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Bockus LB, Shadman R, Poole JE, Dardas TF, Lucci D, Meessen J, Latini R, Maggioni A, Levy WC. Seattle proportional risk model in GISSI-HF: Estimated benefit of ICD in patients with EF less than 50. Am Heart J 2024; 275:35-44. [PMID: 38825218 DOI: 10.1016/j.ahj.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/01/2024] [Accepted: 05/25/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND The Seattle Proportional Risk Model (SPRM) estimates the proportion of sudden cardiac death (SCD) in heart failure (HF) patients, identifying those most likely to benefit from implantable cardioverter-defibrillator (ICD) therapy (those with ≥50% estimated proportion of SCD). The GISSI-HF trial tested fish oil and rosuvastatin in HF patients. We used the SPRM to evaluate its accuracy in this cohort in predicting potential ICD benefit in patients with EF ≤50% and an SPRM-predicted proportion of SCD either ≥50% or <50%. METHODS The SPRM was estimated in patients with EF ≤50% and in a logistic regression model comparing SCD with non-SCD. RESULTS We evaluated 6,750 patients with EF ≤50%. There were 1,892 all-cause deaths, including 610 SCDs. Fifty percent of EF ≤35% patients and 43% with EF 36% to 50% had an SPRM of ≥50%. The SPRM (OR: 1.92, P < 0.0001) accurately predicted the risk of SCD vs non-SCD with an estimated proportion of SCD of 44% vs the observed proportion of 41% at 1 year. By traditional criteria for ICD implantation (EF ≤35%, NYHA class II or III), 64.5% of GISSI-HF patients would be eligible, with an estimated ICD benefit of 0.81. By SPRM >50%, 47.8% may be eligible, including 30.2% with EF >35%. GISSI-HF participants with EF ≤35% with SPRM ≥50% had an estimated ICD HR of 0.64, comparable to patients with EF 36% to 50% with SPRM ≥50% (HR: 0.65). CONCLUSIONS The SPRM discriminated SCD vs non-SCD in GISSI-HF, both in patients with EF ≤35% and with EF 36% to 50%. The comparable estimated ICD benefit in patients with EF ≤35% and EF 36% to 50% supports the use of a proportional risk model for shared decision making with patients being considered for primary prevention ICD therapy.
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Affiliation(s)
- Lee B Bockus
- Department of Medicine,University of Washington, Seattle, WA
| | - Ramin Shadman
- Department of Cardiology, Southern California Permanente Medical Group, Los Angeles, CA
| | - Jeanne E Poole
- Department of Medicine,University of Washington, Seattle, WA
| | - Todd F Dardas
- Department of Medicine,University of Washington, Seattle, WA
| | - Donata Lucci
- Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Florence, Italy
| | - Jennifer Meessen
- Department of Acute Brain and Cardiovascular Injury, Institute for Pharmacological Research Mario Negri IRCCS, Milano, Italy
| | - Roberto Latini
- Department of Acute Brain and Cardiovascular Injury, Institute for Pharmacological Research Mario Negri IRCCS, Milano, Italy
| | - Aldo Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Florence, Italy
| | - Wayne C Levy
- Department of Medicine,University of Washington, Seattle, WA.
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Mullens W, Dauw J, Gustafsson F, Mebazaa A, Steffel J, Witte KK, Delgado V, Linde C, Vernooy K, Anker SD, Chioncel O, Milicic D, Hasenfuß G, Ponikowski P, von Bardeleben RS, Koehler F, Ruschitzka F, Damman K, Schwammenthal E, Testani JM, Zannad F, Böhm M, Cowie MR, Dickstein K, Jaarsma T, Filippatos G, Volterrani M, Thum T, Adamopoulos S, Cohen-Solal A, Moura B, Rakisheva A, Ristic A, Bayes-Genis A, Van Linthout S, Tocchetti CG, Savarese G, Skouri H, Adamo M, Amir O, Yilmaz MB, Simpson M, Tokmakova M, González A, Piepoli M, Seferovic P, Metra M, Coats AJS, Rosano GMC. Integration of implantable device therapy in patients with heart failure. A clinical consensus statement from the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2024; 26:483-501. [PMID: 38269474 DOI: 10.1002/ejhf.3150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 10/27/2023] [Accepted: 01/15/2024] [Indexed: 01/26/2024] Open
Abstract
Implantable devices form an integral part of the management of patients with heart failure (HF) and provide adjunctive therapies in addition to cornerstone drug treatment. Although the number of these devices is growing, only few are supported by robust evidence. Current devices aim to improve haemodynamics, improve reverse remodelling, or provide electrical therapy. A number of these devices have guideline recommendations and some have been shown to improve outcomes such as cardiac resynchronization therapy, implantable cardioverter-defibrillators and long-term mechanical support. For others, more evidence is still needed before large-scale implementation can be strongly advised. Of note, devices and drugs can work synergistically in HF as improved disease control with devices can allow for further optimization of drug therapy. Therefore, some devices might already be considered early in the disease trajectory of HF patients, while others might only be reserved for advanced HF. As such, device therapy should be integrated into HF care programmes. Unfortunately, implementation of devices, including those with the greatest evidence, in clinical care pathways is still suboptimal. This clinical consensus document of the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC) describes the physiological rationale behind device-provided therapy and also device-guided management, offers an overview of current implantable device options recommended by the guidelines and proposes a new integrated model of device therapy as a part of HF care.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
- UHasselt, Biomedical Research Institute, Faculty of Medicine and Life Sciences, LCRC, Diepenbeek, Belgium
| | - Jeroen Dauw
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
- UHasselt, Doctoral School for Medicine and Life Sciences, LCRC, Diepenbeek, Belgium
| | - Finn Gustafsson
- The Heart Center, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Alexandre Mebazaa
- Université de Paris, UMR Inserm - MASCOT; APHP Saint Louis Lariboisière University Hospitals, Department of Anesthesia-Burn-Critical Care, Paris, France
| | - Jan Steffel
- Hirslanden Heart Clinic and University of Zurich, Zurich, Switzerland
| | - Klaus K Witte
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Hospital University Germans Trias i Pujol, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
| | - Cecilia Linde
- Karolinska Institutet, Department of Medicine, Karolinska University Hospital, Heart Vascular and Neurology Theme, Stockholm, Sweden
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK) and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Davor Milicic
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Gerd Hasenfuß
- University Medical Center Göttingen (UMG), Department of Cardiology and Pneumology, German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | | | - Friedrich Koehler
- Medical Department, Division of Cardiology and Angiology, Centre for Cardiovascular Telemedicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Ruschitzka
- Clinic of Cardiology, University Heart Centre, University Hospital, Zurich, Switzerland
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Ehud Schwammenthal
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, and Tel Aviv University, Ramat Aviv, Israel
| | - Jeffrey M Testani
- Division of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 14-33, Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
| | - Michael Böhm
- Universitatsklinikum des Saarlandes, Klinik fur Innere Medizin III, Saarland University, Kardiologie, Angiologie und Internistische Intensivmedizin, Homburg, Germany
| | - Martin R Cowie
- Royal Brompton Hospital, Guy's & St Thomas' NHS Foundation Trust, and School of Cardiovascular Medicine and Sciences, Faculty of Lifesciences & Medicine, King's College London, London, UK
| | - Kenneth Dickstein
- University of Bergen, Bergen, Norway; and Stavanger University Hospital, Stavanger, Norway
| | - Tiny Jaarsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia; Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | | | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany and Fraunhofer institute for Toxicology and Experimental Medicine, Hannover, Germany
| | - Stamatis Adamopoulos
- Heart Failure and Transplant Unit, Onassis Cardiac Surgery Centre, Athens, Greece
| | - Alain Cohen-Solal
- Department of Cardiology, University Hospital Lariboisière, AP-HP, Paris, France; INSERM UMR-S 942, MASCOT, Université Paris Cité, Paris, France
| | - Brenda Moura
- Armed Forces Hospital, Porto, and Faculty of Medicine of Porto, Porto, Portugal
| | - Amina Rakisheva
- Cardiology Department, Scientific Institute of Cardiology and Internal Medicine, Almaty, Kazakhstan
| | - Arsen Ristic
- Universi Faculty of Medicine, University of Belgrade, and Serbian Academy of Arts and Sciences, Belgrade, Serbia
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Badalona, Spain
| | - Sophie Van Linthout
- Berlin Institute of Health (BIH) at Charité - Universitätmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner site Berlin, Berlin, Germany
| | - Carlo Gabriele Tocchetti
- Cardio-Oncology Unit, Department of Translational Medical Sciences (DISMET); Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center for Clinical and Translational Research (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA); Federico II University, Naples, Italy
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Hadi Skouri
- Division of Cardiology, Internal Medicine Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Offer Amir
- Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | | | | | | | - Arantxa González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra, and IdiSNA, Navarra Institute for Health Research, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Massimo Piepoli
- Clinical Cardiac Unit, Policlinico San Donato, University of Milan, Milan, Italy
| | - Petar Seferovic
- Universi Faculty of Medicine, University of Belgrade, and Serbian Academy of Arts and Sciences, Belgrade, Serbia
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Codina P, Zamora E, Levy WC, Cediel G, Santiago-Vacas E, Domingo M, Ruiz-Cueto M, Casquete D, Sarrias A, Borrellas A, Santesmases J, Espriella RDELA, Nuñez J, Aimo A, Lupón J, Bayes-Genis A. Sudden Cardiac Death in Heart Failure: A 20-Year Perspective From a Mediterranean Cohort. J Card Fail 2023; 29:236-245. [PMID: 36521725 DOI: 10.1016/j.cardfail.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The prediction of sudden cardiac death (SCD) in heart failure (HF) remains an unmet need. The aim of our study was to assess the prevalence of SCD over 20 years in outpatients with HF managed in a Mediterranean multidisciplinary HF Clinic, and to compare the proportion of SCD (SCD/all-cause death) to the expected proportional occurrence based on the validated Seattle Proportional Risk Model (SPRM) score. METHODS AND RESULTS This prospective observational registry study included 2772 outpatients with HF admitted between August 2001 and May 2021. Patients were included when the cause of death was known and SPRM score was available. Over the 20-year study period, 1351 patients (48.7%) died during a median follow-up period of 3.8 years (interquartile range 1.6-7.6). Among these patients, the proportion of SCD out of the total of deaths was 13.6%, whereas the predicted by SPRM was 39.6%. This lower proportion of SCD was observed independently of left ventricular ejection fraction, ischemic etiology, and the presence of an implantable cardiac defibrillator. CONCLUSIONS In a Mediterranean cohort of outpatients with HF, the proportion of SCD was lower than expected based on the SPRM score. Future studies should investigate to what extend epidemiological and guideline-directed medical therapy patterns influence SCD.
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Affiliation(s)
- Pau Codina
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Elisabet Zamora
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Wayne C Levy
- UW Medicine Heart Institute, University of Washington, Seattle, Washington
| | - Germán Cediel
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Evelyn Santiago-Vacas
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Mar Domingo
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - María Ruiz-Cueto
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Daniel Casquete
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Axel Sarrias
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Andrea Borrellas
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Javier Santesmases
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Julio Nuñez
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain; Cardiology Department, Hospital Clínico Universitario, INCLIVA Valencia, Spain; Departament of Medicine, Universidad de Valencia, Spain
| | - Alberto Aimo
- Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Josep Lupón
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Antoni Bayes-Genis
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; CIBERCV, Instituto de Salud Carlos III, Madrid, Spain.
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Deng Y, Cheng S, Huang H, Liu X, Yu Y, Gu M, Cai C, Chen X, Niu H, Hua W. Toward Better Risk Stratification for Implantable Cardioverter-Defibrillator Recipients: Implications of Explainable Machine Learning Models. J Cardiovasc Dev Dis 2022; 9:jcdd9090310. [PMID: 36135455 PMCID: PMC9501472 DOI: 10.3390/jcdd9090310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/08/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Current guideline-based implantable cardioverter-defibrillator (ICD) implants fail to meet the demands for precision medicine. Machine learning (ML) designed for survival analysis might facilitate personalized risk stratification. We aimed to develop explainable ML models predicting mortality and the first appropriate shock and compare these to standard Cox proportional hazards (CPH) regression in ICD recipients. Methods and Results: Forty-five routine clinical variables were collected. Four fine-tuned ML approaches (elastic net Cox regression, random survival forests, survival support vector machine, and XGBoost) were applied and compared with the CPH model on the test set using Harrell’s C-index. Of 887 adult patients enrolled, 199 patients died (5.0 per 100 person-years) and 265 first appropriate shocks occurred (12.4 per 100 person-years) during the follow-up. Patients were randomly split into training (75%) and test (25%) sets. Among ML models predicting death, XGBoost achieved the highest accuracy and outperformed the CPH model (C-index: 0.794 vs. 0.760, p < 0.001). For appropriate shock, survival support vector machine showed the highest accuracy, although not statistically different from the CPH model (0.621 vs. 0.611, p = 0.243). The feature contribution of ML models assessed by SHAP values at individual and overall levels was in accordance with established knowledge. Accordingly, a bi-dimensional risk matrix integrating death and shock risk was built. This risk stratification framework further classified patients with different likelihoods of benefiting from ICD implant. Conclusions: Explainable ML models offer a promising tool to identify different risk scenarios in ICD-eligible patients and aid clinical decision making. Further evaluation is needed.
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Qureshi A, Ahmed I, Khan AH. Pacemaker Failure to Capture Caused by Electrocautery: A Rare Pacemaker Pulse Generator Change Complication. Cureus 2022; 14:e28252. [PMID: 36158404 PMCID: PMC9498933 DOI: 10.7759/cureus.28252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2022] [Indexed: 11/05/2022] Open
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Bilchick KC, Wang Y, Curtis JP, Shadman R, Dardas TF, Anand I, Lund LH, Dahlström U, Sartipy U, Levy WC. Survival Probability and Survival Benefit Associated With Primary Prevention Implantable Cardioverter-Defibrillator Generator Changes. J Am Heart Assoc 2022; 11:e023743. [PMID: 35766293 PMCID: PMC9333379 DOI: 10.1161/jaha.121.023743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background As patients derive variable benefit from generator changes (GCs) of implantable cardioverter-defibrillators (ICDs) with an original primary prevention (PP) indication, better predictors of outcomes are needed. Methods and Results In the National Cardiovascular Data Registry ICD Registry, patients undergoing GCs of initial non-cardiac resynchronization therapy PP ICDs in 2012 to 2016, predictors of post-GC survival and survival benefit versus control heart failure patients without ICDs were assessed. These included predicted annual mortality based on the Seattle Heart Failure Model, left ventricular ejection fraction (LVEF) >35%, and the probability that a patient's death would be arrhythmic (proportional risk of arrhythmic death [PRAD]). In 40 933 patients undergoing GCs of initial noncardiac resynchronization therapy PP ICDs (age 67.7±12.0 years, 24.5% women, 34.1% with LVEF >35%), Seattle Heart Failure Model-predicted annual mortality had the greatest effect size for decreased post-GC survival (P<0.0001). Patients undergoing GCs of initial noncardiac resynchronization therapy PP ICDs with LVEF >35% had a lower Seattle Heart Failure Model-adjusted survival versus 23 472 control heart failure patients without ICDs (model interaction hazard ratio, 1.21 [95% CI, 1.11-1.31]). In patients undergoing GCs of initial noncardiac resynchonization therapy PP ICDs with LVEF ≤35%, the model indicated worse survival versus controls in the 21% of patients with a PRAD <43% and improved survival in the 10% with PRAD >65%. The association of the PRAD with survival benefit or harm was similar in patients with or without pre-GC ICD therapies. Conclusions Patients who received replacement of an ICD originally implanted for primary prevention and had at the time of GC either LVEF >35% alone or both LVEF ≤35% and PRAD <43% had worse survival versus controls without ICDs.
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Affiliation(s)
| | - Yongfei Wang
- Center for Outcomes Research and EvaluationYale‐New Haven HospitalNew HavenCT
- Department of Internal MedicineYale UniversityNew HavenCT
| | - Jeptha P. Curtis
- Center for Outcomes Research and EvaluationYale‐New Haven HospitalNew HavenCT
- Department of Internal MedicineYale UniversityNew HavenCT
| | - Ramin Shadman
- Southern California Permanente Medical GroupLos AngelesCT
| | | | | | - Lars H. Lund
- Department of Medicine/CardiologyKarolinska University HospitalStockholmSweden
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring SciencesLinkoping UniversityLinkopingSweden
| | - Ulrik Sartipy
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
- Department of Cardiothoracic SurgeryKarolinska University HospitalStockholmSweden
| | - Wayne C. Levy
- Department of MedicineUniversity of WashingtonSeattleWA
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Deng Y, Cheng SJ, Hua W, Cai MS, Zhang NX, Niu HX, Chen XH, Gu M, Cai C, Liu X, Huang H, Zhang S. N-Terminal Pro-B-Type Natriuretic Peptide in Risk Stratification of Heart Failure Patients With Implantable Cardioverter-Defibrillator. Front Cardiovasc Med 2022; 9:823076. [PMID: 35299981 PMCID: PMC8921256 DOI: 10.3389/fcvm.2022.823076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/01/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in heart failure (HF) is well-established. However, whether it could facilitate the risk stratification of HF patients with implantable cardioverter-defibrillator (ICD) is still unclear.ObjectiveTo determine the associations between baseline NT-proBNP and outcomes of all-cause mortality and first appropriate shock due to sustained ventricular tachycardia/ventricular fibrillation (VT/VF) in ICD recipients.Methods and resultsN-terminal pro-B-type natriuretic peptide was measured before ICD implant in 500 patients (mean age 60.2 ± 12.0 years; 415 (83.0%) men; 231 (46.2%) Non-ischemic dilated cardiomyopathy (DCM); 136 (27.2%) primary prevention). The median NT-proBNP was 854.3 pg/ml (interquartile range [IQR]: 402.0 to 1,817.8 pg/ml). We categorized NT-proBNP levels into quartiles and used a restricted cubic spline to evaluate its nonlinear association with outcomes. The incidence rates of mortality and first appropriate shock were 5.6 and 9.1%, respectively. After adjusting for confounding factors, multivariable Cox regression showed a rise in NT-proBNP was associated with an increased risk of all-cause mortality. Compared with the lowest quartile, the hazard ratios (HRs) with 95% CI across increasing quartiles were 1.77 (0.71, 4.43), 3.98 (1.71, 9.25), and 5.90 (2.43, 14.30) for NT-proBNP (p for trend < 0.001). A restricted cubic spline demonstrated a similar pattern with an inflection point found at 3,231.4 pg/ml, beyond which the increase in NT-proBNP was not associated with increased mortality (p for nonlinearity < 0.001). Fine-Gray regression was used to evaluate the association between NT-proBNP and first appropriate shock accounting for the competing risk of death. In the unadjusted, partial, and fully adjusted analysis, however, no significant association could be found regardless of NT-proBNP as a categorical variable or log-transformed continuous variable (all p > 0.05). No nonlinearity was found, either (p = 0.666). Interactions between NT-proBNP and predefined factors were not found (all p > 0.1).ConclusionIn HF patients with ICD, the rise in NT-proBNP is independently associated with increased mortality until it reaches the inflection point. However, its association with the first appropriate shock was not found. Patients with higher NT-proBNP levels might derive less benefit from ICD implant.
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Deng Y, Zhang N, Hua W, Cheng S, Niu H, Chen X, Gu M, Cai C, Liu X, Huang H, Cai M, Zhang S. Nomogram predicting death and heart transplantation before appropriate ICD shock in dilated cardiomyopathy. ESC Heart Fail 2022; 9:1269-1278. [PMID: 35064655 PMCID: PMC8934923 DOI: 10.1002/ehf2.13808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/23/2021] [Accepted: 01/05/2022] [Indexed: 12/14/2022] Open
Abstract
Aims This study aimed to develop and validate a competing risk nomogram for predicting all‐cause mortality and heart transplantation (HT) before first appropriate shock in non‐ischaemic dilated cardiomyopathy (DCM) patients receiving implantable cardioverter‐defibrillators (ICD). Methods and results A total of 218 consecutive DCM patients implanted with ICD between 2010 and 2019 at our institution were retrospectively enrolled. Cox proportional hazards model was primarily built to identify variables associated with death and HT. Then, a Fine–Gray model, accounting for the appropriate shock as a competing risk, was constructed using these selected variables along with implantation indication (primary vs. secondary). Finally, a nomogram based on the Fine–Gray model was established to predict 1‐, 3‐, and 5‐year probabilities of all‐cause mortality and HT before first appropriate shock. The area under the receiver operating characteristic (ROC) curve (AUC), Harrell's C‐index, and calibration curves were used to evaluate and internally validate the performance of this model. The decision curve analysis was applied to assess its clinical utility. The 1‐, 3‐, and 5‐year cumulative incidence of all‐cause mortality and HT without former appropriate shock were 5.3% [95% confidence interval (CI) 2.9–9.9%], 16.6% (95% CI 11–25.0%), and 25.3% (95% CI 17.2–37.1%), respectively. Five variables including implantation indication, left ventricular end‐diastolic diameter, N‐terminal pro‐brain natriuretic peptide, angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker, and amiodarone treatment were independently associated with it (all P < 0.05) and were used for constructing the nomogram. The 1‐, 3‐, and 5‐year AUC of the nomogram were 0.83 (95% CI 0.73–0.94, P < 0.001), 0.84 (95% CI 0.75–0.93, P < 0.001), and 0.85 (95% CI 0.77–0.94, P < 0.001), respectively. The Harrell's C‐index was 0.788 (95% CI 0.697–0.877, P < 0.001; 0.762 for the optimism‐corrected C‐index), showing the good discriminative ability of the model. The calibration was acceptable (optimism‐corrected slope 0.896). Decision curve analysis identified our model was clinically useful within the entire range of potential treatment thresholds for ICD implantation. Three risk groups stratified by scores were significantly different between cumulative incidence curves (P < 0.001). The identified high‐risk group composed 17.9% of our population and did not derive long‐term benefit from ICD. Conclusions The proposed nomogram is a simple, useful risk stratification tool for selecting potential ICD recipients in DCM patients. It might facilitate the shared decision‐making between patients and clinicians.
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Affiliation(s)
- Yu Deng
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College No. 167 Bei Li Shi Road, Xicheng District Beijing 100037 China
| | - Nixiao Zhang
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College No. 167 Bei Li Shi Road, Xicheng District Beijing 100037 China
| | - Wei Hua
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College No. 167 Bei Li Shi Road, Xicheng District Beijing 100037 China
| | - Sijing Cheng
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College No. 167 Bei Li Shi Road, Xicheng District Beijing 100037 China
| | - Hongxia Niu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College No. 167 Bei Li Shi Road, Xicheng District Beijing 100037 China
| | - Xuhua Chen
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College No. 167 Bei Li Shi Road, Xicheng District Beijing 100037 China
| | - Min Gu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College No. 167 Bei Li Shi Road, Xicheng District Beijing 100037 China
| | - Chi Cai
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College No. 167 Bei Li Shi Road, Xicheng District Beijing 100037 China
| | - Xi Liu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College No. 167 Bei Li Shi Road, Xicheng District Beijing 100037 China
| | - Hao Huang
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College No. 167 Bei Li Shi Road, Xicheng District Beijing 100037 China
| | - Minsi Cai
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College No. 167 Bei Li Shi Road, Xicheng District Beijing 100037 China
| | - Shu Zhang
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College No. 167 Bei Li Shi Road, Xicheng District Beijing 100037 China
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9
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Canepa M, Palmisano P, Dell’Era G, Ziacchi M, Ammendola E, Accogli M, Occhetta E, Biffi M, Nigro G, Ameri P, Stronati G, Porto I, Dello Russo A, Guerra F. Usefulness of the MAGGIC Score in Predicting the Competing Risk of Non-Sudden Death in Heart Failure Patients Receiving an Implantable Cardioverter-Defibrillator: A Sub-Analysis of the OBSERVO-ICD Registry. J Clin Med 2021; 11:jcm11010121. [PMID: 35011862 PMCID: PMC8745772 DOI: 10.3390/jcm11010121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 11/16/2022] Open
Abstract
The role of prognostic risk scores in predicting the competing risk of non-sudden death in heart failure patients with reduced ejection fraction (HFrEF) receiving an implantable cardioverter-defibrillator (ICD) is unclear. To this goal, we evaluated the accuracy and usefulness of the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score. The present analysis included 1089 HFrEF ICD recipients enrolled in the OBSERVO-ICD registry (NCT02735811). During a median follow-up of 36 months (1st-3rd IQR 25-48 months), 193 patients (17.7%) experienced at least one appropriate ICD therapy, and 133 patients died (12.2%) without experiencing any ICD therapy. The frequency of patients receiving ICD therapies was stable around 17-19% across increasing tertiles of 3-year MAGGIC probability of death, whereas non-sudden mortality increased (6.4% to 9.8% to 20.8%, p < 0.0001). Accuracy of MAGGIC score was 0.60 (95% CI, 0.56-0.64) for the overall outcome, 0.53 (95% CI, 0.49-0.57) for ICD therapies and 0.65 (95% CI, 0.60-0.70) for non-sudden death. In patients with higher 3-year MAGGIC probability of death, the increase in the competing risk of non-sudden death during follow-up was greater than that of receiving an appropriate ICD therapy. Results were unaffected when analysis was limited to ICD shocks only. The MAGGIC risk score proved accurate and useful in predicting the competing risk of non-sudden death in HFrEF ICD recipients. Estimation of mortality risk should be taken into greater consideration at the time of ICD implantation.
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Affiliation(s)
- Marco Canepa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiovascular Network, 16100 Genova, Italy; (M.C.); (P.A.); (I.P.)
- Department of Internal Medicine, University of Genova, 16100 Genova, Italy
| | - Pietro Palmisano
- Division of Cardiology, Cardinale G. Panico Hospital, 73039 Tricase, Italy; (P.P.); (M.A.)
| | - Gabriele Dell’Era
- Division of Cardiology, Hospital Maggiore Della Carità, 28100 Novara, Italy; (G.D.); (E.O.)
| | - Matteo Ziacchi
- Institute of Cardiology, University Hospital Policlinic S. Orsola-Malpighi, 40121 Bologna, Italy; (M.Z.); (M.B.)
| | - Ernesto Ammendola
- Division of Cardiology, Vincenzo Monaldi Hospital, 80100 Naples, Italy; (E.A.); (G.N.)
| | - Michele Accogli
- Division of Cardiology, Cardinale G. Panico Hospital, 73039 Tricase, Italy; (P.P.); (M.A.)
| | - Eraldo Occhetta
- Division of Cardiology, Hospital Maggiore Della Carità, 28100 Novara, Italy; (G.D.); (E.O.)
| | - Mauro Biffi
- Institute of Cardiology, University Hospital Policlinic S. Orsola-Malpighi, 40121 Bologna, Italy; (M.Z.); (M.B.)
| | - Gerardo Nigro
- Division of Cardiology, Vincenzo Monaldi Hospital, 80100 Naples, Italy; (E.A.); (G.N.)
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiovascular Network, 16100 Genova, Italy; (M.C.); (P.A.); (I.P.)
- Department of Internal Medicine, University of Genova, 16100 Genova, Italy
| | - Giulia Stronati
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, 60121 Ancona, Italy; (G.S.); (A.D.R.)
| | - Italo Porto
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiovascular Network, 16100 Genova, Italy; (M.C.); (P.A.); (I.P.)
- Department of Internal Medicine, University of Genova, 16100 Genova, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, 60121 Ancona, Italy; (G.S.); (A.D.R.)
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, 60121 Ancona, Italy; (G.S.); (A.D.R.)
- Correspondence: ; Tel.: +39-071-596-5693; Fax: +39-071-596-5624
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10
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Palacios S, Cygankiewicz I, Bayés de Luna A, Pueyo E, Martínez JP. Periodic repolarization dynamics as predictor of risk for sudden cardiac death in chronic heart failure patients. Sci Rep 2021; 11:20546. [PMID: 34654872 PMCID: PMC8519935 DOI: 10.1038/s41598-021-99861-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 09/29/2021] [Indexed: 12/30/2022] Open
Abstract
The two most common modes of death among chronic heart failure (CHF) patients are sudden cardiac death (SCD) and pump failure death (PFD). Periodic repolarization dynamics (PRD) quantifies low-frequency oscillations in the T wave vector of the electrocardiogram (ECG) and has been postulated to reflect sympathetic modulation of ventricular repolarization. This study aims to evaluate the prognostic value of PRD to predict SCD and PFD in a population of CHF patients. 20-min high-resolution (1000 Hz) ECG recordings from 569 CHF patients were analyzed. Patients were divided into two groups, \documentclass[12pt]{minimal}
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\begin{document}$$\hbox {PRD}^+$$\end{document}PRD+ and \documentclass[12pt]{minimal}
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\begin{document}$$\hbox {PRD}^-$$\end{document}PRD-, corresponding to PRD values above and below the optimum cutoff point of PRD in the study population. Univariate Cox regression analysis showed that SCD risk in the \documentclass[12pt]{minimal}
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\begin{document}$$\hbox {PRD}^+$$\end{document}PRD+ group was double the risk in the \documentclass[12pt]{minimal}
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\begin{document}$$\hbox {PRD}^-$$\end{document}PRD- group [hazard ratio (95% CI) 2.001 (1.127–3.554), \documentclass[12pt]{minimal}
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\begin{document}$$\hbox {p}<0.05$$\end{document}p<0.05]. The combination of PRD with other Holter-based ECG indices, such as turbulence slope (TS) and index of average alternans (IAA), improved SCD prediction by identifying groups of patients at high SCD risk. PFD could be predicted by PRD only when combined with TS [hazard ratio 2.758 (1.572–4.838), \documentclass[12pt]{minimal}
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\begin{document}$$\hbox {p}<0.001$$\end{document}p<0.001]. In conclusion, the combination of PRD with IAA and TS can be used to stratify the risk for SCD and PFD, respectively, in CHF patients.
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Affiliation(s)
- Saúl Palacios
- BSICoS Group, Aragón Institute of Engineering Research, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain.
| | - Iwona Cygankiewicz
- Department of Electrocardiology, Medical University of Lodz, Lodz, Poland
| | - Antoni Bayés de Luna
- Cardiovascular Research Foundation, Cardiovascular ICCC-Program, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Esther Pueyo
- BSICoS Group, Aragón Institute of Engineering Research, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain.,CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
| | - Juan Pablo Martínez
- BSICoS Group, Aragón Institute of Engineering Research, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain.,CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
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11
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Carluccio E, Biagioli P, Mengoni A, Zuchi C, Lauciello R, Jacoangeli F, Bardelli G, Oliva V, Ambrosio G. Burden of Ventricular Arrhythmias in Cardiac Resynchronization Therapy Defibrillation and Implantable Cardioverter-Defibrillator Recipients with Recovered Left Ventricular Ejection Fraction: The Additive Role of Speckle-Tracking Echocardiography. J Am Soc Echocardiogr 2021; 35:355-365. [PMID: 34563638 DOI: 10.1016/j.echo.2021.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/01/2021] [Accepted: 09/14/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Patients with heart failure undergoing cardiac resynchronization therapy with or without defibrillator function may exhibit recovery of left ventricular ejection fraction (LVEF) during follow-up. Mechanical dispersion (MD; the SD of time to peak longitudinal strain by two-dimensional speckle-tracking echocardiography) is a known predictor of life-threatening ventricular arrhythmias (VAs). Relationships among LVEF recovery, changes in MD, and incidence of VA are still not extensively investigated. METHODS In this retrospective study, recipients of cardiac resynchronization therapy defibrillation (n = 183) or implantable cardioverter-defibrillators only (n = 87) underwent conventional and speckle-tracking echocardiography, both at baseline and after 10 to 12 months, and were followed clinically. Both a ≥10% increase in LVEF and a final LVEF > 35% defined echocardiographic response (EchoResp). Reduction in MD ≥10 msec defined MD response (MDResp). Risk for appropriate implantable cardioverter-defibrillator therapy for VAs was assessed using a multivariable Cox hazard model. RESULTS The prevalence of EchoResp+ and MDResp+ was 39% and 46%, respectively. During follow-up (49.8 ± 33.5 months), 74 VA events occurred. The incidence rate (per 100 patient-years) of VAs was lowest in the EchoResp+/MDResp+ group (1.66%; 95% CI, 0.69%-3.99%), highest in the EchoResp-/MDResp- group (12.8%; 95% CI, 9.53%-17.2%; P < .0001), and intermediate in the EchoResp-/MDResp+ (5.5%; 95% CI, 3.3%-9.4%) or EchoResp+/MDResp- (5.3%; 95% CI, 3.0%-9.4%) group. Multivariable analysis showed that higher MD at follow-up (>71.4 msec) was associated with VAs independent of whether final LVEF was below or above the guideline-reported cutoff of 35% (P < .05). CONCLUSIONS Among ICD recipients, improvements in both left ventricular function and MD are associated with reduced risk for VAs. In patients whose follow-up LVEFs improved to >35%, risk for VAs, although substantially decreased, remained elevated in the presence of still elevated MD.
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Affiliation(s)
- Erberto Carluccio
- Cardiology and Cardiovascular Pathophysiology, University of Perugia, Perugia, Italy.
| | - Paolo Biagioli
- Cardiology and Cardiovascular Pathophysiology, University of Perugia, Perugia, Italy
| | - Anna Mengoni
- Cardiology and Cardiovascular Pathophysiology, University of Perugia, Perugia, Italy
| | - Cinzia Zuchi
- Cardiology and Cardiovascular Pathophysiology, University of Perugia, Perugia, Italy
| | - Rosanna Lauciello
- Cardiology and Cardiovascular Pathophysiology, University of Perugia, Perugia, Italy
| | - Francesca Jacoangeli
- Cardiology and Cardiovascular Pathophysiology, University of Perugia, Perugia, Italy
| | - Giuliana Bardelli
- Cardiology and Cardiovascular Pathophysiology, University of Perugia, Perugia, Italy
| | - Viviana Oliva
- Cardiology and Cardiovascular Pathophysiology, University of Perugia, Perugia, Italy
| | - Giuseppe Ambrosio
- Cardiology and Cardiovascular Pathophysiology, University of Perugia, Perugia, Italy; CERICLET - Interdepartmental Center for Clinical and Translational Research, University of Perugia, Perugia, Italy
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12
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Verstraelen TE, van Barreveld M, van Dessel PHFM, Boersma LVA, Delnoy PPPHM, Tuinenburg AE, Theuns DAMJ, van der Voort PH, Kimman GP, Buskens E, Hulleman M, Allaart CP, Strikwerda S, Scholten MF, Meine M, Abels R, Maass AH, Firouzi M, Widdershoven JWMG, Elders J, van Gent MWF, Khan M, Vernooy K, Grauss RW, Tukkie R, van Erven L, Spierenburg HAM, Brouwer MA, Bartels GL, Bijsterveld NR, Borger van der Burg AE, Vet MW, Derksen R, Knops RE, Bracke FALE, Harden M, Sticherling C, Willems R, Friede T, Zabel M, Dijkgraaf MGW, Zwinderman AH, Wilde AAM. Development and external validation of prediction models to predict implantable cardioverter-defibrillator efficacy in primary prevention of sudden cardiac death. Europace 2021; 23:887-897. [PMID: 33582797 PMCID: PMC8184225 DOI: 10.1093/europace/euab012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/08/2021] [Indexed: 11/24/2022] Open
Abstract
Aims This study was performed to develop and externally validate prediction models for appropriate implantable cardioverter-defibrillator (ICD) shock and mortality to identify subgroups with insufficient benefit from ICD implantation. Methods and results We recruited patients scheduled for primary prevention ICD implantation and reduced left ventricular function. Bootstrapping-based Cox proportional hazards and Fine and Gray competing risk models with likely candidate predictors were developed for all-cause mortality and appropriate ICD shock, respectively. Between 2014 and 2018, we included 1441 consecutive patients in the development and 1450 patients in the validation cohort. During a median follow-up of 2.4 (IQR 2.1–2.8) years, 109 (7.6%) patients received appropriate ICD shock and 193 (13.4%) died in the development cohort. During a median follow-up of 2.7 (IQR 2.0–3.4) years, 105 (7.2%) received appropriate ICD shock and 223 (15.4%) died in the validation cohort. Selected predictors of appropriate ICD shock were gender, NSVT, ACE/ARB use, atrial fibrillation history, Aldosterone-antagonist use, Digoxin use, eGFR, (N)OAC use, and peripheral vascular disease. Selected predictors of all-cause mortality were age, diuretic use, sodium, NT-pro-BNP, and ACE/ARB use. C-statistic was 0.61 and 0.60 at respectively internal and external validation for appropriate ICD shock and 0.74 at both internal and external validation for mortality. Conclusion Although this cohort study was specifically designed to develop prediction models, risk stratification still remains challenging and no large group with insufficient benefit of ICD implantation was found. However, the prediction models have some clinical utility as we present several scenarios where ICD implantation might be postponed.
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Affiliation(s)
- Tom E Verstraelen
- Department of Cardiology, Amsterdam UMC, Location AMC, University of Amsterdam, Heart Center, Amsterdam, the Netherlands
| | - Marit van Barreveld
- Department of Cardiology, Amsterdam UMC, Location AMC, University of Amsterdam, Heart Center, Amsterdam, the Netherlands.,Department of Clinical Epidemiology, Biostatistics and Bio-informatics, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Pascal H F M van Dessel
- Department of Cardiology, Thorax Center Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Lucas V A Boersma
- Department of Cardiology, Amsterdam UMC, Location AMC, University of Amsterdam, Heart Center, Amsterdam, the Netherlands.,Cardiology Department, St. Antonius Ziekenhuis Nieuwegein, the Netherlands
| | | | - Anton E Tuinenburg
- Division of Heart and Lungs, Department of Cardiology, University Medical Centre, Utrecht, the Netherlands
| | | | | | - Gerardus P Kimman
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Erik Buskens
- Department of Epidemiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Michiel Hulleman
- Department of Cardiology, Amsterdam UMC, Location AMC, University of Amsterdam, Heart Center, Amsterdam, the Netherlands
| | - Cornelis P Allaart
- Department of Cardiology, Amsterdam UMC, Location VUMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sipke Strikwerda
- Department of Cardiology, Amphia Hospitals, Breda, the Netherlands
| | - Marcoen F Scholten
- Department of Cardiology, Thorax Center Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Mathias Meine
- Division of Heart and Lungs, Department of Cardiology, University Medical Centre, Utrecht, the Netherlands
| | - René Abels
- Department of Cardiology, Haga hospitals, the Hague, the Netherlands
| | - Alexander H Maass
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Mehran Firouzi
- Department of Cardiology, Maasstad hospital, Rotterdam, the Netherlands
| | - Jos W M G Widdershoven
- Department of Cardiology, Elisabeth Tweesteden Hospital Tilburg, Tilburg, the Netherlands
| | - Jan Elders
- Department of Cardiology, Canisius Wilhelmina hospital, Nijmegen, the Netherlands
| | - Marco W F van Gent
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Muchtiar Khan
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Robert W Grauss
- Department of Cardiology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Raymond Tukkie
- Department of Cardiology, Spaarne Gasthuis, Haarlem, the Netherlands
| | - Lieselot van Erven
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Han A M Spierenburg
- Department of Cardiology, Sint Franciscus Vlietland Group, Schiedam, the Netherlands
| | - Marc A Brouwer
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gerard L Bartels
- Department of Cardiology, Martini hospital, Groningen, the Netherlands
| | | | | | - Mattheus W Vet
- Department of Cardiology, Scheper Hospital, Emmen, the Netherlands
| | - Richard Derksen
- Department of Cardiology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Reinoud E Knops
- Department of Cardiology, Amsterdam UMC, Location AMC, University of Amsterdam, Heart Center, Amsterdam, the Netherlands
| | - Frank A L E Bracke
- Department of Cardiology, Catharina Ziekenhuis Eindhoven, Eindhoven, the Netherlands
| | - Markus Harden
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany and DZHK (German Center for Cardiovascular Research), Partnersite, Göttingen, Germany
| | - Christian Sticherling
- Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Rik Willems
- Department of Cardiovascular Sciences, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany and DZHK (German Center for Cardiovascular Research), Partnersite, Göttingen, Germany
| | - Markus Zabel
- Department of Cardiology and Pneumology-Heart Center, University of Göttingen Medical Center, Göttingen, Germany.,DZHK (German Center for Cardiovascular Research), Partner site, Göttingen, Germany
| | - Marcel G W Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics and Bio-informatics, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Biostatistics and Bio-informatics, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Arthur A M Wilde
- Department of Cardiology, Amsterdam UMC, Location AMC, University of Amsterdam, Heart Center, Amsterdam, the Netherlands
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13
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Fukuoka R, Kohsaka S, Shiraishi Y, Sawano M, Abe T, Levy WC, Nagatomo Y, Nishihata Y, Goda A, Kohno T, Kawamura A, Fukuda K, Yoshikawa T. Sudden cardiac death after acute decompensation in heart failure patients: implications of discharge haemoglobin levels. ESC Heart Fail 2021; 8:3917-3928. [PMID: 34323007 PMCID: PMC8497203 DOI: 10.1002/ehf2.13414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 11/19/2022] Open
Abstract
Aims Heart failure (HF) patients have a high risk of mortality due to sudden cardiac death (SCD) and non‐SCD, including pump failure death (PFD). Anaemia predicts more severe symptomatic burden and higher morbidity, as noted by markedly increased hospitalizations and readmission rates, and mortality, underscoring its importance in HF management. Herein, we aimed to determine whether haemoglobin (Hb) level at discharge affects the mode of death and influences SCD risk prediction. Methods We evaluated the data of 3020 consecutive acute HF patients from a Japanese prospective multicentre registry. Patients were divided into four groups based on discharge Hb levels. SCD was defined as an unexpected and otherwise unexplained death in a previously stable patient or death due to documented or presumed cardiac arrhythmia without a clear non‐cardiovascular cause. The mode of death (SCD, PFD or other cause) was adjudicated by a central committee. Finally, we investigated whether adding Hb level to the Seattle Proportional Risk Model (SPRM; established risk score utilized to estimate ‘proportion’ of SCD among death events) would affect its performance. Results The mean age of studied patients was 74.3 ± 12.9 years, and 59.8% were male. The mean Hb level was 12.0 ± 2.1 g/dL (61.3% of patients had anaemia defined by World Health Organization criteria). During the 2‐year follow‐up, 474 deaths (15.7%) occurred, including 93 SCDs (3.1%), 171 PFDs (5.7%) and 210 other deaths (7.0%; predominantly non‐cardiac death). Absolute risk of PFD (P < 0.001) or other death (P < 0.001) increased along with the severity of anaemia, whereas the incidence of SCD was low but remained consistent across all four groups (P = 0.440). As a proportion of total deaths in each Hb level group, the contributions from non‐SCD increased and from SCD decreased along with anaemia severity (P = 0.007). Adding Hb level to the SPRM improved the overall discrimination (c‐index: 0.62 [95% confidence interval (CI) 0.56–0.69] to 0.65 [95% CI 0.59–0.71]), regardless of the baseline ejection fraction (EF) (c‐index: 0.64 [95% CI 0.55–0.73] to 0.67 [95% CI 0.58–0.75] for reduced EF and 0.55 [95% CI 0.45–0.66] to 0.61 [95% CI 0.52–0.70] for preserved EF). Conclusions The discharge Hb level provides information about both absolute and proportional risks for each mode of death in acute HF patients, and the addition of Hb level improves the performance of SPRM by identifying more non‐SCD cases. Future ‘proportional’ SCD risk models should incorporate Hb level as a covariate to meet this high performance.
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Affiliation(s)
- Ryoma Fukuoka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.,Department of Cardiology, International University of Health and Welfare, School of Medicine, Chiba, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Takayuki Abe
- School of Data Science, Yokohama City University, Yokohama, Japan
| | - Wayne C Levy
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
| | - Yosuke Nishihata
- Department of Cardiology, Cardiovascular Centre, St. Luke's International Hospital, Tokyo, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Akio Kawamura
- Department of Cardiology, International University of Health and Welfare, School of Medicine, Chiba, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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14
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Shen L, Claggett BL, Jhund PS, Abraham WT, Desai AS, Dickstein K, Gong J, Køber LV, Lefkowitz MP, Rouleau JL, Shi VC, Swedberg K, Zile MR, Solomon SD, McMurray JJV. Development and external validation of prognostic models to predict sudden and pump-failure death in patients with HFrEF from PARADIGM-HF and ATMOSPHERE. Clin Res Cardiol 2021; 110:1334-1349. [PMID: 34101002 PMCID: PMC8318968 DOI: 10.1007/s00392-021-01888-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 06/01/2021] [Indexed: 12/11/2022]
Abstract
Background Sudden death (SD) and pump failure death (PFD) are the two leading causes of death in patients with heart failure and reduced ejection fraction (HFrEF). Objective Identifying patients at higher risk for mode-specific death would allow better targeting of individual patients for relevant device and other therapies. Methods We developed models in 7156 patients with HFrEF from the Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure (PARADIGM-HF) trial, using Fine-Gray regressions counting other deaths as competing risks. The derived models were externally validated in the Aliskiren Trial to Minimize Outcomes in Patients with Heart Failure (ATMOSPHERE) trial. Results NYHA class and NT-proBNP were independent predictors for both modes of death. The SD model additionally included male sex, Asian or Black race, prior CABG or PCI, cancer history, MI history, treatment with LCZ696 vs. enalapril, QRS duration and ECG left ventricular hypertrophy. While LVEF, ischemic etiology, systolic blood pressure, HF duration, ECG bundle branch block, and serum albumin, chloride and creatinine were included in the PFD model. Model discrimination was good for SD and excellent for PFD with Harrell’s C of 0.67 and 0.78 after correction for optimism, respectively. The observed and predicted incidences were similar in each quartile of risk scores at 3 years in each model. The performance of both models remained robust in ATMOSPHERE. Conclusion We developed and validated models which separately predict SD and PFD in patients with HFrEF. These models may help clinicians and patients consider therapies targeted at these modes of death. Trial registration number PARADIGM-HF: ClinicalTrials.gov NCT01035255, ATMOSPHERE: ClinicalTrials.gov NCT00853658. Graphics abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01888-x.
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Affiliation(s)
- Li Shen
- Division of Medicine, Hangzhou Normal University, Hangzhou, China
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Brian L Claggett
- The Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - William T Abraham
- The Division of Cardiovascular Medicine, Davis Heart and Lung Research Institute, Ohio State University, Columbus, USA
| | - Akshay Suvas Desai
- The Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Kenneth Dickstein
- Stavanger University Hospital, Stavanger, Norway
- The Institute of Internal Medicine, University of Bergen, Bergen, Norway
| | - Jianjian Gong
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Lars V Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Jean L Rouleau
- Institut de Cardiologie, Université de Montréal, Montreal, Canada
| | - Victor C Shi
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Michael R Zile
- Department of Veterans Administration Medical Center, Medical University of South Carolina and RHJ, Charleston, USA
| | - Scott D Solomon
- The Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
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15
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Martignani C, Massaro G, Diemberger I, Ziacchi M, Angeletti A, Galiè N, Biffi M. Cost-effectiveness of cardiac resynchronization therapy. J Med Econ 2020; 23:1375-1378. [PMID: 33026264 DOI: 10.1080/13696998.2020.1833893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Cristian Martignani
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Giulia Massaro
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Igor Diemberger
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Matteo Ziacchi
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Andrea Angeletti
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Nazzareno Galiè
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Mauro Biffi
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
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16
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Kutyifa V, Brown MW, Beck CA, McNitt S, Miller C, Cox K, Zareba W, Rosero SZ, Gleva MJ, Poole JE. AnaLysIs of Both sex and device specific factoRs on outcomes in pAtients with non-ischemic cardiomyopathy (BIO-LIBRA): Design and clinical protocol. Heart Rhythm O2 2020; 1:376-384. [PMID: 34113895 PMCID: PMC8183973 DOI: 10.1016/j.hroo.2020.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Background Outcomes of patients with nonischemic cardiomyopathy and low ejection fraction implanted with an implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy with a defibrillator (CRT-D), especially in contemporary, real-life cohorts, are not fully understood. Objective We aimed to better characterize outcomes of death and ventricular tachyarrhythmias in patients with nonischemic cardiomyopathy, implanted with an ICD or CRT-D, and specifically assess differences by sex. Methods The AnaLysIs of Both Sex and Device Specific FactoRs on Outcomes in PAtients with Non-Ischemic Cardiomyopathy (BIO-LIBRA) study was designed to prospectively assess outcomes of device-treated ventricular tachyarrhythmias and all-cause mortality events in nonischemic cardiomyopathy patients, indicated for an ICD or CRT-D implantation for the primary prevention of sudden cardiac death (SCD), with a specific focus on sex differences. We will enroll a total of 1000 subjects across 50 U.S. sites and follow patients for up to 3 years. Results The primary objective of BIO-LIBRA is to evaluate the combined risk of all-cause mortality and treated ventricular tachycardia (VT) or ventricular fibrillation (VF) events by subject sex and by implanted device type. We will also assess all-cause mortality, VT or VF alone, cardiac death, and SCD in the total cohort, as well as by subject sex and by the implanted device type. In addition, the previously validated Seattle Proportional Risk Model (SPRM) will be used to compare the SPRM predicted incidence of SCD to the observed incidence. Conclusions The BIO-LIBRA study will provide novel and contemporary information regarding outcomes in patients with a NICM who receive a defibrillator.
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Affiliation(s)
- Valentina Kutyifa
- Clinical Cardiovascular Research Center, Cardiology Division, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Mary W Brown
- Clinical Cardiovascular Research Center, Cardiology Division, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Christopher A Beck
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York
| | - Scott McNitt
- Clinical Cardiovascular Research Center, Cardiology Division, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | | | | | - Wojciech Zareba
- Clinical Cardiovascular Research Center, Cardiology Division, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Spencer Z Rosero
- Clinical Cardiovascular Research Center, Cardiology Division, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Marye J Gleva
- Washington University in St Louis School of Medicine, St. Louis, Missouri
| | - Jeanne E Poole
- Department of Cardiology, University of Washington, Seattle, Washington
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17
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Sabbag A, Glikson M, Suleiman M, Boulos M, Goldenberg I, Beinart R, Nof E. Arrhythmic burden among asymptomatic patients with ischemic cardiomyopathy and an implantable cardioverter-defibrillator. Heart Rhythm 2020; 16:813-819. [PMID: 31153454 DOI: 10.1016/j.hrthm.2019.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The clinical benefit of primary prevention implantable cardioverter-defibrillator (ICD) therapy in asymptomatic patients (New York Heart Association [NYHA] functional class I) with ischemic cardiomyopathy and left ventricular dysfunction is continually disputed. OBJECTIVE The purpose of this study was to evaluate the incidence of ventricular arrhythmias, mortality rates, and appropriate device therapies by NYHA class in a prospective national ICD registry. METHODS The study comprised 1670 consecutive patients with ischemic cardiomyopathy who were implanted with a primary prevention ICD and enrolled in the prospective national Israeli ICD Registry from 2010. The risk for clinical and arrhythmic events was assessed by NYHA class. RESULTS Asymptomatic patients (NYHA I) composed 19% of the study cohort. Comparison according to NYHA class showed that the highest mortality rate was in the NYHA III-IV group vs NYHA I and NYHA II (10.5% vs 5.4% and 5.8%, respectively; log rank P = .003). Conversely, cumulative incidence of appropriate ICD therapies, corrected for death as a competing risk, were higher among patients with NYHA I (11% vs 7%; P = .021). In a multivariate model, NYHA I vs ≥II remained independently associated with a significant 2-fold risk for appropriate ICD therapy (hazard ratio 2.03; 95% confidence interval 1.28-3.24). CONCLUSION Our findings indicate that patients with ischemic cardiomyopathy without heart failure symptoms have a higher risk of appropriate ICD therapy compared with symptomatic patients after adjustment for the competing risk of death, suggesting possible incremental benefit of primary ICD implantation in this population.
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Affiliation(s)
- Avi Sabbag
- Davidai Arrhythmia Center, Leviev Heart Center, Sheba Medical Center Ramat Gan, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | | | | - Monther Boulos
- Cardiology Department, Rambam Health Care Campus, Haifa, Israel
| | - Ilan Goldenberg
- Clinical Cardiovascular Research Center Cardiology Division, University of Rochester Medical Center, Rochester, New York
| | - Roy Beinart
- Davidai Arrhythmia Center, Leviev Heart Center, Sheba Medical Center Ramat Gan, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Nof
- Davidai Arrhythmia Center, Leviev Heart Center, Sheba Medical Center Ramat Gan, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Bilchick KC, Wang Y, Curtis JP, Cheng A, Dharmarajan K, Shadman R, Dardas TF, Anand I, Lund LH, Dahlström U, Sartipy U, Maggioni A, O'Connor C, Levy WC. Modeling defibrillation benefit for survival among cardiac resynchronization therapy defibrillator recipients. Am Heart J 2020; 222:93-104. [PMID: 32032927 DOI: 10.1016/j.ahj.2019.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 12/21/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patients with heart failure having a low expected probability of arrhythmic death may not benefit from implantable cardioverter defibrillators (ICDs). OBJECTIVE The objective was to validate models to identify cardiac resynchronization therapy (CRT) candidates who may not require CRT devices with ICD functionality. METHODS Heart failure (HF) patients with CRT-Ds and non-CRT ICDs from the National Cardiovascular Data Registry and others with no device from 3 separate registries and 3 heart failure trials were analyzed using multivariable Cox proportional hazards regression for survival with the Seattle Heart Failure Model (SHFM; estimates overall mortality) and the Seattle Proportional Risk Model (SPRM; estimates proportional risk of arrhythmic death). RESULTS Among 60,185 patients (age 68.6 ± 11.3 years, 31.9% female) meeting CRT-D criteria, 38,348 had CRT-Ds, 11,389 had non-CRT ICDs, and 10,448 had no device. CRT-D patients had a prominent adjusted survival benefit (HR 0.52, 95% CI 0.50-0.55, P < .0001 versus no device). CRT-D patients with SHFM-predicted 4-year survival ≥81% (median) and a low SPRM-predicted probability of an arrhythmic mode of death ≤42% (median) had an absolute adjusted risk reduction attributable to ICD functionality of just 0.95%/year with the majority of survival benefit (70%) attributable to CRT pacing. In contrast, CRT-D patients with SHFM-predicted survival <median or SPRM >median had substantially more ICD-attributable benefit (absolute risk reduction of 2.6%/year combined; P < .0001). CONCLUSIONS The SPRM and SHFM identified a quarter of real-world, primary prevention CRT-D patients with minimal benefit from ICD functionality. Further studies to evaluate CRT pacemakers in these low-risk CRT candidates are indicated.
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19
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Merchant FM, Levy WC, Kramer DB. Time to Shock the System: Moving Beyond the Current Paradigm for Primary Prevention Implantable Cardioverter-Defibrillator Use. J Am Heart Assoc 2020; 9:e015139. [PMID: 32089058 PMCID: PMC7335546 DOI: 10.1161/jaha.119.015139] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Faisal M Merchant
- Section of Cardiac Electrophysiology Emory University School of Medicine Atlanta GA
| | - Wayne C Levy
- Cardiology Division University of Washington Seattle WA
| | - Daniel B Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Harvard Medical School Boston MA
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20
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Canepa M, Ameri P, Lucci D, Nicolosi GL, Marchioli R, Porcu M, Tognoni G, Franzosi MG, Latini R, Maseri A, Tavazzi L, Maggioni AP. Modes of death and prognostic outliers in chronic heart failure. Am Heart J 2019; 208:100-109. [PMID: 30580128 DOI: 10.1016/j.ahj.2018.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/18/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND The impact of incident sudden cardiac death (SCD) on the predictive accuracy of prognostic risk scores for patients with chronic heart failure (HF) has rarely been examined. We assessed the relationship between estimated probability of death and modes of death in this population, as well as the predictors of death and survival in prognostic outliers. METHODS AND RESULTS The MAGGIC 3-year probability of death was estimated in 6,859 participants of the GISSI-HF trial (mean age 67±11 years, 78% men, 91% with ejection fraction <40%, mean follow-up 3.5±1.3 years, observed mortality 28.4%). The incidence of SCD progressively decreased with increased probability of death, and occurred in 52.5% of patients estimated at low-risk (N = 61 with probability <14%) vs. in 23.5% of the high-risk ones (N = 375 with probability >56%, P < .0001). On the contrary, death from worsening HF was significantly more frequent in the latter group (19.7% vs. 46.1%, P < .0001). The overall predictive accuracy of the MAGGIC model improved after excluding deaths from SCD (AUC from 0.731 to 0.760, P = .0034). Among patients estimated at low-risk (N = 61 dead, 743 alive), independent predictors of death were older age, longer history of HF, higher serum uric acid and chronic obstructive pulmonary disease. The only predictor of survival in patients estimated at high-risk (N = 210 alive, 375 dead) was higher systolic blood pressure. CONCLUSIONS The MAGGIC risk score demonstrated its scarce ability to capture SCD, particularly in chronic HF patients estimated at low risk of death. Newer and better prognostic tools in the evolving horizon of HF are needed.
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Affiliation(s)
- Marco Canepa
- Cardiovascular Disease Unit, Policlinic Hospital San Martino IRCCS & Department of Internal Medicine, University of Genova, Genova, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, Policlinic Hospital San Martino IRCCS & Department of Internal Medicine, University of Genova, Genova, Italy
| | - Donata Lucci
- ANMCO Research Centre, Florence, Fondazione per il Tuo cuore - HCF onluse, Florence, Italy
| | - Gian Luigi Nicolosi
- Department of Cardiology, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | | | - Maurizio Porcu
- Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera G. Brotzu-San Michele, Cagliari, Italy
| | - Gianni Tognoni
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Maria Grazia Franzosi
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Roberto Latini
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Attilio Maseri
- Fondazione per il Tuo cuore - HCF onlus, Florence, Italy
| | - Luigi Tavazzi
- Scientific Direction, Maria Cecilia Hospital, GVM Care and Research, Ettore Sansavini Health Science Foundation, Cotignola, Italy
| | - Aldo Pietro Maggioni
- ANMCO Research Centre, Florence, Fondazione per il Tuo cuore - HCF onluse, Florence, Italy.
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Travin MI. Assessing arrhythmic risk with 123I-mIBG and analogous tracers: Image interpretation from a different viewpoint. J Nucl Cardiol 2019; 26:118-122. [PMID: 28681337 DOI: 10.1007/s12350-017-0968-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 06/19/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Mark I Travin
- Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467-2490, USA.
- Division of Nuclear Medicine, Department of Radiology, Albert Einstein College of Medicine, Bronx, NY, USA.
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22
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Boriani G, Malavasi VL. Extending survival by reducing sudden death with implantable cardioverter-defibrillators: a challenging clinical issue in non-ischaemic and ischaemic cardiomyopathies. Eur J Heart Fail 2017; 20:420-426. [PMID: 29164794 DOI: 10.1002/ejhf.1080] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 09/26/2017] [Accepted: 10/15/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Vincenzo Livio Malavasi
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
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23
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Curcio A, De Rosa S, Indolfi C. Should we rethink the indications for implantable cardioverter-defibrillators in non-ischaemic dilated cardiomyopathy? Eur J Heart Fail 2017; 20:417-419. [PMID: 28925037 DOI: 10.1002/ejhf.948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 06/08/2017] [Accepted: 06/29/2017] [Indexed: 11/09/2022] Open
Affiliation(s)
- Antonio Curcio
- Division of Cardiology, Department of Medical and Surgical Sciences, University Magna Graecia, Catanzaro, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, University Magna Graecia, Catanzaro, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, University Magna Graecia, Catanzaro, Italy.,Unità di Ricerca presso Terzi (URT), Consiglio Nazionale delle Ricerche (CNR), Istituto di Fisiologia Clinica (IFC), Catanzaro, Italy
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Madeira M, António N, Milner J, Ventura M, Cristóvão J, Costa M, Nascimento J, Elvas L, Gonçalves L, Mariano Pego G. Who still remains at risk of arrhythmic death at time of implantable cardioverter-defibrillator generator replacement? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1129-1138. [DOI: 10.1111/pace.13163] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 06/25/2017] [Accepted: 07/09/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Marta Madeira
- Serviço de Cardiologia; Centro Hospitalar e Universitário de Coimbra - Hospital Geral; Coimbra Portugal
- Faculdade de Medicina da Universidade de Coimbra; Coimbra Portugal
| | - Natália António
- Faculdade de Medicina da Universidade de Coimbra; Coimbra Portugal
- Serviço de Cardiologia; Centro Hospitalar e Universitário de Coimbra - Hospital Universitário de Coimbra; Coimbra Portugal
| | - James Milner
- Serviço de Cardiologia; Centro Hospitalar e Universitário de Coimbra - Hospital Universitário de Coimbra; Coimbra Portugal
| | - Miguel Ventura
- Serviço de Cardiologia; Centro Hospitalar e Universitário de Coimbra - Hospital Universitário de Coimbra; Coimbra Portugal
| | - João Cristóvão
- Serviço de Cardiologia; Centro Hospitalar e Universitário de Coimbra - Hospital Universitário de Coimbra; Coimbra Portugal
| | - Marco Costa
- Faculdade de Medicina da Universidade de Coimbra; Coimbra Portugal
| | - José Nascimento
- Faculdade de Medicina da Universidade de Coimbra; Coimbra Portugal
| | - Luís Elvas
- Serviço de Cardiologia; Centro Hospitalar e Universitário de Coimbra - Hospital Universitário de Coimbra; Coimbra Portugal
| | - Lino Gonçalves
- Serviço de Cardiologia; Centro Hospitalar e Universitário de Coimbra - Hospital Geral; Coimbra Portugal
- Faculdade de Medicina da Universidade de Coimbra; Coimbra Portugal
| | - Guilherme Mariano Pego
- Serviço de Cardiologia; Centro Hospitalar e Universitário de Coimbra - Hospital Universitário de Coimbra; Coimbra Portugal
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Friedman DJ, Al-Khatib SM, Zeitler EP, Han J, Bardy GH, Poole JE, Bigger JT, Buxton AE, Moss AJ, Lee KL, Steinman R, Dorian P, Cappato R, Kadish AH, Kudenchuk PJ, Mark DB, Inoue LYT, Sanders GD. New York Heart Association class and the survival benefit from primary prevention implantable cardioverter defibrillators: A pooled analysis of 4 randomized controlled trials. Am Heart J 2017; 191:21-29. [PMID: 28888266 DOI: 10.1016/j.ahj.2017.06.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 06/06/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Primary prevention implantable cardioverter defibrillator (ICD) reduce all-cause mortality by reducing sudden cardiac death. There are conflicting data regarding whether patients with more advanced heart failure derive ICD benefit owing to the competing risk of nonsudden death. METHODS We performed a patient-level meta-analysis of New York Heart Association (NYHA) class II/III heart failure patients (left ventricular ejection fraction ≤35%) from 4 primary prevention ICD trials (MADIT-I, MADIT-II, DEFINITE, SCD-HeFT). Bayesian-Weibull survival regression models were used to assess the impact of NYHA class on the relationship between ICD use and mortality. RESULTS Of the 2,763 patients who met study criteria, 68% (n=1,867) were NYHA II and 52% (n=1,435) were randomized to an ICD. In a multivariable model including all study patients, the ICD reduced mortality (hazard ratio [HR] 0.65, 95% posterior credibility interval [PCI]) 0.40-0.99). The interaction between NYHA class and the ICD on mortality was significant (posterior probability of no interaction=.036). In models including an interaction term for the NYHA class and ICD, the ICD reduced mortality among NYHA class II patients (HR 0.55, PCI 0.35-0.85), and the point estimate suggested reduced mortality in NYHA class III patients (HR 0.76, PCI 0.48-1.24), although this was not statistically significant. CONCLUSIONS Primary prevention ICDs reduce mortality in NYHA class II patients and trend toward reducing mortality in the heterogeneous group of NYHA class III patients. Improved risk stratification tools are required to guide patient selection and shared decision making among NYHA class III primary prevention ICD candidates.
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Affiliation(s)
- Daniel J Friedman
- Duke University Hospital, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Sana M Al-Khatib
- Duke University Hospital, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Emily P Zeitler
- Duke University Hospital, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | | | | | | | | | | | - Kerry L Lee
- Duke Clinical Research Institute, Durham, NC
| | | | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | - Riccardo Cappato
- Humanitas University and Humanitas Clinical Research Center, Milan, Italy
| | - Alan H Kadish
- Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, IL
| | | | - Daniel B Mark
- Duke University Hospital, Durham, NC; Duke Clinical Research Institute, Durham, NC
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26
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Fallavollita JA, Dare JD, Carter RL, Baldwa S, Canty JM. Denervated Myocardium Is Preferentially Associated With Sudden Cardiac Arrest in Ischemic Cardiomyopathy: A Pilot Competing Risks Analysis of Cause-Specific Mortality. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.117.006446. [PMID: 28794139 DOI: 10.1161/circimaging.117.006446] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/19/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Previous studies have identified multiple risk factors that are associated with total cardiac mortality. Nevertheless, identifying specific factors that distinguish patients at risk of arrhythmic death versus heart failure could better target patients likely to benefit from implantable cardiac defibrillators, which have no impact on nonsudden cardiac death. METHODS AND RESULTS We performed a pilot competing risks analysis of the National Institutes of Health-sponsored PAREPET trial (Prediction of Arrhythmic Events with Positron Emission Tomography). Death from cardiac causes was ascertained in subjects with ischemic cardiomyopathy (n=204) eligible for an implantable cardiac defibrillator for the primary prevention of sudden cardiac arrest after baseline clinical evaluation and imaging at enrollment (positron emission tomography and 2-dimensional echo). Mean age was 67±11 years with an ejection fraction of 27±9%, and 90% were men. During 4.1 years of follow-up, there were 33 sudden cardiac arrests (arrhythmic death or implantable cardiac defibrillator discharge for ventricular fibrillation or ventricular tachycardia >240 bpm) and 36 nonsudden cardiac deaths. Sudden cardiac arrest was correlated with a greater volume of denervated myocardium (defect of the positron emission tomography norepinephrine analog 11C-hydroxyephedrine), lack of angiotensin inhibition therapy, elevated B-type natriuretic peptide, and larger left ventricular end-diastolic volume index. In contrast, nonsudden cardiac death was associated with a higher resting heart rate, older age, elevated creatinine, larger left atrial volume index, and larger left ventricular end-diastolic volume index. CONCLUSIONS Distinct clinical, laboratory, and imaging variables are associated with cause-specific cardiac mortality in primary-prevention candidates with ischemic cardiomyopathy. If prospectively validated, these multivariable associations may help target specific therapies to those at the greatest risk of sudden and nonsudden cardiac death. CLINICAL TRIAL REGISTRATION URL: https://clinicaltrials.gov. Unique identifier: NCT01400334.
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Affiliation(s)
- James A Fallavollita
- From the VA Western New York Health Care System at Buffalo (J.A.F., S.B., J.M.C.), Clinical and Translational Science Institute (J.A.F., J.M.C.), Population Health Observatory (J.D.D., R.L.C.), Department of Medicine (J.A.F., S.B., J.M.C.), Department of Biostatistics (J.D.D., R.L.C.), Department of Physiology and Biophysics (J.M.C.), and Department of Biomedical Engineering (J.M.C.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY.
| | - Jonathan D Dare
- From the VA Western New York Health Care System at Buffalo (J.A.F., S.B., J.M.C.), Clinical and Translational Science Institute (J.A.F., J.M.C.), Population Health Observatory (J.D.D., R.L.C.), Department of Medicine (J.A.F., S.B., J.M.C.), Department of Biostatistics (J.D.D., R.L.C.), Department of Physiology and Biophysics (J.M.C.), and Department of Biomedical Engineering (J.M.C.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY
| | - Randolph L Carter
- From the VA Western New York Health Care System at Buffalo (J.A.F., S.B., J.M.C.), Clinical and Translational Science Institute (J.A.F., J.M.C.), Population Health Observatory (J.D.D., R.L.C.), Department of Medicine (J.A.F., S.B., J.M.C.), Department of Biostatistics (J.D.D., R.L.C.), Department of Physiology and Biophysics (J.M.C.), and Department of Biomedical Engineering (J.M.C.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY
| | - Sunil Baldwa
- From the VA Western New York Health Care System at Buffalo (J.A.F., S.B., J.M.C.), Clinical and Translational Science Institute (J.A.F., J.M.C.), Population Health Observatory (J.D.D., R.L.C.), Department of Medicine (J.A.F., S.B., J.M.C.), Department of Biostatistics (J.D.D., R.L.C.), Department of Physiology and Biophysics (J.M.C.), and Department of Biomedical Engineering (J.M.C.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY
| | - John M Canty
- From the VA Western New York Health Care System at Buffalo (J.A.F., S.B., J.M.C.), Clinical and Translational Science Institute (J.A.F., J.M.C.), Population Health Observatory (J.D.D., R.L.C.), Department of Medicine (J.A.F., S.B., J.M.C.), Department of Biostatistics (J.D.D., R.L.C.), Department of Physiology and Biophysics (J.M.C.), and Department of Biomedical Engineering (J.M.C.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY
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27
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Bilchick KC, Wang Y, Cheng A, Curtis JP, Dharmarajan K, Stukenborg GJ, Shadman R, Anand I, Lund LH, Dahlström U, Sartipy U, Maggioni A, Swedberg K, O'Conner C, Levy WC. Seattle Heart Failure and Proportional Risk Models Predict Benefit From Implantable Cardioverter-Defibrillators. J Am Coll Cardiol 2017; 69:2606-2618. [PMID: 28545633 DOI: 10.1016/j.jacc.2017.03.568] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 02/27/2017] [Accepted: 03/17/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Recent clinical trials highlight the need for better models to identify patients at higher risk of sudden death. OBJECTIVES The authors hypothesized that the Seattle Heart Failure Model (SHFM) for overall survival and the Seattle Proportional Risk Model (SPRM) for proportional risk of sudden death, including death from ventricular arrhythmias, would predict the survival benefit with an implantable cardioverter-defibrillator (ICD). METHODS Patients with primary prevention ICDs from the National Cardiovascular Data Registry (NCDR) were compared with control patients with heart failure (HF) without ICDs with respect to 5-year survival using multivariable Cox proportional hazards regression. RESULTS Among 98,846 patients with HF (87,914 with ICDs and 10,932 without ICDs), the SHFM was strongly associated with all-cause mortality (p < 0.0001). The ICD-SPRM interaction was significant (p < 0.0001), such that SPRM quintile 5 patients had approximately twice the reduction in mortality with the ICD versus SPRM quintile 1 patients (adjusted hazard ratios [HR]: 0.602; 95% confidence interval [CI]: 0.537 to 0.675 vs. 0.793; 95% CI: 0.736 to 0.855, respectively). Among patients with SHFM-predicted annual mortality ≤5.7%, those with a SPRM-predicted risk of sudden death below the median had no reduction in mortality with the ICD (adjusted ICD HR: 0.921; 95% CI: 0.787 to 1.08; p = 0.31), whereas those with SPRM above the median derived the greatest benefit (adjusted HR: 0.599; 95% CI: 0.530 to 0.677; p < 0.0001). CONCLUSIONS The SHFM predicted all-cause mortality in a large cohort with and without ICDs, and the SPRM discriminated and calibrated the potential ICD benefit. Together, the models identified patients less likely to derive a survival benefit from primary prevention ICDs.
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Affiliation(s)
- Kenneth C Bilchick
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia.
| | - Yongfei Wang
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut; Department of Internal Medicine, Yale University, New Haven, Connecticut
| | - Alan Cheng
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut; Department of Internal Medicine, Yale University, New Haven, Connecticut
| | - Kumar Dharmarajan
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut; Department of Internal Medicine, Yale University, New Haven, Connecticut
| | - George J Stukenborg
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Ramin Shadman
- Southern California Permanente Medical Group, Los Angeles, California
| | - Inder Anand
- University of Minnesota, Minneapolis, Minnesota
| | - Lars H Lund
- Department of Medicine/Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ulf Dahlström
- Department of Cardiology and Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden
| | - Ulrik Sartipy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Section of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Aldo Maggioni
- Italian Association of Hospital Cardiologists Research Center, Florence, Italy
| | - Karl Swedberg
- Department of Clinical and Molecular Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Wayne C Levy
- Department of Medicine, University of Washington, Seattle, Washington
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