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Gerra L, Bonini N, Mei DA, Imberti JF, Vitolo M, Bucci T, Boriani G, Lip GYH. Cardiac resynchronization therapy (CRT) nonresponders in the contemporary era: A state-of-the-art review. Heart Rhythm 2024:S1547-5271(24)02670-5. [PMID: 38848860 DOI: 10.1016/j.hrthm.2024.05.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/09/2024]
Abstract
In the 2000s, cardiac resynchronization therapy (CRT) became a revolutionary treatment of heart failure with reduced left ventricular ejection fraction (HFrEF) and wide QRS. However, about one-third of CRT recipients do not show a favorable response. This review of the current literature aims to better define the concept of CRT response/nonresponse. The diagnosis of CRT nonresponder should be viewed as a continuum, and it cannot rely solely on a single parameter. Moreover, baseline features of some patients might predict an unfavorable response. A strong collaboration between heart failure specialists and electrophysiologists is key to overcoming this challenge with multiple strategies. In the contemporary era, new pacing modalities, such as His-bundle pacing and left bundle branch area pacing, represent a promising alternative to CRT. Observational studies have demonstrated their potential; however, several limitations should be addressed. Large randomized controlled trials are needed to prove their efficacy in HFrEF with electromechanical dyssynchrony.
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Affiliation(s)
- Luigi Gerra
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolò Bonini
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Davide Antonio Mei
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Jacopo Francesco Imberti
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of General and Specialized Surgery, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Boriani
- Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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2
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Coppola G, Madaudo C, Mascioli G, D'Ardia G, Greca CL, Prezioso A, Corrado E. Tighter is better: Can a simple and cost-free parameter predict response to cardiac synchronization therapy? Pacing Clin Electrophysiol 2024. [PMID: 38830778 DOI: 10.1111/pace.15021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 04/20/2024] [Accepted: 05/22/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Several studies have evaluated the role of QRS duration (QRSd) or QRS narrowing as a predictor of response to cardiac resynchronization therapy (CRT) to reduce nonresponders. AIM Our study aimed to determine the correlation between the relative change in QRS index (QI) compared to clinical outcome and prognosis in patients who underwent CRT implantation. METHODS A three-centers study involving 398 patients with a CRT device was conducted. Clinical, echocardiographic and pharmacological variables, QRSd before and after CRT implantation and QI were measured. RESULTS In a 6-month follow-up, a significant improvement in left ventricular ejection fraction (LVEF), left ventricular end-diastolic and systolic volumes (LVEDV and LVESV) were observed. QI was related to reverse remodeling (multiple r-squared: 0.48, adjusted r-squared: 0.43, p = .001), and the cut-off value that best predicted LV reverse remodeling after 6 months of CRT was 12.25% (AUC 0.7, p = .001). At 24 months, a statistically significant difference was found between patients with a QI ≤ 12.25% and those with a QI > 12.25% regarding NYHA class worsening (p = .04). The mean of the QI of patients who died from cardiovascular causes was lower than patients who died of other causes (p = .0179). A correlation between pre-CRT QRSd/LVEDV and QI was observed (r = + 0.20; p = .0003). A higher QRSd/LVEDV ratio was associated with an improved LVEF, LVEDV, and LVESV (p < .0001) at follow-up. CONCLUSIONS QI narrowing after CRT was related to greater echocardiographic reverse remodeling and a lower rate of adverse events (death or cardiovascular hospitalizations). The QI can improve the prediction of adverse events in a population with CRT regardless of comorbidities according to the Charlson Comorbidity Index. QI could be used to predict CRT response.
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Affiliation(s)
- Giuseppe Coppola
- Operative Unit of Cardiology - UTIC, University Hospital "Paolo Giaccone", University of Palermo, AOUP Paolo Giaccone, Via del Vespro 129, Palermo, Italy
| | - Cristina Madaudo
- Operative Unit of Cardiology - UTIC, University Hospital "Paolo Giaccone", University of Palermo, AOUP Paolo Giaccone, Via del Vespro 129, Palermo, Italy
| | - Giosuè Mascioli
- Operative Unit of Cardiology - UTIC, Desenzano's Hospital "ASST GARDA", Brescia, Italy
| | - Giulio D'Ardia
- Operative Unit of Cardiology - UTIC, University Hospital "Paolo Giaccone", University of Palermo, AOUP Paolo Giaccone, Via del Vespro 129, Palermo, Italy
| | - Carmelo La Greca
- Electrophysiology Unit, Cardiovascular Department, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Amedeo Prezioso
- Electrophysiology Unit, Cardiovascular Department, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Egle Corrado
- Operative Unit of Cardiology - UTIC, University Hospital "Paolo Giaccone", University of Palermo, AOUP Paolo Giaccone, Via del Vespro 129, Palermo, Italy
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3
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Witt CT, Mols RE, Bakos I, Horváth-Puhó E, Christensen B, Løgstrup BB, Nielsen JC, Eiskjær H. Influence of multimorbidity and socioeconomic position on long-term healthcare utilization and prognosis in patients after cardiac resynchronization therapy implantation. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae029. [PMID: 38828270 PMCID: PMC11143480 DOI: 10.1093/ehjopen/oeae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/01/2024] [Accepted: 03/14/2024] [Indexed: 06/05/2024]
Abstract
Aims We aimed to investigate the influence of socioeconomic position (SEP) and multimorbidity on cross-sectional healthcare utilization and prognosis in patients after cardiac resynchronization therapy (CRT) implantation. Methods and results We included first-time CRT recipients with left ventricular ejection fraction ≤35% implanted between 2000 and 2017. Data on chronic conditions, use of healthcare services, and demographics were obtained from Danish national administrative and health registries. Healthcare utilization (in- and outpatient hospitalizations, activities in general practice) was compared by multimorbidity categories and SEP by using a negative binomial regression model. The association between SEP, multimorbidity, and prognostic outcomes was analysed using Cox proportional hazards regression. We followed 2007 patients (median age of 70 years), 79% were male, 75% were on early retirement or state pension, 37% were living alone, and 41% had low education level for a median of 5.2 [inter-quartile range: 2.2-7.3) years. In adjusted regression models, a higher number of chronic conditions were associated with increased healthcare utilization. Both cardiovascular and non-cardiovascular hospital contacts were increased. Patients with low SEP had a higher number of chronic conditions, but SEP had limited influence on healthcare utilization. Patients living alone and those with low educational level had a trend towards a higher risk of all-cause mortality [adjusted hazard ratio (aHR): 1.17, 95% confidence interval (CI) 1.03-1.33, and aHR 1.09, 95% CI 0.96-1.24). Conclusion Multimorbidity increased the use of cross-sectional healthcare services, whereas low SEP had minor influence on the utilizations. Living alone and low educational level showed a trend towards a higher risk of mortality after CRT implantation.
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Affiliation(s)
- Christoffer Tobias Witt
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Rikke Elmose Mols
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - István Bakos
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
| | - Erzsébet Horváth-Puhó
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
| | - Bo Christensen
- Department of Public Health, Research Unit for General Practice, Aarhus University Bartholins Allé 2, 8000 Aarhus C, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Brian Bridal Løgstrup
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
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Bray JJH, Coronelli M, Scott SGC, Henry JA, Couch LS, Ahmad M, Ormerod J, Gamble J, Betts TR, Lewis A, Rider OJ, Green PG, Herring N. The effect of sodium-glucose co-transporter 2 inhibitors on outcomes after cardiac resynchronization therapy. ESC Heart Fail 2024. [PMID: 38649305 DOI: 10.1002/ehf2.14784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/14/2024] [Accepted: 03/10/2024] [Indexed: 04/25/2024] Open
Abstract
AIMS The trials upon which recommendations for the use of cardiac resynchronization therapy (CRT) in heart failure used optimal medical therapy (OMT) before sodium-glucose co-transporter 2 inhibitors (SGLT2i). Moreover, the SGLT2i heart failure trials included only a small proportion of participants with CRT, and therefore, it remains uncertain whether SGLT2i should be considered part of OMT prior to CRT. METHODS AND RESULTS We compared electrocardiogram (ECG) and echocardiographic responses to CRT as well as hospitalization and mortality rates in consecutive patients undergoing implantation at a large tertiary centre between January 2019 to June 2022 with and without SGLT2i treatment. Three hundred seventy-four participants were included aged 74.0 ± 11.5 years (mean ± standard deviation), with a left ventricular ejection fraction (LVEF) of 31.8 ± 9.9% and QRS duration of 161 ± 29 ms. The majority had non-ischaemic cardiomyopathy (58%) and were in NYHA Class II/III (83.6%). These characteristics were similar between patients with (n = 66) and without (n = 308) prior SGLT2i treatment. Both groups demonstrated similar evidence of response to CRT in terms of QRS duration shortening, and improvements in LVEF, left ventricular end-diastolic inner-dimension (LVIDd) and diastolic function (E/A and e/e'). While there was no difference in rates of hospitalization (for heart failure or overall), mortality was significantly lower in patients treated with SGLT2i compared with those who were not (6.5 vs. 16.6%, P = 0.049). CONCLUSIONS We observed an improvement in mortality in patients undergoing CRT prescribed SGLT2i compared with those not prescribed SGLT2i, despite similar degrees of reverse remodelling. The authors recommend starting SGLT2i prior to CRT implantation, where it does not delay implantation.
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Affiliation(s)
- Jonathan J H Bray
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Marco Coronelli
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Sam G C Scott
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - John A Henry
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Liam S Couch
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Mahmood Ahmad
- UCL Medical School, University College London, London, UK
| | - Julian Ormerod
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - James Gamble
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Timothy R Betts
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Andrew Lewis
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Oliver J Rider
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Peregrine G Green
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Neil Herring
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
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5
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Gold MR, Auricchio A, Leclercq C, Wold N, Stein KM, Ellenbogen KA. Atrioventricular optimization improves cardiac resynchronization response in patients with long interventricular electrical delays: A pooled analysis of the SMART-AV and SMART-CRT trials. Heart Rhythm 2024:S1547-5271(24)02277-X. [PMID: 38604592 DOI: 10.1016/j.hrthm.2024.03.1783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND The utility of atrioventricular (AV) optimization (AVO) algorithms remains in question. A substudy of the SMART-AV trial found that patients with prolonged interventricular delays ≥70 ms were more likely to benefit from cardiac resynchronization therapy (CRT) with AVO. The SMART-CRT trial evaluated AVO on the basis of these results, but the study was underpowered. OBJECTIVE To increase statistical power, data from SMART-AV patients meeting the inclusion criterion of interventricular delay ≥70 ms were pooled with data from SMART-CRT to reassess AVO. METHODS SMART-CRT and SMART-AV were prospective, randomized, multicenter clinical trials. Patients in both studies were randomized to be programmed with an AVO algorithm (SmartDelay) or fixed AV delay (120 ms). Paired echocardiograms obtained at baseline and 6 months were compared, with CRT response defined as ≥15% reduction in left ventricular end-systolic volume. RESULTS A total of 451 complete patient data sets were pooled and analyzed. The baseline demographics between studies did not differ statistically in terms of age, sex, left ventricular ejection fraction, or left ventricular end-systolic volume. The AVO group had a greater proportion of CRT responders (SmartDelay, 73.9%; fixed, 63.1%; P = .014) and greater changes in measures of reverse remodeling. SmartDelay patients with a recommended sensed AV delay outside the nominal range (100-120 ms) had 2.3 greater odds of CRT response than fixed AV delay patients. CONCLUSION Greater CRT response and measures of reverse remodeling were observed in patients with SmartDelay enabled vs a fixed AV delay. This study supports the use of SmartDelay in patients with a CRT indication and interventricular delay ≥70 ms. CLINICALTRIALS GOV REGISTRATION NCT00677014 and NCT03089281.
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Affiliation(s)
- Michael R Gold
- Medical University of South Carolina, Charleston, South Carolina.
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6
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Bijnens J, Trenson S, Voros G, Martens P, Ingelaere S, Betschart P, Voigt JU, Dupont M, Breitenstein A, Steffel J, Willems R, Ruschitzka F, Mullens W, Winnik S, Vandenberk B. Landmark Evolutions in Time and Indication for Cardiac Resynchronization Therapy: Results from a Multicenter Retrospective Registry. J Clin Med 2024; 13:1903. [PMID: 38610667 PMCID: PMC11012510 DOI: 10.3390/jcm13071903] [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: 02/19/2024] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Cardiac resynchronization therapy (CRT) has evolved into an established therapy for patients with chronic heart failure and a wide QRS complex. Data on long-term outcomes over time are scarce and the criteria for implantation remain a subject of investigation. Methods: An international, multicenter, retrospective registry includes 2275 patients who received CRT between 30 November 2000 and 31 December 2019, with a mean follow-up of 3.6 ± 2.7 years. Four time periods were defined, based on landmark trials and guidelines. The combined endpoint was a composite of all-cause mortality, heart transplantation, or left ventricular assist device implantation. Results: The composite endpoint occurred in 656 patients (29.2%). The mean annual implantation rate tripled from 31.5 ± 17.4/year in the first period to 107.4 ± 62.4/year in the last period. In the adjusted Cox regression analysis, the hazard ratio for the composite endpoint was not statistically different between time periods. When compared to sinus rhythm with left bundle branch block (LBBB), a non-LBBB conduction pattern (sinus rhythm: HR 1.51, 95% CI 1.12-2.03; atrial fibrillation: HR 2.08, 95% CI 1.30-3.33) and a QRS duration below 130 ms (HR 1.64, 95% CI 1.29-2.09) were associated with a higher hazard ratio. Conclusions: Despite innovations, an adjusted regression analysis revealed stable overall survival over time, which can at least partially be explained by a shift in patient characteristics.
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Affiliation(s)
- Jeroen Bijnens
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium (G.V.)
| | - Sander Trenson
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium (G.V.)
- Department of Cardiology, Sint-Jan Hospital Bruges, 8000 Bruges, Belgium
- Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Gabor Voros
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium (G.V.)
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium (M.D.)
| | | | - Pascal Betschart
- Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Jens-Uwe Voigt
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium (G.V.)
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium (M.D.)
| | | | - Jan Steffel
- Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland
- Hirslanden Heart Clinic, 8008 Zurich, Switzerland
| | - Rik Willems
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium (G.V.)
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium (M.D.)
- Department of Life Sciences, Hasselt University, 3500 Hasselt, Belgium
| | - Stephan Winnik
- Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland
- Zurich Regional Health Center Wetzikon, 8620 Zurich, Switzerland
| | - Bert Vandenberk
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium (G.V.)
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
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7
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Dural M, Ghossein MA, Gerrits W, Daniels F, Meine M, Maass AH, Rienstra M, Prinzen FW, Vernooy K, van Stipdonk AMW. Association of vectorcardiographic T-wave area with clinical and echocardiographic outcomes in cardiac resynchronization therapy. Europace 2023; 26:euad370. [PMID: 38146837 PMCID: PMC10766142 DOI: 10.1093/europace/euad370] [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: 10/26/2023] [Accepted: 12/19/2023] [Indexed: 12/27/2023] Open
Abstract
AIMS Data on repolarization parameters in cardiac resynchronization therapy (CRT) are scarce. We investigated the association of baseline T-wave area, with both clinical and echocardiographic outcomes of CRT in a large, multi-centre cohort of CRT recipients. Also, we evaluated the association between the baseline T-wave area and QRS area. METHODS AND RESULTS In this retrospective study, 1355 consecutive CRT recipients were evaluated. Pre-implantation T-wave and QRS area were calculated from vectorcardiograms. Echocardiographic response was defined as a reduction of ≥15% in left ventricular end-systolic volume between 3 and 12 months after implantation. The clinical outcome was a combination of all-cause mortality, heart transplantation, and left ventricular assist device implantation. Left ventricular end-systolic volume reduction was largest in patients with QRS area ≥ 109 μVs and T-wave area ≥ 66 μVs compared with QRS area ≥ 109 μVs and T-wave area < 66 μVs (P = 0.004), QRS area < 109 μVs and T-wave area ≥ 66 μVs (P < 0.001) and QRS area < 109 μVs and T-wave area < 66 μVs (P < 0.001). Event-free survival rate was higher in the subgroup of patients with QRS area ≥ 109 μVs and T-wave area ≥ 66 μVs (n = 616, P < 0.001) and QRS area ≥ 109 μVs and T-wave area < 66 μVs (n = 100, P < 0.001) than the other subgroups. In the multivariate analysis, T-wave area remained associated with echocardiographic response (P = 0.008), but not with the clinical outcome (P = 0.143), when QRS area was included in the model. CONCLUSION Baseline T-wave area has a significant association with both clinical and echocardiographic outcomes after CRT. The association of T-wave area with echocardiographic response is independent from QRS area; the association with clinical outcome, however, is not.
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Affiliation(s)
- Muhammet Dural
- Department of Cardiology, Eskişehir Osmangazi University Faculty of Medicine, Odunpazarı, Eskişehir 26040, Turkey
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht 6202, The Netherlands
| | - Mohammed A Ghossein
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Willem Gerrits
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Fenna Daniels
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mathias Meine
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Alexander H Maass
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht 6202, The Netherlands
| | - Antonius M W van Stipdonk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht 6202, The Netherlands
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8
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Manolis AA, Manolis TA, Manolis AS. Neurohumoral Activation in Heart Failure. Int J Mol Sci 2023; 24:15472. [PMID: 37895150 PMCID: PMC10607846 DOI: 10.3390/ijms242015472] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/16/2023] [Accepted: 10/21/2023] [Indexed: 10/29/2023] Open
Abstract
In patients with heart failure (HF), the neuroendocrine systems of the sympathetic nervous system (SNS), the renin-angiotensin-aldosterone system (RAAS) and the arginine vasopressin (AVP) system, are activated to various degrees producing often-observed tachycardia and concomitant increased systemic vascular resistance. Furthermore, sustained neurohormonal activation plays a key role in the progression of HF and may be responsible for the pathogenetic mechanisms leading to the perpetuation of the pathophysiology and worsening of the HF signs and symptoms. There are biomarkers of activation of these neurohormonal pathways, such as the natriuretic peptides, catecholamine levels and neprilysin and various newer ones, which may be employed to better understand the mechanisms of HF drugs and also aid in defining the subgroups of patients who might benefit from specific therapies, irrespective of the degree of left ventricular dysfunction. These therapies are directed against these neurohumoral systems (neurohumoral antagonists) and classically comprise beta blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers and vaptans. Recently, the RAAS blockade has been refined by the introduction of the angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril/valsartan, which combines the RAAS inhibition and neprilysin blocking, enhancing the actions of natriuretic peptides. All these issues relating to the neurohumoral activation in HF are herein reviewed, and the underlying mechanisms are pictorially illustrated.
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Affiliation(s)
- Antonis A Manolis
- First Department of Cardiology, Evagelismos Hospital, 106 76 Athens, Greece
| | - Theodora A Manolis
- Department of Psychiatry, Aiginiteio University Hospital, 115 28 Athens, Greece
| | - Antonis S Manolis
- First Department of Cardiology, Ippokrateio University Hospital, 115 27 Athens, Greece
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9
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Veres B, Fehérvári P, Engh MA, Hegyi P, Gharehdaghi S, Zima E, Duray G, Merkely B, Kosztin A. Time-trend treatment effect of cardiac resynchronization therapy with or without defibrillator on mortality: a systematic review and meta-analysis. Europace 2023; 25:euad289. [PMID: 37766466 PMCID: PMC10585357 DOI: 10.1093/europace/euad289] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
AIMS This study aimed to investigate the impact of cardiac resynchronization therapy with a defibrillator (CRT-D) on mortality, comparing it with CRT with a pacemaker (CRT-P). Additionally, the study sought to identify subgroups, evaluate the time trend in treatment effects, and analyze patient characteristics, considering the changing indications over the past decades. METHODS AND RESULTS PubMed, CENTRAL, and Embase up to October 2021 were screened for studies comparing CRT-P and CRT-D, focusing on mortality. Altogether 26 observational studies were selected comprising 128 030 CRT patients, including 55 469 with CRT-P and 72 561 with CRT-D device. Cardiac resynchronization therapy with defibrillator was able to reduce all-cause mortality by almost 20% over CRT-P [adjusted hazard ratio (HR): 0.85; 95% confidence interval (CI): 0.76-0.94; P < 0.01] even in propensity-matched studies (HR: 0.83; 95% CI: 0.80-0.87; P < 0.001) but not in those with non-ischaemic aetiology (HR: 0.95; 95% CI: 0.79-1.15; P = 0.19) or over 75 years (HR: 1.08; 95% CI 0.96-1.21; P = 0.17). When treatment effect on mortality was investigated by the median year of inclusion, there was a difference between studies released before 2015 and those thereafter. Time-trend effects could be also observed in patients' characteristics: CRT-P candidates were getting older and the prevalence of ischaemic aetiology was increasing over time. CONCLUSION The results of this systematic review of observational studies, mostly retrospective with meta-analysis, suggest that patients with CRT-D had a lower risk of mortality compared with CRT-P. However, subgroups could be identified, where CRT-D was not superior such as non-ischaemic and older patients. An improved treatment effect of CRT-D on mortality could be observed between the early and late studies partly related to the changed characteristics of CRT candidates.
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Affiliation(s)
- Boglárka Veres
- Heart and Vascular Center, Semmelweis University, Városmajor Str. 68, 1122 Budapest, Hungary
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Fehérvári
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biostatistics, University of Veterinary Medicine, Budapest, Hungary
| | - Marie Anne Engh
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Sara Gharehdaghi
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Gottsegen György National Cardiovascular Institute, Budapest, Hungary
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, Városmajor Str. 68, 1122 Budapest, Hungary
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Gábor Duray
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Central Hospital of Northern Pest-Military Hospital, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Városmajor Str. 68, 1122 Budapest, Hungary
| | - Annamária Kosztin
- Heart and Vascular Center, Semmelweis University, Városmajor Str. 68, 1122 Budapest, Hungary
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
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10
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Boriani G, Bertini M, Manzo M, Calò L, Santini L, Savarese G, Dello Russo A, Santobuono VE, Lavalle C, Viscusi M, Amellone C, Calvanese R, Santoro A, Rapacciuolo A, Ziacchi M, Arena G, Imberti JF, Campari M, Valsecchi S, D’Onofrio A. Performance of a multi-sensor implantable defibrillator algorithm for heart failure monitoring in the presence of atrial fibrillation. Europace 2023; 25:euad261. [PMID: 37656991 PMCID: PMC10498140 DOI: 10.1093/europace/euad261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/14/2023] [Indexed: 09/03/2023] Open
Abstract
AIMS The HeartLogic Index combines data from multiple implantable cardioverter defibrillators (ICDs) sensors and has been shown to accurately stratify patients at risk of heart failure (HF) events. We evaluated and compared the performance of this algorithm during sinus rhythm and during long-lasting atrial fibrillation (AF). METHODS AND RESULTS HeartLogic was activated in 568 ICD patients from 26 centres. We found periods of ≥30 consecutive days with an atrial high-rate episode (AHRE) burden <1 h/day and periods with an AHRE burden ≥20 h/day. We then identified patients who met both criteria during the follow-up (AHRE group, n = 53), to allow pairwise comparison of periods. For control purposes, we identified patients with an AHRE burden <1 h throughout their follow-up and implemented 2:1 propensity score matching vs. the AHRE group (matched non-AHRE group, n = 106). In the AHRE group, the rate of alerts was 1.2 [95% confidence interval (CI): 1.0-1.5]/patient-year during periods with an AHRE burden <1 h/day and 2.0 (95% CI: 1.5-2.6)/patient-year during periods with an AHRE-burden ≥20 h/day (P = 0.004). The rate of HF hospitalizations was 0.34 (95% CI: 0.15-0.69)/patient-year during IN-alert periods and 0.06 (95% CI: 0.02-0.14)/patient-year during OUT-of-alert periods (P < 0.001). The IN/OUT-of-alert state incidence rate ratio of HF hospitalizations was 8.59 (95% CI: 1.67-55.31) during periods with an AHRE burden <1 h/day and 2.70 (95% CI: 1.01-28.33) during periods with an AHRE burden ≥20 h/day. In the matched non-AHRE group, the rate of HF hospitalizations was 0.29 (95% CI: 0.12-0.60)/patient-year during IN-alert periods and 0.04 (95% CI: 0.02-0.08)/patient-year during OUT-of-alert periods (P < 0.001). The incidence rate ratio was 7.11 (95% CI: 2.19-22.44). CONCLUSION Patients received more alerts during periods of AF. The ability of the algorithm to identify increased risk of HF events was confirmed during AF, despite a lower IN/OUT-of-alert incidence rate ratio in comparison with non-AF periods and non-AF patients. CLINICAL TRIAL REGISTRATION http://clinicaltrials.gov/Identifier: NCT02275637.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Matteo Bertini
- Cardiology Department, University of Ferrara, S. Anna University Hospital, Ferrara, Italy
| | - Michele Manzo
- Cardiology Department, OO.RR. San Giovanni di Dio Ruggi d'Aragona, Salerno, Italy
| | - Leonardo Calò
- Division of Cardiology, Policlinico Casilino, Rome, Italy
| | - Luca Santini
- Division of Cardiology, Giovan Battista Grassi’ Hospital, Rome, Italy
| | - Gianluca Savarese
- Division of Cardiology, ‘S. Giovanni Battista’ Hospital, Foligno, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, Ancona, Italy
| | - Vincenzo Ezio Santobuono
- University Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Policlinico di Bari, Bari, Italy
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Miguel Viscusi
- Cardiology Department, S. Anna e S. Sebastiano Hospital, Caserta, Italy
| | | | | | | | - Antonio Rapacciuolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Matteo Ziacchi
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Arena
- Cardiology Department, Ospedale Civile Apuane, Massa (MS), Italy
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Monica Campari
- Rhythm Management Division, Boston Scientific, Milan, Italy
| | | | - Antonio D’Onofrio
- Unità Operativa di Elettrofisiologia, Studio e Terapia delle Aritmie, Monaldi Hospital, Naples, Italy
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11
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Cheng S, Deng Y, Huang H, Yu Y, Niu H, Hua W. Effectiveness of adding a defibrillator with cardiac resynchronization therapy in heart failure according to the modified Model for End-stage Liver Disease-Albumin score. Europace 2023; 25:euad232. [PMID: 37539723 PMCID: PMC10401322 DOI: 10.1093/europace/euad232] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 07/18/2023] [Indexed: 08/05/2023] Open
Abstract
Current guidelines lack clear recommendations between the implantation of cardiac resynchronization therapy (CRT) with defibrillator (CRT-D) and CRT with pacemaker (CRT-P). We hypothesized that modified model for end-stage liver disease score including albumin (MELD-Albumin score), could be used to select patients who may not benefit from CRT-D. We consecutively included patients with CRT-P or CRT-D implantation between 2010 and 2022. The primary endpoint was the composite of all-cause mortality or worsening heart failure. We performed multivariable-adjusted Cox proportional hazard regression. We assessed the interaction between the MELD-Albumin score and the effect of adding a defibrillator with CRT.A total of 752 patients were included in this study, with 291 implanted CRT-P. During a median follow-up of 880 days, 205 patients reached the primary endpoint. MELD-Albumin score was significantly associated with the primary endpoint in the CRT-D group [HR 1.16 (1.09-1.24); P < 0.001] but not in the CRT-P group [HR 1.03 (0.95-1.12); P = 0.49]. There was a significant interaction between the MELD-Albumin score and the effect of CRTD (P = 0.013). The optimal cut-off value of the MELD-Albumin score was 12. For patients with MELD-Albumin ≥ 12, CRT-D was associated with a higher occurrence of the primary endpoint [HR 1.99 (1.10-3.58); P = 0.02], whereas not in patients with MELD-Albumin < 12 [HR 1.19 (0.83-1.70); P = 0.35). Our findings suggest that CRT-D is associated with an excess risk of composite clinical endpoints in HF patients with higher MELD-Albumin score.
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Affiliation(s)
- Sijing Cheng
- The Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Beijing 100037, China
| | - Yu Deng
- The Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Beijing 100037, China
| | - Hao Huang
- The Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Beijing 100037, China
| | - Yu Yu
- The Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Beijing 100037, China
| | - Hongxia Niu
- The Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Beijing 100037, China
| | - Wei Hua
- The Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Beijing 100037, China
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