women With Heart Failure
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Abstracts
(C-CIED) implantation from a tertiary to a regional cardiac centre on implant rates. Methods: All Waitemata District Health Board (WDHB) patients who underwent ICD/CRT implantation from Jan 2007 – Dec 2015 were reviewed. This includes de novo implantations, and upgrade from pacemaker to ICD/CRT. From mid-2012 these procedures were repatriated from Auckland City Hospital to North Shore Hospital (ADHB to WDHB). The total number of implants and complication rates at both sites were compared. Results: From 2007, to mid-2012 207 individuals from WDHB catchment area underwent C-CIED implantation at Auckland. Since mid-2012, WDHB has implanted 247 CCIED. There was a trend of increasing number of C-CIED implanted since repatriation. Figure 1 showed the total number of C-CIED implanted at both sites for WDHB patients. The increasing number of C-CIED implanted was mainly due to increased number of referrals for primary prevention C-CIED (Figure 2) The complication rates were no different between sites (4% vs.10% at WDHB and ADHB respectively, p = 0.09).
May-2015 were included. All-cause mortality and procedurerelated complications were compared between different stages of CKD. Results: A total of 200 patients were implanted with CRT during the study period. Majority [89(44%)] were in CKD stage 2 (mean eGFR 71.2 9.1 mL/min/1.73 m2) (Figure 1) No patients were on renal replacement therapies (CKD stage 5). Acute procedural complications occurred more frequently in patients with CKD stage 3 and 4 (6.1% and 33.3%, respectively) but there were no differences in the late complications between the CKD groups (P = 0.16). No difference in mortality rates between CKD groups were noted (P = 0.5807). Figure 2 showed the Kaplan Meier survival curve of the CRT patients with different stages of CKD.
Conclusion: In “real-world” clinical practice, HF patients with severe CKD (stage 5) were excluded from receiving CRT. HF patients with CKD stage 3 and 4 have higher rates of acute procedural complications. Additional studies are needed to further evaluate the role of CRT on morbidity and mortality in such patients. http://dx.doi.org/10.1016/j.hlc.2016.05.069 Conclusion: Establishment of a C-CIED service at a regional cardiac centre with appropriate facilities and support is feasible, safe and has the potential to improve access to C-CIED implantation and management. http://dx.doi.org/10.1016/j.hlc.2016.05.068 P39 Cardiac Resynchronisation Therapy In Heart Failure Patients with Chronic Kidney Disease Khang-Li Looi 1*, Lisa Cooper 1, Karishma Sidhu 1, Liane Dawson 2, Debbie Slipper 2, Andrew Gavin 2, Nigel Lever 1 1
Auckland City Hospital, Auckland, New Zealand North Shore Hospital, Auckland, New Zealand * Corresponding author. 2
Background: Patients with both heart failure (HF) and chronic kidney disease (CKD) have increased risk of mortality and morbidity. Majority of studies supporting the use of cardiac resynchronisation therapy (CRT) have limited data on HF patients with CKD. We examine the trends in CRT use and outcomes in HF patients with CKD. Methods: All HF patients from the Northern Region of New Zealand implanted with CRT devices from Jan-2007 to
P40 Underuse of Primary Prevention Implantable Cardioverter Defibrillator in Women With Heart Failure Khang-Li Looi 1*, Lisa Cooper 1, Karishma Sidhu 1, Liane Dawson 2, Debbie Slipper 2, Andrew Gavin 2, Nigel Lever 1 1
Auckland City Hospital, Auckland, New Zealand North Shore Hospital, Auckland, New Zealand * Corresponding author. 2
Background: Implantable cardioverter-defibrillators (ICDs) prevent sudden cardiac death in patients with heart failure (HF) and impaired left ventricular (LV) function. Women have been under-represented in randomised ICD clinical trials. Our study examines the outcomes of men and women with HF receiving primary prevention ICDs in “realworld” clinical practice. Methods: HF patients with impaired LV function from the Northern Region of New Zealand implanted with de-novo ICD and cardiac resynchronisation therapy with defibrillator (CRTD) from Jan-2007 to May-2015 were included. Results: Of 344 patients who received primary prevention ICD/CRT-D, only 48 (13.9%) were women and 14 of 48 (29%)
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received CR-TD. There was no difference in baseline characteristics in men and women except women presented a higher proportion of non-ischaemic cardiomyopathy (66.7% versus 47.9%, P = 0.0163), and lower prevalence of chronic atrial fibrillation (6.3% versus 20.3%, P = 0.0198). Women also had higher rates of acute procedural complications (8.3% vs. 1.7%, P = 0.02). During a mean follow-up of 3.6 2.2 years, no genderspecific interaction was observed for appropriate ICD therapies (8.3% vs.17.2%, P = 0.12), inappropriate shocks (10.4% vs. 9.5%, P = 0.79), and all-cause mortality (8.3% vs. 16.9%, P = 0.19). Conclusion: In “real-world” clinical practice, women with HF remain a minority of primary prevention ICD recipients. The incidence of appropriate ICD therapies, inappropriate shocks and all-cause mortality was comparable to men with HF who received primary prevention ICD. The low referral rate for primary prevention ICD in women with HF requires further investigation as do the reasons for higher implantation complications. http://dx.doi.org/10.1016/j.hlc.2016.05.070
Cardiac Imaging P41 Direct Access to Echocardiography in Line with New Zealand Regional Minimum Standards Leads to Early Detection and Treatment of Valvular Pathology. We Provided Quantitative Data to Facilitate Planning of Similar Care Pathways Danielle Gelbart, Tammy Pegg, Nick Fisher, Steve White * Nelson Marlborough DHB, Nelson, New Zealand * Corresponding author. Background: Direct access to echocardiograms by general practitioners for murmur assessment in adult populations is variably available across New Zealand. There is a paucity of published data on detection rates for pathology and for knock-on effects for clinical services. This audit examines outcomes of GP-referred echocardiograms for murmur assessment in the Nelson-Marlborough region. Access was determined by Central Region minimum standards for referral and access to secondary cardiac care. Methods: Detection rates for valvular pathology were audited over a two-year period with subsequent care pathway decisions. Results: In a population of 136,995 residents, 252 echocardiograms were performed. Pathology was found in 133 patients (53%). 75 patients had aortic stenosis, 78 had mitral regurgitation, and 49 had aortic regurgitation. 39% with normal aortic valves had turbulent flow murmurs. 62 patients entered a technician-led valve follow-up service, 25 required a formal first specialist assessment (FSA), and 26 patients required 44 further investigations, leading to nine surgical interventions.
Abstracts
When standardised to a 100,000 patient rate, Nelson-Marlborough could expect to generate 45 valve follow-up scans, 18 FSA appointments, 32 further investigations and seven patients referred for surgery over two years. Conclusion: A direct access pathway to echocardiography if appropriately utilised in line with Central Region minimum standards for access to care leads to early detection and treatment of valvular pathology. This data provides valuable information for clinical services wishing to provide such access. It quantifies detection rates by auscultation for valvulopathies and subsequent effects for clinical services, including expected numbers of further investigations, FSA appointments and valvular operations. http://dx.doi.org/10.1016/j.hlc.2016.05.071
P42 The Establishment of CTCA at Northland District Health Board Stephen Jennison *, Samraj Nandra, Erin Doherty, Bruce O’Brien, Natalie Presnall Northland DHB, Whangarei, New Zealand * Corresponding author. Background: With the arrival of a new GE Revolution scanner at the Northland DHB, the opportunity to establish a CT coronary angiography service presented itself. Prior to this, patients had to travel to Auckland for any coronary artery imaging. Northland’s population of 160,000 has higher than the national average level of deprivation and below average health outcomes. Northland is geographically dispersed and road travel from north to south takes over five hours. Methods: The service was started as a joint project between the radiology and cardiology departments at Whangarei hospital, with the radiologist involved being the only member of the team having had prior experience with CTCA. A multidisciplinary working group was formed to ensure all aspects of service provision were addressed. Cardiologists completed training in Australia and the United Kingdom, and continue to receive clinical support from cardiologists involved in CTCA at Waitemata and Counties Manukau DHBs. Radiology and nursing staff also received support and education from these DHB’s. Results: The service commenced in October 2015. At the time of abstract submission 75 cases had been performed, resulting in 20 patients being referred for coronary angiograms, 16 patients requiring clinic follow-up or further stress testing and 39 patients being discharged from the cardiology service. The impact of CTCA on the region will be evaluated following a year of the service running. Conclusion: The cardiology and radiology teams embraced the fortuity of this scanning capability, and embarked on a path to develop its potential, particularly in the evaluation of low and intermediate risk chest pain patients within the region. http://dx.doi.org/10.1016/j.hlc.2016.05.072
Abstracts
(C-CIED) implantation from a tertiary to a regional cardiac centre on implant rates. Methods: All Waitemata District Health Board (WDHB) patients who underwent ICD/CRT implantation from Jan 2007 – Dec 2015 were reviewed. This includes de novo implantations, and upgrade from pacemaker to ICD/CRT. From mid-2012 these procedures were repatriated from Auckland City Hospital to North Shore Hospital (ADHB to WDHB). The total number of implants and complication rates at both sites were compared. Results: From 2007, to mid-2012 207 individuals from WDHB catchment area underwent C-CIED implantation at Auckland. Since mid-2012, WDHB has implanted 247 CCIED. There was a trend of increasing number of C-CIED implanted since repatriation. Figure 1 showed the total number of C-CIED implanted at both sites for WDHB patients. The increasing number of C-CIED implanted was mainly due to increased number of referrals for primary prevention C-CIED (Figure 2) The complication rates were no different between sites (4% vs.10% at WDHB and ADHB respectively, p = 0.09).
May-2015 were included. All-cause mortality and procedurerelated complications were compared between different stages of CKD. Results: A total of 200 patients were implanted with CRT during the study period. Majority [89(44%)] were in CKD stage 2 (mean eGFR 71.2 9.1 mL/min/1.73 m2) (Figure 1) No patients were on renal replacement therapies (CKD stage 5). Acute procedural complications occurred more frequently in patients with CKD stage 3 and 4 (6.1% and 33.3%, respectively) but there were no differences in the late complications between the CKD groups (P = 0.16). No difference in mortality rates between CKD groups were noted (P = 0.5807). Figure 2 showed the Kaplan Meier survival curve of the CRT patients with different stages of CKD.
Conclusion: In “real-world” clinical practice, HF patients with severe CKD (stage 5) were excluded from receiving CRT. HF patients with CKD stage 3 and 4 have higher rates of acute procedural complications. Additional studies are needed to further evaluate the role of CRT on morbidity and mortality in such patients. http://dx.doi.org/10.1016/j.hlc.2016.05.069 Conclusion: Establishment of a C-CIED service at a regional cardiac centre with appropriate facilities and support is feasible, safe and has the potential to improve access to C-CIED implantation and management. http://dx.doi.org/10.1016/j.hlc.2016.05.068 P39 Cardiac Resynchronisation Therapy In Heart Failure Patients with Chronic Kidney Disease Khang-Li Looi 1*, Lisa Cooper 1, Karishma Sidhu 1, Liane Dawson 2, Debbie Slipper 2, Andrew Gavin 2, Nigel Lever 1 1
Auckland City Hospital, Auckland, New Zealand North Shore Hospital, Auckland, New Zealand * Corresponding author. 2
Background: Patients with both heart failure (HF) and chronic kidney disease (CKD) have increased risk of mortality and morbidity. Majority of studies supporting the use of cardiac resynchronisation therapy (CRT) have limited data on HF patients with CKD. We examine the trends in CRT use and outcomes in HF patients with CKD. Methods: All HF patients from the Northern Region of New Zealand implanted with CRT devices from Jan-2007 to
P40 Underuse of Primary Prevention Implantable Cardioverter Defibrillator in Women With Heart Failure Khang-Li Looi 1*, Lisa Cooper 1, Karishma Sidhu 1, Liane Dawson 2, Debbie Slipper 2, Andrew Gavin 2, Nigel Lever 1 1
Auckland City Hospital, Auckland, New Zealand North Shore Hospital, Auckland, New Zealand * Corresponding author. 2
Background: Implantable cardioverter-defibrillators (ICDs) prevent sudden cardiac death in patients with heart failure (HF) and impaired left ventricular (LV) function. Women have been under-represented in randomised ICD clinical trials. Our study examines the outcomes of men and women with HF receiving primary prevention ICDs in “realworld” clinical practice. Methods: HF patients with impaired LV function from the Northern Region of New Zealand implanted with de-novo ICD and cardiac resynchronisation therapy with defibrillator (CRTD) from Jan-2007 to May-2015 were included. Results: Of 344 patients who received primary prevention ICD/CRT-D, only 48 (13.9%) were women and 14 of 48 (29%)
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received CR-TD. There was no difference in baseline characteristics in men and women except women presented a higher proportion of non-ischaemic cardiomyopathy (66.7% versus 47.9%, P = 0.0163), and lower prevalence of chronic atrial fibrillation (6.3% versus 20.3%, P = 0.0198). Women also had higher rates of acute procedural complications (8.3% vs. 1.7%, P = 0.02). During a mean follow-up of 3.6 2.2 years, no genderspecific interaction was observed for appropriate ICD therapies (8.3% vs.17.2%, P = 0.12), inappropriate shocks (10.4% vs. 9.5%, P = 0.79), and all-cause mortality (8.3% vs. 16.9%, P = 0.19). Conclusion: In “real-world” clinical practice, women with HF remain a minority of primary prevention ICD recipients. The incidence of appropriate ICD therapies, inappropriate shocks and all-cause mortality was comparable to men with HF who received primary prevention ICD. The low referral rate for primary prevention ICD in women with HF requires further investigation as do the reasons for higher implantation complications. http://dx.doi.org/10.1016/j.hlc.2016.05.070
Cardiac Imaging P41 Direct Access to Echocardiography in Line with New Zealand Regional Minimum Standards Leads to Early Detection and Treatment of Valvular Pathology. We Provided Quantitative Data to Facilitate Planning of Similar Care Pathways Danielle Gelbart, Tammy Pegg, Nick Fisher, Steve White * Nelson Marlborough DHB, Nelson, New Zealand * Corresponding author. Background: Direct access to echocardiograms by general practitioners for murmur assessment in adult populations is variably available across New Zealand. There is a paucity of published data on detection rates for pathology and for knock-on effects for clinical services. This audit examines outcomes of GP-referred echocardiograms for murmur assessment in the Nelson-Marlborough region. Access was determined by Central Region minimum standards for referral and access to secondary cardiac care. Methods: Detection rates for valvular pathology were audited over a two-year period with subsequent care pathway decisions. Results: In a population of 136,995 residents, 252 echocardiograms were performed. Pathology was found in 133 patients (53%). 75 patients had aortic stenosis, 78 had mitral regurgitation, and 49 had aortic regurgitation. 39% with normal aortic valves had turbulent flow murmurs. 62 patients entered a technician-led valve follow-up service, 25 required a formal first specialist assessment (FSA), and 26 patients required 44 further investigations, leading to nine surgical interventions.
Abstracts
When standardised to a 100,000 patient rate, Nelson-Marlborough could expect to generate 45 valve follow-up scans, 18 FSA appointments, 32 further investigations and seven patients referred for surgery over two years. Conclusion: A direct access pathway to echocardiography if appropriately utilised in line with Central Region minimum standards for access to care leads to early detection and treatment of valvular pathology. This data provides valuable information for clinical services wishing to provide such access. It quantifies detection rates by auscultation for valvulopathies and subsequent effects for clinical services, including expected numbers of further investigations, FSA appointments and valvular operations. http://dx.doi.org/10.1016/j.hlc.2016.05.071
P42 The Establishment of CTCA at Northland District Health Board Stephen Jennison *, Samraj Nandra, Erin Doherty, Bruce O’Brien, Natalie Presnall Northland DHB, Whangarei, New Zealand * Corresponding author. Background: With the arrival of a new GE Revolution scanner at the Northland DHB, the opportunity to establish a CT coronary angiography service presented itself. Prior to this, patients had to travel to Auckland for any coronary artery imaging. Northland’s population of 160,000 has higher than the national average level of deprivation and below average health outcomes. Northland is geographically dispersed and road travel from north to south takes over five hours. Methods: The service was started as a joint project between the radiology and cardiology departments at Whangarei hospital, with the radiologist involved being the only member of the team having had prior experience with CTCA. A multidisciplinary working group was formed to ensure all aspects of service provision were addressed. Cardiologists completed training in Australia and the United Kingdom, and continue to receive clinical support from cardiologists involved in CTCA at Waitemata and Counties Manukau DHBs. Radiology and nursing staff also received support and education from these DHB’s. Results: The service commenced in October 2015. At the time of abstract submission 75 cases had been performed, resulting in 20 patients being referred for coronary angiograms, 16 patients requiring clinic follow-up or further stress testing and 39 patients being discharged from the cardiology service. The impact of CTCA on the region will be evaluated following a year of the service running. Conclusion: The cardiology and radiology teams embraced the fortuity of this scanning capability, and embarked on a path to develop its potential, particularly in the evaluation of low and intermediate risk chest pain patients within the region. http://dx.doi.org/10.1016/j.hlc.2016.05.072