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Gutiérrez-Carretero E, Campos AM, Giménez-Miranda L, Rezaei K, Peña A, Rossel J, Praena JM, Smani T, Ordoñez A, Medrano FJ. [Prognostic value of electrical bioimpedance measured with a portable and wireless device in acute heart failure]. Med Clin (Barc) 2024; 163:175-182. [PMID: 38821829 DOI: 10.1016/j.medcli.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 02/21/2024] [Accepted: 02/25/2024] [Indexed: 06/02/2024]
Abstract
INTRODUCTION AND OBJECTIVES The current evaluation of acute heart failure (HF) does not allow an adequate prediction of its evolution. The electrical bioimpedance (BI) allows knowing the state of blood volume, until now only with fixed equipment. We have developed and validated a portable and wireless device to measure BI at the ankle (IVOL). The objective of the study is to know the long-term prognostic value of the point measurement of BI with IVOL in patients with acute HF. METHODS A prospective cohort study of unselected patients admitted for acute HF in a tertiary hospital. The association between BI and different clinical, analytical and echocardiographic variables on admission and clinical evolution were analyzed. RESULTS 76 patients were included (mean age 66.1 years, 71.1% men, 68.4% hypertensive, 34.2% diabetic, mean NT-ProBNP: 7,103 pg / ml). Of these, 52.6% with non-preserved left ventricular ejection fraction (LVEF) (<50%) and 56.6% with right ventricular (RV) dysfunction. 26.3% died during a mean follow-up of 35.8 months. Survival in patients with BI≤21,8Ω was lower, globally and in the subgroups of patients without preserved LVEF and with RV dysfunction, P<.008). In the multivariate analysis, a BI≥21.8Ω was an independent survival factor (HR: 0.242; 95% CI: 0.86-0.681; P=.007). CONCLUSIONS BI values measured with IVOL may be an independent predictor of long-term mortality in patients hospitalized for acute HF. This prognostic value is maintained in patients without preserved LVEF function and with RV dysfunction.
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Affiliation(s)
- Encarnación Gutiérrez-Carretero
- Unidad Clínica de Cardiología y Cirugía Cardiovascular, Hospital Universitario Virgen del Rocío, Sevilla, España; Instituto de Biomedicina de Sevilla (IBiS), Hospital Virgen del Rocio, CSIC, Universidad de Sevilla, Sevilla, España
| | - Ana María Campos
- Unidad Clínica de Cardiología y Cirugía Cardiovascular, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Luis Giménez-Miranda
- Unidad Clínica de Cardiología y Cirugía Cardiovascular, Hospital Universitario Virgen del Rocío, Sevilla, España; Instituto de Biomedicina de Sevilla (IBiS), Hospital Virgen del Rocio, CSIC, Universidad de Sevilla, Sevilla, España
| | - Kambitz Rezaei
- Unidad Clínica de Cardiología y Cirugía Cardiovascular, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Amelia Peña
- Unidad Clínica de Cardiología y Cirugía Cardiovascular, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Javier Rossel
- Departamento de Ingeniería Electrónica, Universidad Politécnica de Cataluña, Barcelona, España
| | - Juan Manuel Praena
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Sevilla, España; Departamento de Enfermería, Universidad de Sevilla, Sevilla, España
| | - Tarik Smani
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Virgen del Rocio, CSIC, Universidad de Sevilla, Sevilla, España
| | - Antonio Ordoñez
- Unidad Clínica de Cardiología y Cirugía Cardiovascular, Hospital Universitario Virgen del Rocío, Sevilla, España; Instituto de Biomedicina de Sevilla (IBiS), Hospital Virgen del Rocio, CSIC, Universidad de Sevilla, Sevilla, España; Departamento de Cirugía, Universidad de Sevilla, Sevilla, España.
| | - Francisco Javier Medrano
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Virgen del Rocio, CSIC, Universidad de Sevilla, Sevilla, España; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Sevilla, España; Departamento de Medicina, Universidad de Sevilla, Sevilla, España
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Tedeschi A, Palazzini M, Trimarchi G, Conti N, Di Spigno F, Gentile P, D’Angelo L, Garascia A, Ammirati E, Morici N, Aschieri D. Heart Failure Management through Telehealth: Expanding Care and Connecting Hearts. J Clin Med 2024; 13:2592. [PMID: 38731120 PMCID: PMC11084728 DOI: 10.3390/jcm13092592] [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: 03/28/2024] [Revised: 04/21/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024] Open
Abstract
Heart failure (HF) is a leading cause of morbidity worldwide, imposing a significant burden on deaths, hospitalizations, and health costs. Anticipating patients' deterioration is a cornerstone of HF treatment: preventing congestion and end organ damage while titrating HF therapies is the aim of the majority of clinical trials. Anyway, real-life medicine struggles with resource optimization, often reducing the chances of providing a patient-tailored follow-up. Telehealth holds the potential to drive substantial qualitative improvement in clinical practice through the development of patient-centered care, facilitating resource optimization, leading to decreased outpatient visits, hospitalizations, and lengths of hospital stays. Different technologies are rising to offer the best possible care to many subsets of patients, facing any stage of HF, and challenging extreme scenarios such as heart transplantation and ventricular assist devices. This article aims to thoroughly examine the potential advantages and obstacles presented by both existing and emerging telehealth technologies, including artificial intelligence.
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Affiliation(s)
- Andrea Tedeschi
- Cardiology Unit of Emergency Department, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy; (F.D.S.); (D.A.)
| | - Matteo Palazzini
- “De Gasperis” Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (M.P.); (N.C.); (P.G.); (L.D.); (A.G.); (E.A.)
| | - Giancarlo Trimarchi
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy;
| | - Nicolina Conti
- “De Gasperis” Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (M.P.); (N.C.); (P.G.); (L.D.); (A.G.); (E.A.)
| | - Francesco Di Spigno
- Cardiology Unit of Emergency Department, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy; (F.D.S.); (D.A.)
| | - Piero Gentile
- “De Gasperis” Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (M.P.); (N.C.); (P.G.); (L.D.); (A.G.); (E.A.)
| | - Luciana D’Angelo
- “De Gasperis” Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (M.P.); (N.C.); (P.G.); (L.D.); (A.G.); (E.A.)
| | - Andrea Garascia
- “De Gasperis” Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (M.P.); (N.C.); (P.G.); (L.D.); (A.G.); (E.A.)
| | - Enrico Ammirati
- “De Gasperis” Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (M.P.); (N.C.); (P.G.); (L.D.); (A.G.); (E.A.)
| | - Nuccia Morici
- IRCCS Fondazione Don Carlo Gnocchi, 20148 Milan, Italy;
| | - Daniela Aschieri
- Cardiology Unit of Emergency Department, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy; (F.D.S.); (D.A.)
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3
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Rodio G, Iacopino S, Pisanò EC, Calvi V, Rovaris G, Marini M, Giammaria M, Caravati F, Maglia G, Zanotto G, Della Bella P, Biffi M, Curnis A, Maines M, Orsida D, Santamaria M, Bisignani G, Baroni M, Lissoni F, Duca A, Forleo GB, Piemontese C, De Salvia A, Miracapillo G, Celentano E, Zecchin M, Luzzi G, Giacopelli D, Gargaro A, D'Onofrio A. Temporal association between drops in thoracic impedance and malignant ventricular arrhythmia: A longitudinal analysis of remote monitoring trends. J Cardiovasc Electrophysiol 2023; 34:947-956. [PMID: 36709469 DOI: 10.1111/jce.15834] [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: 06/03/2022] [Revised: 12/23/2022] [Accepted: 01/22/2023] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Thoracic impedance (TI) drops measured by implantable cardioverter-defibrillators (ICDs) have been reported to correlate with ventricular tachycardia/fibrillation (VT/VF). The aim of our study was to assess the temporal association of decreasing TI trends with VT/VF episodes through a longitudinal analysis of daily remote monitoring data from ICDs and cardiac resynchronization therapy defibrillators (CRT-Ds). METHODS AND RESULTS Retrospective data from 2384 patients were randomized 1:1 into a derivation or validation cohort. The TI decrease rate was defined as the percentage of rolling weeks with a continuously decreasing TI trend. The derivation cohort was used to determine a TI decrease rate threshold for a ≥99% specificity of arrhythmia prediction. The associated risk of VT/VF episodes was estimated in the validation cohort by dividing the available follow-up into 60-day assessment intervals. Analyses were performed separately for 1354 ICD and 1030 CRT-D patients. During a median follow-up of 2.0 years, 727 patients (30.4%) experienced 3298 confirmed VT/VF episodes. In the ICD group, a TI decrease rate of >60% was associated with a higher risk of VT/VF episode in a 60-day assessment interval (stratified hazard ratio, 1.42; 95% confidence interval (CI), 1.05-1.92; p = .023). The TI decrease preceded (40.8%) or followed (59.2%) the VT/VF episodes. In the CRT-D group, no association between TI decrease and VT/VF episodes was observed (p = .84). CONCLUSION In our longitudinal analysis, TI decrease was associated with VT/VF episodes only in ICD patients. Preventive interventions may be difficult since episodes can occur before or after TI decrease.
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Affiliation(s)
- Giovanna Rodio
- Division of Cardiology, Ospedale Santissima Annunziata, Taranto, Italy
| | | | | | - Valeria Calvi
- Azienda Ospedaliero Universitaria Policlinico "G.Rodolico - San Marco", Catania, Italy
| | | | | | | | | | | | | | | | - Mauro Biffi
- Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | | | | | | | | | | | - Matteo Baroni
- ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | | | | | | | | | | | | | | | - Giovanni Luzzi
- Division of Cardiology, Ospedale Santissima Annunziata, Taranto, Italy
| | - Daniele Giacopelli
- Biotronik Italia S.P.A., Vimodrone, Italy
- University of Padova, Padua, Italy
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Brons M, Ten Klooster I, van Gemert-Pijnen L, Jaarsma T, Asselbergs FW, Oerlemans MIFJ, Koudstaal S, Rutten FH. Patterns in the Use of Heart Failure Telemonitoring: Post Hoc Analysis of the e-Vita Heart Failure Trial. JMIR Cardio 2023; 7:e41248. [PMID: 36719715 PMCID: PMC9929726 DOI: 10.2196/41248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/04/2022] [Accepted: 11/23/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Research on the use of home telemonitoring data and adherence to it can provide new insights into telemonitoring for the daily management of patients with heart failure (HF). OBJECTIVE We described the use of a telemonitoring platform-including remote patient monitoring of blood pressure, pulse, and weight-and the use of the electronic personal health record. Patient characteristics were assessed in both adherent and nonadherent patients to weight transmissions. METHODS We used the data of the e-Vita HF study, a 3-arm parallel randomized trial performed in stable patients with HF managed in outpatient clinics in the Netherlands. In this study, data were analyzed from the participants in the intervention arm (ie, e-Vita HF platform). Adherence to weight transmissions was defined as transmitting weight ≥3 times per week for at least 42 weeks during a year. RESULTS Data from 150 patients (mean age 67, SD 11 years; n=37, 25% female; n=123, 82% self-assessed New York Heart Association class I-II) were analyzed. One-year adherence to weight transmissions was 74% (n=111). Patients adherent to weight transmissions were less often hospitalized for HF in the 6 months before enrollment in the study compared to those who were nonadherent (n=9, 8% vs n=9, 23%; P=.02). The percentage of patients visiting the personal health record dropped steadily over time (n=140, 93% vs n=59, 39% at one year). With univariable analyses, there was no significant correlation between patient characteristics and adherence to weight transmissions. CONCLUSIONS Adherence to remote patient monitoring was high among stable patients with HF and best for weighing; however, adherence decreased over time. Clinical and demographic variables seem not related to adherence to transmitting weight. TRIAL REGISTRATION ClinicalTrials.gov NCT01755988; https://clinicaltrials.gov/ct2/show/NCT01755988.
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Affiliation(s)
- Maaike Brons
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Iris Ten Klooster
- Department of Psychology, Health and Technology, Center for eHealth Research and Disease Management, University of Twente, Enschede, Netherlands
| | - Lisette van Gemert-Pijnen
- Department of Psychology, Health and Technology, Center for eHealth Research and Disease Management, University of Twente, Enschede, Netherlands
| | - Tiny Jaarsma
- Department of Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Health, Medicine and Care, Linköping University, Linköping, Sweden
| | - Folkert W Asselbergs
- Department of Cardiology, University of Amsterdam, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Health Data Research UK and Institute of Health Informatics, University College London, London, United Kingdom
| | | | - Stefan Koudstaal
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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5
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Mastoris I, Spall HGCV, Sheldon SH, Pimentel RC, Steinkamp L, Shah Z, Al-Khatib SM, Singh JP, Sauer AJ. Emerging Implantable Device Technology for Patients at the Intersection of Electrophysiology and Heart Failure Interdisciplinary Care. J Card Fail 2021; 28:991-1015. [PMID: 34774748 DOI: 10.1016/j.cardfail.2021.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/01/2021] [Accepted: 11/05/2021] [Indexed: 01/01/2023]
Abstract
Cardiac implantable electronic devices (CIEDs), including implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT), are part of guideline- indicated treatment for a subset of patients with heart failure with reduced ejection fraction (HFrEF). Current technological advancements in CIEDs have allowed the detection of specific patient physiologic parameters used for forecasting clinical decompensation through algorithmic, multiparameter remote monitoring. Other recent emerging technologies, including cardiac contractility modulation (CCM) and baroreflex activation therapy (BAT), may provide symptomatic or physiologic benefit in patients without an indication for CRT. Our goal in this state-of-the-art review is to describe the commercially available new technologies, purported mechanisms of action, evidence surrounding their clinical role, limitations, and future directions. Finally, we underline the need for standardized workflow and close interdisciplinary management of this population to ensure the delivery of high-quality care.
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Affiliation(s)
- Ioannis Mastoris
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Harriette G C Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence, and Impact, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Seth H Sheldon
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Rhea C Pimentel
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Leslie Steinkamp
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Zubair Shah
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Sana M Al-Khatib
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jagmeet P Singh
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Sauer
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, Kansas.
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6
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Ahmed FZ, Sammut-Powell C, Kwok CS, Tay T, Motwani M, Martin GP, Taylor JK. Remote monitoring data from cardiac implantable electronic devices predicts all-cause mortality. Europace 2021; 24:245-255. [PMID: 34601572 PMCID: PMC8824524 DOI: 10.1093/europace/euab160] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Indexed: 11/13/2022] Open
Abstract
Aims To determine if remotely monitored physiological data from cardiac implantable electronic devices (CIEDs) can be used to identify patients at high risk of mortality. Methods and results This study evaluated whether a risk score based on CIED physiological data (Triage-Heart Failure Risk Status, ‘Triage-HFRS’, previously validated to predict heart failure (HF) events) can identify patients at high risk of death. Four hundred and thirty-nine adults with CIEDs were prospectively enrolled. Primary observed outcome was all-cause mortality (median follow-up: 702 days). Several physiological parameters [including heart rate profile, atrial fibrillation/tachycardia (AF/AT) burden, ventricular rate during AT/AF, physical activity, thoracic impedance, therapies for ventricular tachycardia/fibrillation] were continuously monitored by CIEDs and dynamically combined to produce a Triage-HFRS every 24 h. According to transmissions patients were categorized into ‘high-risk’ or ‘never high-risk’ groups. During follow-up, 285 patients (65%) had a high-risk episode and 60 patients (14%) died (50 in high-risk group; 10 in never high-risk group). Significantly more cardiovascular deaths were observed in the high-risk group, with mortality rates across groups of high vs. never-high 10.3% vs. <4.0%; P = 0.03. Experiencing any high-risk episode was associated with a substantially increased risk of death [odds ratio (OR): 3.07, 95% confidence interval (CI): 1.57–6.58, P = 0.002]. Furthermore, each high-risk episode ≥14 consecutive days was associated with increased odds of death (OR: 1.26, 95% CI: 1.06–1.48; P = 0.006). Conclusion Remote monitoring data from CIEDs can be used to identify patients at higher risk of all-cause mortality as well as HF events. Distinct from other prognostic scores, this approach is automated and continuously updated.
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Affiliation(s)
- Fozia Zahir Ahmed
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Oxford Rd, Manchester, UK
| | - Camilla Sammut-Powell
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Chun Shing Kwok
- School of Primary, Community and Social Care, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Tricia Tay
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Manish Motwani
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Oxford Rd, Manchester, UK
| | - Glen P Martin
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Joanne K Taylor
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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7
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OptiVol for Volume Assessment in Patients With Continuous Flow Left Ventricular Assist Device. ASAIO J 2021; 67:192-195. [PMID: 33512914 DOI: 10.1097/mat.0000000000001244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OptiVol (Medtronic PLC, Minneapolis, MN) is a diagnostic feature of some cardiac implantable electronic devices (CIEDs) based on changes in thoracic impedance (TI) over time. Changes in TI can predict heart failure (HF) hospitalizations and mortality in HF populations. However, the utility of this feature is unknown in patients with a left ventricular assist device (LVAD). To determine if OptiVol and TI correlate with clinical HF events in a population of LVAD patients, hospitalization outcomes were collected retrospectively from the electronic health records at a single academic medical center in 80 LVAD patients with an OptiVol-capable CIED. Demographics, medical history, and available clinical data were reviewed and reported. The primary outcomes of interest were TI and OptiVol trends before and after hospitalization, and association of trends before and after these events was evaluated. Most patients had a HeartMate II LVAD and most CIEDs were defibrillators, and 23 (29%) had at least one HF hospitalization during the study period. HF hospitalizations were preceded by signs of volume overload in Optivol (60%) and TI (78%) with recovery of these measures post hospitalization in 33% and 25% of patients, respectively. Monitoring of TI and OptiVol may be one effective component of HF management in LVAD patients as part of a comprehensive program.
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8
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Al‐Damluji MS, Singhvi A, Snuckel M, Zaghloul A, Kluger J. Do ICD diagnostics predict failure of ventricular tachycardia response to antitachycardia pacing and need for shock? Pacing Clin Electrophysiol 2020; 43:1302-1308. [DOI: 10.1111/pace.14002] [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: 01/23/2020] [Revised: 06/20/2020] [Accepted: 06/28/2020] [Indexed: 11/30/2022]
Affiliation(s)
| | - Aditi Singhvi
- Cardiovascular Medicine Hartford Hospital Hartford Connecticut
| | - Meghan Snuckel
- Internal Medicine University of Connecticut Health Center Farmington Connecticut
| | - Ahmed Zaghloul
- Cardiovascular Medicine University of Iowa Iowa City Iowa
| | - Jeffrey Kluger
- Cardiovascular Medicine Hartford Hospital Hartford Connecticut
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Hankinson SJ, Williams CH, Ton VK, Gottlieb SS, Hong CC. Should we overcome the resistance to bioelectrical impedance in heart failure? Expert Rev Med Devices 2020; 17:785-794. [PMID: 32658589 PMCID: PMC8356137 DOI: 10.1080/17434440.2020.1791701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Heart failure is associated with increased neurohormonal activation that results in changes in body composition including volume overload and the loss of skeletal muscle, body fat, and bone density. Bioelectrical impedance measures body composition based on the conduction of electrical current through body fluids. AREAS COVERED The PubMed and Scopus databases were reviewed up to the third week of June 2020. Cross-sectional studies, retrospective observational studies, prospective observational studies, and randomized controlled trials have examined numerous bioelectrical impedance monitoring strategies to guide the diagnosis, prognosis, and treatment of heart failure. These monitoring strategies include intrathoracic impedance, lung impedance, bioelectrical impedance vector analysis, leg bioelectrical impedance, and thoracic bioreactance. EXPERT COMMENTARY Based on the current evidence, more studies are needed to validate bioelectrical impedance in heart failure. Lung impedance appears to be useful for guiding heart failure treatment in patients with ST-elevation myocardial infarction and improving outcomes in outpatients with heart failure. Furthermore, bioelectrical impedance has potential as a noninvasive, quantitative heart failure variable for population-based research.
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Affiliation(s)
- Stephen J. Hankinson
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Charles H. Williams
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Van-Khue Ton
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Harvard Medical School, Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen S. Gottlieb
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Charles C. Hong
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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10
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Relationship between Atrial Tachyarrhythmias and Intrathoracic Impedance in Patients with a Pacemaker and Preserved Ejection Fraction. J Clin Med 2019; 9:jcm9010105. [PMID: 31906103 PMCID: PMC7020002 DOI: 10.3390/jcm9010105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/22/2019] [Accepted: 12/29/2019] [Indexed: 11/17/2022] Open
Abstract
Atrial fibrillation (AF) is responsible for significant morbidity and mortality in patients with heart failure (HF). Modern pacemakers provide an index of intrathoracic fluid status (OptiVol fluid index-OVFI) by measuring daily intrathoracic impedance. This study aimed to determine whether OVFI is associated with increased atrial tachycardia/fibrillation (AT/AF) events in patients with a preserved ejection fraction (EF). We retrospectively reviewed data from patients with Medtronic Advisa pacemakers between 2012 and 2014 in our hospital. The association and temporal relationship between OVFI and AT/AF events were determined. A total of 150 patients with 211 follow-up visits (mean 1.4 visits per patient) were evaluated. The device-detected AT/AF prevalence was 47%. Device-measured OVFI ≥ 20 Ω-days was significantly associated with the onset of AT/AF ≥ 4 h. OVFI threshold crossing preceded AT/AF events in 55.1% of cases, followed by AT/AF events in only 18.7%. Fluid overload represented by OVFI may trigger AT/AF episodes in patients with a preserved EF more often than that previously reported in patients with a reduced EF. Our findings support the view that worsening pulmonary congestion is associated with increased AT/AF frequency and suggests that fluid overload could trigger and perpetuate AT/AF events in patients with a preserved EF.
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Alvarez CK, Cronin E, Baker WL, Kluger J. Heart failure as a substrate and trigger for ventricular tachycardia. J Interv Card Electrophysiol 2019; 56:229-247. [PMID: 31598875 DOI: 10.1007/s10840-019-00623-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 09/06/2019] [Indexed: 02/06/2023]
Abstract
Heart failure (HF) is a major cause of morbidity and mortality with more than 5.1 million individuals affected in the USA. Ventricular tachyarrhythmias (VAs) including ventricular tachycardia and ventricular fibrillation are common in patients with heart failure. The pathophysiology of these mechanisms as well as the contribution of heart failure to the genesis of these arrhythmias is complex and multifaceted. Myocardial hypertrophy and stretch with increased preload and afterload lead to shortening of the action potential at early repolarization and lengthening of the action potential at final repolarization which can result in re-entrant ventricular tachycardia. Myocardial fibrosis and scar can create the substrate for re-entrant ventricular tachycardia. Altered calcium handling in the failing heart can lead to the development of proarrhythmic early and delayed after depolarizations. Various medications used in the treatment of HF such as loop diuretics and angiotensin converting enzyme inhibitors have not demonstrated a reduction in sudden cardiac death (SCD); however, beta-blockers (BB) are effective in reducing mortality and SCD. Amongst patients who have HF with reduced ejection fraction, the angiotensin receptor-neprilysin inhibitor (sacubitril/valsartan) has been shown to reduce cardiovascular mortality, specifically by reducing SCD, as well as death due to worsening HF. Implantable cardioverter-defibrillator (ICD) implantation in HF patients reduces the risk of SCD; however, subsequent mortality is increased in those who receive ICD shocks. Prophylactic ICD implantation reduces death from arrhythmia but does not reduce overall mortality during the acute post-myocardial infarction (MI) period (less than 40 days), for those with reduced ejection fraction and impaired autonomic dysfunction. Furthermore, although death from arrhythmias is reduced, this is offset by an increase in the mortality from non-arrhythmic causes. This article provides a review of the aforementioned mechanisms of arrhythmogenesis in heart failure; the role and impact of HF therapy such as cardiac resynchronization therapy (CRT), including the role, if any, of CRT-P and CRT-D in preventing VAs; the utility of both non-invasive parameters as well as multiple implant-based parameters for telemonitoring in HF; and the effect of left ventricular assist device implantation on VAs.
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Affiliation(s)
- Chikezie K Alvarez
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA.
| | - Edmond Cronin
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - William L Baker
- University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Jeffrey Kluger
- Hartford Healthcare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
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12
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Manlucu J, Sharma V, Koehler J, Warman EN, Wells GA, Gula LJ, Yee R, Tang AS. Incremental Value of Implantable Cardiac Device Diagnostic Variables Over Clinical Parameters to Predict Mortality in Patients With Mild to Moderate Heart Failure. J Am Heart Assoc 2019; 8:e010998. [PMID: 31291801 PMCID: PMC6662119 DOI: 10.1161/jaha.118.010998] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Heart failure remains a leading cause of morbidity and mortality. Clinical prediction models provide suboptimal estimates of mortality in this population. We sought to determine the incremental value of implantable device diagnostics over clinical prediction models for mortality. Methods and Results RAFT (Resynchronization/Defibrillation for Ambulatory Heart Failure Trial) patients with implanted devices capable of device diagnostic monitoring were included, and demographic and clinical parameters were used to compute Meta‐Analysis Global Group in Chronic Heart Failure (MAGGIC) heart failure risk scores. Patients were classified according to MAGGIC score into low (0–16), intermediate (17–24), or high (>24) risk groups. Mortality was evaluated from 6 months postimplant in accordance with the RAFT protocol. In a subset of 1036 patients, multivariable analysis revealed that intermediate and high MAGGIC scores, fluid index, atrial fibrillation, and low activity flags were independent predictors of mortality. A device‐integrated diagnostic parameter that included a fluid index flag and either a positive atrial fibrillation flag or a positive activity flag was able to significantly differentiate higher from lower risk for mortality in the intermediate MAGGIC cohort. The effect was more pronounced in the high‐risk MAGGIC cohort, in which device‐integrated diagnostic–positive patients had a shorter time to death than those who were device‐integrated diagnostic negative. Conclusions Device diagnostics using a combination of fluid index trends, atrial fibrillation burden, and patient activity provide significant incremental prognostic value over clinical heart failure prediction scores in higher‐risk patients. This suggests that combining clinical and device diagnostic parameters may lead to models with better predictive power. Whether this risk is modifiable with early medical intervention would warrant further studies. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00251251.
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Affiliation(s)
| | | | | | | | - George A Wells
- 3 University of Ottawa Heart Institute Ottawa Ontario Canada
| | | | | | - Anthony S Tang
- 1 Western University London Ontario Canada.,3 University of Ottawa Heart Institute Ottawa Ontario Canada
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13
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Auld JP, Mudd JO, Gelow JM, Lyons KS, Hiatt SO, Lee CS. Device-detected congestion is associated with worse patient-reported outcomes in heart failure. Heart Lung 2019; 48:208-214. [PMID: 30611529 DOI: 10.1016/j.hrtlng.2018.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 11/07/2018] [Accepted: 12/04/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Congestion is a common cause of symptoms in heart failure (HF). Yet, intrathoracic impedance, an objective marker of cardiopulmonary congestion, has not been examined in relation to HF symptoms. OBJECTIVE To determine whether device-detected cardiopulmonary congestion is a predictor of physical and psychological symptoms and health-related quality of life (HRQOL) in adults with HF over 3 months. METHODS Multivariate generalized linear modeling was used to quantify the association of cardiopulmonary congestion (Optivol® Index exceeding 60 Ω threshold) with HRQOL (12-item Kansas City Cardiomyopathy Questionnaire) and both physical symptoms (Functional Assessment of Chronic Illness Therapy-Fatigue Scale; HF Somatic Perception Scale Dyspnea and Early & Subtle Symptoms subscales) and affective symptoms (9-item Patient Health Questionnaire; 6-item Patient-Reported Outcomes Measurement Information System Anxiety Scale). RESULTS The mean age of the sample (n = 49) was 62years old, 39% were women, and 63% had NYHA class III/IV HF. Participants who experienced threshold crossings in the previous 90days reported on average, 130% higher dyspnea (p = 0.017; confidence interval (CI) 10.2%, 437%), 40% higher early & subtle symptoms (p = 0.029; CI 3.4%, 89.7%), 106% higher depressive symptoms (p = 0.003; CI 19.1%, 257%) and 40% higher anxiety (p = 0.028; CI 3.7%, 89.1%). Threshold crossings in the previous 90days were also significantly associated with a clinically meaningful decrease in HRQOL (β = -16.16 ± 6.32; p = 0.01). CONCLUSIONS Intrathoracic impedance measured with the Optivol Index can provide additional information regarding the patient experience of hallmark physical and psychological HF symptoms and HRQOL over 3months.
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Affiliation(s)
- Jonathan P Auld
- Oregon Health & Science University School of Nursing, 3455 SW US Veterans Hospital Rd., SN-ADM, Portland, OR 97239-2941, USA.
| | - James O Mudd
- Oregon Health & Science University, Knight Cardiovascular Institute, 3181 S.W. Sam Jackson Park Rd., Portland, OR 97239-3098, USA
| | - Jill M Gelow
- Oregon Health & Science University, Knight Cardiovascular Institute, 3181 S.W. Sam Jackson Park Rd., Portland, OR 97239-3098, USA
| | - Karen S Lyons
- Oregon Health & Science University School of Nursing, 3455 SW US Veterans Hospital Rd., SN-ADM, Portland, OR 97239-2941, USA
| | - Shirin O Hiatt
- Oregon Health & Science University School of Nursing, 3455 SW US Veterans Hospital Rd., SN-ADM, Portland, OR 97239-2941, USA
| | - Christopher S Lee
- William F. Connell School of Nursing, Boston College, Maloney Hall, 231140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA
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14
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Abou Hassan OK, Refaat MM. Changes in intrathoracic impedance and episodes of ventricular arrhythmias in patients with heart failure and reduced ejection fraction. Pacing Clin Electrophysiol 2018; 41:1583-1584. [DOI: 10.1111/pace.13536] [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: 10/15/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Ossama K. Abou Hassan
- Division of Cardiology; American University of Beirut Medical Center; Beirut Lebanon
| | - Marwan M. Refaat
- Division of Cardiology; American University of Beirut Medical Center; Beirut Lebanon
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15
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Osman M, Ahmed A, Alzubi H, Kheiri B, Osman K, Barbarawi M, Ríos-Bedoya CF, Bachuwa G, Hassan M. Association between changes in the intrathoracic impedance and ventricular arrhythmias in patients with heart failure. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1577-1582. [PMID: 30362185 DOI: 10.1111/pace.13535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 07/21/2018] [Accepted: 08/04/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ventricular arrhythmias (VAs) are independently related to mortality risk in patients with heart failure (HF). The wide availability of implantable cardioverter defibrillators and cardiac resynchronization therapy devices now offers an opportunity to clinically correlate the two disease processes. We hypothesized that there is an association between changes in the intrathoracic impedance and episodes of VA. METHODS Nonconcurrent prospective study of adults (age >20 years) with known HF with reduced ejection fraction (<35%). The OptiVol threshold was categorized as follows: 0-30 Ω-days, 31-60 Ω-days, 61-90 Ω-days, 91-120 Ω-days, and >120 Ω-days. Patients with OptiVol values at 0-30 Ω-days were used as the reference group. Receiver operating characteristic analysis was used to estimate the sensitivity and specificity at each threshold. RESULTS Of the 87 eligible patients, 65.5% were males. The mean age of the sample was 73.3 years (±12.7). Compared to patients in the 0-30 Ω-days category, those in the 31-60, 61-90, 91-120, and >120 Ω-days groups had, on average, 1.48, 1.64, 2.24, and 1.6 more VAs, respectively (P = 0.002, 0.009, 0.010 and 0.009, respectively). The sensitivity and specificity of each threshold were as follows: 82.6% and 61.7% at 31-60 Ω-days, 43.5% and 78.3% at 61-90 Ω-days, 30.4% and 85.0% at 91-120 Ω-days, and 21.7% and 88.3% at >121 Ω-days. CONCLUSION Our study found a significant positive relationship between changes in intrathoracic impedance and episodes of VAs in patients with HF.
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Affiliation(s)
- Mohammed Osman
- Internal Medicine Department, Hurley Medical Center/Michigan State University, Flint, MI, USA.,Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Azza Ahmed
- Internal Medicine Department, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Hussam Alzubi
- Internal Medicine Department, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Babikir Kheiri
- Internal Medicine Department, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Khansa Osman
- Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | - Mahmoud Barbarawi
- Internal Medicine Department, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Carlos F Ríos-Bedoya
- Internal Medicine Department, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Ghassan Bachuwa
- Internal Medicine Department, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Mustafa Hassan
- Internal Medicine Department, Hurley Medical Center/Michigan State University, Flint, MI, USA
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16
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Alruwaili F, Cluff K, Griffith J, Farhoud H. Passive Self Resonant Skin Patch Sensor to Monitor Cardiac Intraventricular Stroke Volume Using Electromagnetic Properties of Blood. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE-JTEHM 2018; 6:1900709. [PMID: 30416893 PMCID: PMC6214405 DOI: 10.1109/jtehm.2018.2870589] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/29/2018] [Accepted: 09/04/2018] [Indexed: 12/24/2022]
Abstract
This paper focuses on the development of a passive, lightweight skin patch sensor that can measure fluid volume changes in the heart in a non-invasive, point-of-care setting. The wearable sensor is an electromagnetic, self-resonant sensor configured into a specific pattern to formulate its three passive elements (resistance, capacitance, and inductance). In an animal model, a bladder was inserted into the left ventricle (LV) of a bovine heart, and fluid was injected using a syringe to simulate stoke volume (SV). In a human study, to assess the dynamic fluid volume changes of the heart in real time, the sensor frequency response was obtained from a participant in a 30° head-up tilt (HUT), 10° HUT, supine, and 10° head-down tilt positions over time. In the animal model, an 80-mL fluid volume change in the LV resulted in a downward frequency shift of 80.16 kHz. In the human study, there was a patterned frequency shift over time which correlated with ventricular volume changes in the heart during the cardiac cycle. Statistical analysis showed a linear correlation \documentclass[12pt]{minimal}
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\end{document} and 0.87 between the frequency shifts and fluid volume changes in the LV of the bovine heart and human participant, respectively. In addition, the patch sensor detected heart rate in a continuous manner with a 0.179% relative error compared to electrocardiography. These results provide promising data regarding the ability of the patch sensor to be a potential technology for SV monitoring in a non-invasive, continuous, and non-clinical setting.
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Affiliation(s)
- Fayez Alruwaili
- Biomedical Engineering DepartmentWichita State UniversityWichitaKS67260USA
| | - Kim Cluff
- Biomedical Engineering DepartmentWichita State UniversityWichitaKS67260USA
| | - Jacob Griffith
- Biomedical Engineering DepartmentWichita State UniversityWichitaKS67260USA
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17
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Brown JR, Alonso A, Warman EN, Bilchick KC. Long-term impact of intrathoracic impedance findings on survival and heart failure hospitalizations after cardiac resynchronization therapy in ICD Registry patients. Europace 2018; 20:1138-1145. [PMID: 29016777 PMCID: PMC6041970 DOI: 10.1093/europace/eux197] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/11/2017] [Accepted: 05/15/2017] [Indexed: 11/13/2022] Open
Abstract
Aims To determine adjusted associations among OptiVol® threshold crossings, long-term survival, and hospitalizations among heart failure (HF) patients with Medicare coverage in the United States. Methods and results A cohort with OptiVol®-enabled cardiac resynchronization therapy defibrillators (CRT-D) devices from the Implantable Cardioverter Defibrillator Registry was linked to both Medicare claims/summary data and Medtronic's CareLink® Network data. An extended multivariable Cox model was used to analyse associations among OptiVol® threshold crossings (treated as time-dependent covariates), mortality, and HF-related hospitalizations (HFH). We analysed N = 1565 patients with OptiVol®-enabled CRT-D devices (mean age 72.8, 28% women). The median follow-up was 6.3 years. Patients with >15.1% of days above OptiVol® threshold (highest quartile) had more than a 4-fold increase in mortality [hazard ratio (HR) 4.2, 95% confidence interval (CI): 3.3-5.3] and more than a 3-fold increase in HFH (HR 3.2, 95% CI: 2.4-4.2) compared with patients having <4.1% of days above threshold (lowest quartile) after adjustment for key covariates. In addition, a single OptiVol® crossing was associated with significantly increased rates of both mortality (HR 1.87, 95% CI: 1.27-2.75) and HFH (HR 1.70, 95% CI: 1.28-2.27). Conclusion In a CRT-D cohort with over 6 years of follow-up, both single OptiVol® crossings and time above OptiVol® threshold were associated with increased rates of mortality and hospitalization, which has important implications for clinical care. This is the first study integrating device data with Medicare outcomes to validate the long-term significance of OptiVol® findings.
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Affiliation(s)
- Jason R Brown
- Cardiac Rhythm and Heart Failure, Medtronic PLC, 8200 Coral Sea Street NE, MVN61, Minneapolis, MN, USA
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, 1300 South 2nd Street, Minneapolis, MN, USA
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Eduardo N Warman
- Cardiac Rhythm and Heart Failure, Medtronic PLC, 8200 Coral Sea Street NE, MVN61, Minneapolis, MN, USA
| | - Kenneth C Bilchick
- Heart and Vascular Center, University of Virginia Health System, Second Floor, 1215 Lee St., Charlottesville, VA, USA
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18
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Abubakar H, Osman M, Akintoye E, Subahi A, Osman K, Abidov A. Intra-thoracic Impedance and the Onset of Atrial and Ventricular Tachyarrhythmias: A Meta-analysis. Int J Cardiol 2018; 258:144-150. [DOI: 10.1016/j.ijcard.2017.12.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/08/2017] [Accepted: 12/21/2017] [Indexed: 11/30/2022]
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19
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Abstract
Cardiac resynchronization therapy (CRT) is increasingly used in heart failure treatment and management of these patients imposes significant challenges. Remote monitoring is becoming essential for CRT follow-up and allows close surveillance of device function and patient condition. It is helpful to reduce clinic visits, increase device longevity and provide early detection of device failure. Clinical effects include prevention of appropriate and inappropriate shocks and early detection of arrhythmias, such as atrial fibrillation. For modification of heart failure the addition of monitoring to CRT by means of device-based multiparameters may help to modify disease progression and improve survival.
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Affiliation(s)
- Cecilia Linde
- Department of Cardiology, Karolinska University Hospital, Karolinska Institutet, Stockholm S-17176, Sweden.
| | - Frieder Braunschweig
- Department of Cardiology, Karolinska University Hospital, Karolinska Institutet, Stockholm S-17176, Sweden
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20
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Mohan RC, Heywood JT, Small RS. Remote Monitoring in Heart Failure: the Current State. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:22. [PMID: 28299615 DOI: 10.1007/s11936-017-0519-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OPINION STATEMENT The treatment of congestive heart failure is an expensive undertaking with much of this cost occurring as a result of hospitalization. It is not surprising that many remote monitoring strategies have been developed to help patients maintain clinical stability by avoiding congestion. Most of these have failed. It seems very unlikely that these failures were the result of any one underlying false assumption but rather from the fact that heart failure is a progressive, deadly disease and that human behavior is hard to modify. One lesson that does stand out from the myriad of methods to detect congestion is that surrogates of congestion, such as weight and impedance, are not reliable or actionable enough to influence outcomes. Too many factors influence these surrogates to successfully and confidently use them to affect HF hospitalization. Surrogates are often attractive because they can be inexpensively measured and followed. They are, however, indirect estimations of congestion, and due to the lack specificity, the time and expense expended affecting the surrogate do not provide enough benefit to warrant its use. We know that high filling pressures cause transudation of fluid into tissues and that pulmonary edema and peripheral edema drive patients to seek medical assistance. Direct measurement of these filling pressures appears to be the sole remote monitoring modality that shows a benefit in altering the course of the disease in these patients. Congestive heart failure is such a serious problem and the consequences of hospitalization so onerous in terms of patient well-being and costs to society that actual hemodynamic monitoring, despite its costs, is beneficial in carefully selected high-risk patients. Those patients who benefit are ones with a prior hospitalization and ongoing New York Heart Association (NYHA) class III symptoms. Patients with NYHA class I and II symptoms do not require hemodynamic monitoring because they largely have normal hemodynamics. Those with NYHA class IV symptoms do not benefit because their hemodynamics are so deranged that they cannot be substantially altered except by mechanical circulatory support or heart transplantation. Finally, hemodynamic monitoring offers substantial hope to those patients with normal ejection fraction (EF) heart failure, a large group for whom medical therapy has largely been a failure. These patients have not benefited from the neurohormonal revolution that improved the lives of their brothers and sisters with reduced ejection fractions. Hemodynamic stabilization improves the condition of both but more so of the normal EF cohort. This is an important observation that will help us design future trials for the 50% of heart failure patients with normal systolic function.
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Affiliation(s)
- Rajeev C Mohan
- Advanced Heart Failure and Mechanical Circulatory Support Program, Pulmonary Hypertension Program, Division of Cardiology, Scripps Clinic, 9898 Genesee Avenue, AMP Suite #300, La Jolla, CA, 92037, USA.
| | - J Thomas Heywood
- Advanced Heart Failure and Mechanical Circulatory Support Program, Pulmonary Hypertension Program, Division of Cardiology, Scripps Clinic, 9898 Genesee Avenue, AMP Suite #300, La Jolla, CA, 92037, USA
| | - Roy S Small
- Cardiology, Lancaster Heart and Vascular Institute, Lancaster General Hospital/Penn Medicine, Lancaster, PA, USA
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21
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Linde C, Braunschweig F. Cardiac Resynchronization Therapy Follow-up: Role of Remote Monitoring. Card Electrophysiol Clin 2016; 7:797-807. [PMID: 26596821 DOI: 10.1016/j.ccep.2015.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Cardiac resynchronization therapy (CRT) is increasingly used in heart failure treatment and management of these patients imposes significant challenges. Remote monitoring is becoming essential for CRT follow-up and allows close surveillance of device function and patient condition. It is helpful to reduce clinic visits, increase device longevity and provide early detection of device failure. Clinical effects include prevention of appropriate and inappropriate shocks and early detection of arrhythmias, such as atrial fibrillation. For modification of heart failure the addition of monitoring to CRT by means of device-based multiparameters may help to modify disease progression and improve survival.
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Affiliation(s)
- Cecilia Linde
- Department of Cardiology, Karolinska University Hospital, Karolinska Institutet, Stockholm S-17176, Sweden.
| | - Frieder Braunschweig
- Department of Cardiology, Karolinska University Hospital, Karolinska Institutet, Stockholm S-17176, Sweden
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22
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Gudmundsson K, Lyngå P, Rosenqvist M, Braunschweig F. Monitoring of Daily Body Weight and Intrathoracic Impedance in Heart Failure Patients With a High Risk of Volume Overload Decompensation. Clin Cardiol 2016; 39:446-52. [PMID: 27175605 DOI: 10.1002/clc.22547] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 03/14/2016] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Decompensation is frequent in heart failure (HF) patients and predicts poor prognosis. HYPOTHESIS Volume-overload events in HF patients are preceded by changes in intrathoracic impedance (Z) and body weight (BW); monitoring these parameters may be useful to predict decompensation. METHODS Forty-three HF patients (LVEF 25% ± 12%) with a recent HF event and an implantable cardioverter-defibrillator providing daily Z were equipped with telemonitoring scales submitting daily BW. Changes in BW and Z 30 days prior to major (HF hospitalization) and minor (ambulatory adjustment of diuretics) were analyzed. RESULTS During median of 427 days follow-up 25 major and 41 minor events occurred. Z decreased by -4.8 (95% confidence interval [CI]: CI -6.7 to -3.0) and -4.3 (95% CI: -5.5 to -3.2) within 30 days prior to major and minor events respectively (P < 0.001). BW increased before major events by 2.3 kg (95% CI: 1.0 to 3.5, P < 0.01) and minor events 1 kg (95% CI: 0.5 to 1.4, P < 0.001). Sensitivity of Z for major/minor HF events was 83.3% (95% CI: 71.7 to 91.0) and for BW 43.9% (95% CI: 31.9 to 56.7). The unexplained detection rate per patient-year was 1.6 (interquartile range [IQR], 0-3.1) for Z and 4.8 (IQR 1.6-11.1) for BW. Combined Z and BW sensitivity was 42.4% (95% CI: 30.6 to 55.2) and unexplained detection rate was 0.8 (IQR, 0-1.5) per patient-year. CONCLUSIONS Decompensation is marked by a decrease in Z and increase in BW the preceding 30 days. Monitoring of Z predicts HF decompensations with better sensitivity and lower unexplained detection rate than BW.
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Affiliation(s)
- Kristjan Gudmundsson
- Karolinska Institute, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Patrik Lyngå
- Department of Clinical Science and Education (Lyngå), Stockholm South General Hospital, Stockholm, Sweden
| | - Mårten Rosenqvist
- Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
| | - Frieder Braunschweig
- Karolinska Institute, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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Böhm M, Drexler H, Oswald H, Rybak K, Bosch R, Butter C, Klein G, Gerritse B, Monteiro J, Israel C, Bimmel D, Käab S, Huegl B, Brachmann J. Fluid status telemedicine alerts for heart failure: a randomized controlled trial. Eur Heart J 2016; 37:3154-3163. [DOI: 10.1093/eurheartj/ehw099] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 12/21/2015] [Accepted: 02/22/2016] [Indexed: 11/14/2022] Open
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Small RS, Tang WHW. Assessing Impedance in Heart Failure: From Device Diagnostics to Population Health Opportunities? Circ Heart Fail 2015; 9:e002761. [PMID: 26699395 DOI: 10.1161/circheartfailure.115.002761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Roy S Small
- From The Heart Group of Lancaster General Hospital, Lancaster, PA (R.S.S.); and Heart and Vascular Institute, Cleveland Clinic, OH (W.H.W.T.)
| | - W H Wilson Tang
- From The Heart Group of Lancaster General Hospital, Lancaster, PA (R.S.S.); and Heart and Vascular Institute, Cleveland Clinic, OH (W.H.W.T.)
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25
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Zile MR, Sharma V, Johnson JW, Warman EN, Baicu CF, Bennett TD. Prediction of All-Cause Mortality Based on the Direct Measurement of Intrathoracic Impedance. Circ Heart Fail 2015; 9:e002543. [PMID: 26699393 DOI: 10.1161/circheartfailure.115.002543] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/08/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Intrathoracic impedance-derived OptiVol fluid index calculated using implanted devices has been shown to predict mortality; direct measurements of impedance have not been examined. We hypothesized that baseline measured impedance predicts all-cause mortality; changes in measured impedance result in a change in the predicted mortality; and the prognostic value of measured impedance is additive to the calculated OptiVol fluid index. METHODS AND RESULTS A retrospective analysis of 146,238 patients within the Medtronic CareLink database with implanted devices was performed. Baseline measured impedance was determined using daily values averaged from month 6 to 9 after implant and were used to divide patients into tertiles: group L = low impedance, ≤ 65 ohms; group M = medium impedance, 66 to 72 ohms; group H = high impedance, ≥ 73 ohms. Change in measured impedance was determined from values averaged from month 9 to 12 post implant compared with the 6- to 9-month values. OptiVol fluid index was calculated using published methods. All-cause mortality was assessed beginning 9 months post implant; changes in mortality was assessed beginning 12 months post implant. Baseline measured impedance predicted all-cause mortality; 5-year mortality for group L was 41%, M was 29%, and H was 25%, P < 0.001 among all groups. Changes in measured impedance resulted in a change in the predicted mortality; the prognostic value of measured impedance was additive to the OptiVol fluid index. CONCLUSIONS Direct measurements of intrathoracic impedance using an implanted device can be used to stratify patients at varying mortality risk.
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Affiliation(s)
- Michael R Zile
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina and RHJ Department of Veterans Affairs Medical Center, Charleston (M.R.Z., C.F.B.); and Medtronic, Plc., Minneapolis, MN (V.S., J.W.J., E.N.W., T.D.B.).
| | - Vinod Sharma
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina and RHJ Department of Veterans Affairs Medical Center, Charleston (M.R.Z., C.F.B.); and Medtronic, Plc., Minneapolis, MN (V.S., J.W.J., E.N.W., T.D.B.)
| | - James W Johnson
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina and RHJ Department of Veterans Affairs Medical Center, Charleston (M.R.Z., C.F.B.); and Medtronic, Plc., Minneapolis, MN (V.S., J.W.J., E.N.W., T.D.B.)
| | - Eduardo N Warman
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina and RHJ Department of Veterans Affairs Medical Center, Charleston (M.R.Z., C.F.B.); and Medtronic, Plc., Minneapolis, MN (V.S., J.W.J., E.N.W., T.D.B.)
| | - Catalin F Baicu
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina and RHJ Department of Veterans Affairs Medical Center, Charleston (M.R.Z., C.F.B.); and Medtronic, Plc., Minneapolis, MN (V.S., J.W.J., E.N.W., T.D.B.)
| | - Tom D Bennett
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina and RHJ Department of Veterans Affairs Medical Center, Charleston (M.R.Z., C.F.B.); and Medtronic, Plc., Minneapolis, MN (V.S., J.W.J., E.N.W., T.D.B.)
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Analysis of different device-based intrathoracic impedance vectors for detection of heart failure events (from the Detect Fluid Early from Intrathoracic Impedance Monitoring study). Am J Cardiol 2014; 114:1249-56. [PMID: 25150135 DOI: 10.1016/j.amjcard.2014.07.048] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Revised: 07/16/2014] [Accepted: 07/16/2014] [Indexed: 11/22/2022]
Abstract
Detect Fluid Early from Intrathoracic Impedance Monitoring (DEFEAT-PE) is a prospective, multicenter study of multiple intrathoracic impedance vectors to detect pulmonary congestion (PC) events. Changes in intrathoracic impedance between the right ventricular (RV) coil and device can (RVcoil→Can) of implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy ICDs (CRT-Ds) are used clinically for the detection of PC events, but other impedance vectors and algorithms have not been studied prospectively. An initial 75-patient study was used to derive optimal impedance vectors to detect PC events, with 2 vector combinations selected for prospective analysis in DEFEAT-PE (ICD vectors: RVring→Can + RVcoil→Can, detection threshold 13 days; CRT-D vectors: left ventricular ring→Can + RVcoil→Can, detection threshold 14 days). Impedance changes were considered true positive if detected <30 days before an adjudicated PC event. One hundred sixty-two patients were enrolled (80 with ICDs and 82 with CRT-Ds), all with ≥1 previous PC event. One hundred forty-four patients provided study data, with 214 patient-years of follow-up and 139 PC events. Sensitivity for PC events of the prespecified algorithms was as follows: ICD: sensitivity 32.3%, false-positive rate 1.28 per patient-year; CRT-D: sensitivity 32.4%, false-positive rate 1.66 per patient-year. An alternative algorithm, ultimately approved by the US Food and Drug Administration (RVring→Can + RVcoil→Can, detection threshold 14 days), resulted in (for all patients) sensitivity of 21.6% and a false-positive rate of 0.9 per patient-year. The CRT-D thoracic impedance vector algorithm selected in the derivation study was not superior to the ICD algorithm RVring→Can + RVcoil→Can when studied prospectively. In conclusion, to achieve an acceptably low false-positive rate, the intrathoracic impedance algorithms studied in DEFEAT-PE resulted in low sensitivity for the prediction of heart failure events.
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Transient variations of transthoracic impedance as a predictor of heart failure and death in patients with implanted defibrillators. Int J Cardiol 2014; 175:473-7. [DOI: 10.1016/j.ijcard.2014.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 06/20/2014] [Indexed: 11/19/2022]
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Andriulli JA, Moore HJ, Hettrick DA, Ousdigian KT, Johnson J, Markowitz SM. Atrial tachyarrhythmias temporally precede fluid accumulation in implantable device patients. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 37:554-61. [PMID: 24341570 DOI: 10.1111/pace.12309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 10/03/2013] [Accepted: 10/09/2013] [Indexed: 12/24/2022]
Abstract
BACKGROUND The complex relationship between heart failure and atrial tachyarrhythmias (AT/atrial fibrillation [AF]) is not well understood. We examined the temporal association between changes in intrathoracic impedance, suggesting thoracic fluid accumulation, and AT/AF occurrence in cardiac resynchronization therapy-defibrillator and implantable cardioverter defibrillator (ICD) patients. METHODS A retrospective analysis was conducted on stored implantable device data to identify patients with automatic monitoring of daily AT/AF burden and intrathoracic impedance. Daily population trends in AT/AF burden before and after a fluid index threshold crossing (FIC) were determined. RESULTS A total of 73,018 patients (68 ± 12 years, 51% ICD, 75% male) were evaluated over 18.6 ± 11.5 months. Kaplan-Meier analysis indicated a significantly higher probability of FIC events in the first month following the onset of persistent AT/AF when compared to a matched group without persistent AT/AF (hazard ratio [HR] 1.65, 95% confidence interval [CI] [1.58, 1.72], P < 0.001). Conversely, patients were significantly more likely to experience an episode of persistent AF in the first month after the FIC event (HR 1.32, 95% CI [1.08, 1.63], P = 0.008). The probability of a fluid index crossing within 30 days of the onset of persistent AT/AF was significantly lower in a subgroup of patients with adequate rate control (35.8% [34.3-37.4%] vs 42.0% [39.6-44.6%]; HR 1.24 [1.13-1.36]). CONCLUSION Thoracic fluid accumulation, as indicated by decreasing intrathoracic impedance, was more likely to occur immediately after the onset of persistent AT/AF, especially in the presence of inadequate rate control. Likewise, the onset of persistent AT/AF was more likely following a decrease in intrathoracic impedance.
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Affiliation(s)
- John A Andriulli
- Department of Cardiology, Cooper University Hospital, Cooper Medical School at Rowan University, Camden, New Jersey
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