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Vandenberk B, Floré V, Röver C, Vos MA, Dunnink A, Leftheriotis D, Friede T, Flevari P, Zabel M, Willems R. Repeating noninvasive risk stratification improves prediction of outcome in ICD patients. Ann Noninvasive Electrocardiol 2020; 25:e12794. [PMID: 32804415 PMCID: PMC7679829 DOI: 10.1111/anec.12794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/12/2020] [Accepted: 06/16/2020] [Indexed: 02/05/2023] Open
Abstract
Background Noninvasive risk stratification aims to detect abnormalities in the pathophysiological mechanisms underlying ventricular arrhythmias. We studied the predictive value of repeating risk stratification in patients with an implantable cardioverter‐defibrillator (ICD). Methods The EUTrigTreat clinical study was a prospective multicenter trial including ischemic and nonischemic cardiomyopathies and arrhythmogenic heart disease. Left ventricular ejection fraction ≤40% (LVEF), premature ventricular complexes >400/24 hr (PVC), non‐negative microvolt T‐wave alternans (MTWA), and abnormal heart rate turbulence (HRT) were considered high risk. Tests were repeated within 12 months after inclusion. Adjusted Cox regression analysis was performed for mortality and appropriate ICD shocks. Results In total, 635 patients had analyzable baseline data with a median follow‐up of 4.4 years. Worsening of LVEF was associated with increased mortality (HR 3.59, 95% CI 1.17–11.04), as was consistent abnormal HRT (HR 8.34, 95%CI 1.06–65.54). HRT improvement was associated with improved survival when compared to consistent abnormal HRT (HR 0.10, 95%CI 0.01–0.82). For appropriate ICD shocks, a non‐negative MTWA test or high PVC count at any moment was associated with increased arrhythmic risk independent of the evolution of test results (worsening: HR 3.76 (95%CI 1.43–9.88) and HR 2.50 (95%CI 1.15–5.46); improvement: HR 2.80 (95%CI 1.03–7.61) and HR 2.45 (95%CI 1.07–5.62); consistent: HR 2.47 (95%CI 0.95–6.45) and HR 2.40 (95%CI 1.33–4.33), respectively). LVEF improvement was associated with a lower arrhythmic risk (HR 0.34, 95%CI 0.12–0.94). Conclusions Repeating LVEF and HRT improved the prediction of mortality, whereas stratification of ventricular arrhythmias may be improved by repeating LVEF measurements, MTWA and ECG Holter monitoring.
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Affiliation(s)
- Bert Vandenberk
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Vincent Floré
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Christian Röver
- Department of Medical Statistics, University Medical Center Göttingen, Gottingen, The Netherlands
| | - Mark A Vos
- Department of Physiology, University Medical Center Utrecht, UMCU, Utrecht, The Netherlands
| | - Albert Dunnink
- Department of Physiology, University Medical Center Utrecht, UMCU, Utrecht, The Netherlands
| | | | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Gottingen, The Netherlands
| | - Panagiota Flevari
- Department of Cardiology, Attikon University Hospital, AUH, Athens, Greece
| | - Markus Zabel
- Department of Cardiology, Heart Centre, University Medical Center Göttingen, Gottingen, The Netherlands
| | - Rik Willems
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
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2
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Zabel M, Schlögl S, Lubinski A, Svendsen JH, Bauer A, Arbelo E, Brusich S, Conen D, Cygankiewicz I, Dommasch M, Flevari P, Galuszka J, Hansen J, Hasenfuß G, Hatala R, Huikuri HV, Kenttä T, Kucejko T, Haarmann H, Harden M, Iovev S, Kääb S, Kaliska G, Katsimardos A, Kasprzak JD, Qavoq D, Lüthje L, Malik M, Novotný T, Pavlović N, Perge P, Röver C, Schmidt G, Shalganov T, Sritharan R, Svetlosak M, Sallo Z, Szavits-Nossan J, Traykov V, Vandenberk B, Velchev V, Vos MA, Willich SN, Friede T, Willems R, Merkely B, Sticherling C. Present criteria for prophylactic ICD implantation: Insights from the EU-CERT-ICD (Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter Defibrillators in EUrope) project. J Electrocardiol 2019; 57S:S34-S39. [PMID: 31526572 DOI: 10.1016/j.jelectrocard.2019.09.001] [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: 05/28/2019] [Revised: 08/28/2019] [Accepted: 09/04/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The clinical effectiveness of primary prevention implantable cardioverter defibrillator (ICD) therapy is under debate. It is urgently needed to better identify patients who benefit from prophylactic ICD therapy. The EUropean Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter Defibrillators (EU-CERT-ICD) completed in 2019 will assess this issue. SUMMARY The EU-CERT-ICD is a prospective investigator-initiated non-randomized, controlled, multicenter observational cohort study done in 44 centers across 15 European countries. A total of 2327 patients with heart failure due to ischemic heart disease or dilated cardiomyopathy indicated for primary prophylactic ICD implantation were recruited between 2014 and 2018 (>1500 patients at first ICD implantation, >750 patients non-randomized non-ICD control group). The primary endpoint was all-cause mortality, and first appropriate shock was co-primary endpoint. At baseline, all patients underwent 12‑lead ECG and Holter-ECG analysis using multiple advanced methods for risk stratification as well as documentation of clinical characteristics and laboratory values. The EU-CERT-ICD data will provide much needed information on the survival benefit of preventive ICD therapy and expand on previous prospective risk stratification studies which showed very good applicability of clinical parameters and advanced risk stratifiers in order to define patient subgroups with above or below average ICD benefit. CONCLUSION The EU-CERT-ICD study will provide new and current data about effectiveness of primary prophylactic ICD implantation. The study also aims for improved risk stratification and patient selection using clinical risk markers in general, and advanced ECG risk markers in particular.
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Affiliation(s)
- Markus Zabel
- Dept. of Cardiology and Pneumology, Heart Center, University Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany.
| | - Simon Schlögl
- Dept. of Cardiology and Pneumology, Heart Center, University Medical Center, Göttingen, Germany
| | - Andrzej Lubinski
- Dept. of Cardiology, Medical University of Lodz (MUL) WAM Hospital, Lodz, Poland
| | - Jesper Hastrup Svendsen
- Dept. of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Axel Bauer
- Dept. of Cardiology, Klinikum Großhadern, Ludwig-Maximilians-Universität Munich, Germany
| | - Elena Arbelo
- IDIBAPS, Dept. of Cardiology, Hospital Clinic Barcelona, Spain
| | - Sandro Brusich
- Dept. of Cardiovascular Disease, KBC Rijeka, Rijeka, Croatia
| | - David Conen
- University Hospital, University of Basel, Switzerland; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Iwona Cygankiewicz
- Dept. of Cardiology, Medical University of Lodz (MUL) CKD Hospital, Lodz, Poland
| | - Michael Dommasch
- Med. Klinik und Poliklinik I, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Panagiota Flevari
- 2nd Dept. of Cardiology, Attikon University Hospital, Athens, Greece
| | - Jan Galuszka
- Dept. of Cardiology, University Hospital, Olomouc, Czech Republic; Faculty of Medicine and Dentistry, Palacký University, Olomouc, Czech Republic
| | | | - Gerd Hasenfuß
- Dept. of Cardiology and Pneumology, Heart Center, University Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Robert Hatala
- Slovak Medical University, Bratislava, Slovakia; NUSCH, Bratislava, Slovakia
| | - Heikki V Huikuri
- Medical Research Center, Oulu University Hospital, Finland; University of Oulu, Finland
| | - Tuomas Kenttä
- Medical Research Center, Oulu University Hospital, Finland; University of Oulu, Finland
| | - Tomasz Kucejko
- Dept. of Cardiology, Medical University of Lodz (MUL) WAM Hospital, Lodz, Poland
| | - Helge Haarmann
- Dept. of Cardiology and Pneumology, Heart Center, University Medical Center, Göttingen, Germany
| | - Markus Harden
- Dept. of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Svetoslav Iovev
- Dept. of Cardiology, St. Ekaterina University Hospital, Sofia, Bulgaria
| | - Stefan Kääb
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Jaroslaw D Kasprzak
- Chair and Dept. of Cardiology, Bieganski Hospital, Medical University of Lodz (MUL), Lodz, Poland
| | - Dariusz Qavoq
- Chair and Dept. of Cardiology, Bieganski Hospital, Medical University of Lodz (MUL), Lodz, Poland
| | - Lars Lüthje
- Dept. of Cardiology and Pneumology, Heart Center, University Medical Center, Göttingen, Germany
| | - Marek Malik
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Tomáš Novotný
- Dept. of Internal Medicine and Cardiology, University Hospital Brno, Masaryk University, Brno, Czech Republic
| | - Nikola Pavlović
- Dept. of Cardiology, KBC Sestre Milosrdnice, Zagreb, Croatia
| | - Peter Perge
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Christian Röver
- Dept. of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Georg Schmidt
- Med. Klinik und Poliklinik I, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | | | - Rajeeva Sritharan
- Dept. of Cardiology and Pneumology, Heart Center, University Medical Center, Göttingen, Germany
| | - Martin Svetlosak
- Slovak Medical University, Bratislava, Slovakia; NUSCH, Bratislava, Slovakia
| | - Zoltan Sallo
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Vassil Traykov
- Dept. of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | | | - Vasil Velchev
- Dept. of Cardiology, St. Anna Hospital, Sofia, Bulgaria
| | - Marc A Vos
- Dept. of Medical Physiology, University Medical Center Utrecht, Netherlands
| | - Stefan N Willich
- Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tim Friede
- DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany; Dept. of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Rik Willems
- University Hospitals of Leuven, Leuven, Belgium
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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3
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Bergau L, Willems R, Sprenkeler DJ, Fischer TH, Flevari P, Hasenfuß G, Katsaras D, Kirova A, Lehnart SE, Lüthje L, Röver C, Seegers J, Sossalla S, Dunnink A, Sritharan R, Tuinenburg AE, Vandenberk B, Vos MA, Wijers SC, Friede T, Zabel M. Differential multivariable risk prediction of appropriate shock versus competing mortality - A prospective cohort study to estimate benefits from ICD therapy. Int J Cardiol 2018; 272:102-107. [PMID: 29983251 DOI: 10.1016/j.ijcard.2018.06.103] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/18/2018] [Accepted: 06/27/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVE We prospectively investigated combinations of risk stratifiers including multiple EP diagnostics in a cohort study of ICD patients. METHODS For 672 enrolled patients, we collected history, LVEF, EP study and T-wave alternans testing, 24-h Holter, NT-proBNP, and the eGFR. All-cause mortality and first appropriate ICD shock were predefined endpoints. RESULTS The 635 patients included in the final analyses were 63 ± 13 years old, 81% were male, LVEF averaged 40 ± 14%, 20% were inducible at EP study, 63% had a primary prophylactic ICD. During follow-up over 4.3 ± 1.5 years, 108 patients died (4.0% per year), and appropriate shock therapy occurred in n = 96 (3.9% per year). In multivariate regression, age (p < 0.001), LVEF (p < 0.001), NYHA functional class (p = 0.007), eGFR (p = 0.024), a history of atrial fibrillation (p = 0.011), and NT-pro-BNP (p = 0.002) were predictors of mortality. LVEF (p = 0.002), inducibility at EP study (p = 0.007), and secondary prophylaxis (p = 0.002) were identified as independent predictors of appropriate shocks. A high annualized risk of shocks of about 10% per year was prevalent in the upper quintile of the shock score. In contrast, a low annual risk of shocks (1.8% per year) was found in the lower two quintiles of the shock score. The lower two quintiles of the mortality score featured an annual mortality <0.6%. CONCLUSIONS In a prospective ICD patient cohort, a very good approximation of mortality versus arrhythmic risk was possible using a multivariable diagnostic strategy. EP stimulation is the best test to assess risk of arrhythmias resulting in ICD shocks.
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Affiliation(s)
- Leonard Bergau
- University Medical Center Göttingen, Dept. of Cardiology and Pneumology, Göttingen, Germany
| | - Rik Willems
- University Hospitals of Leuven, Leuven, Belgium
| | - David J Sprenkeler
- University Medical Center Utrecht, Dept. of Medical Physiology, Utrecht, Netherlands
| | - Thomas H Fischer
- University Medical Center Göttingen, Dept. of Cardiology and Pneumology, Göttingen, Germany
| | - Panayota Flevari
- Attikon University Hospital, Dept. of Cardiology, Athens, Greece
| | - Gerd Hasenfuß
- University Medical Center Göttingen, Dept. of Cardiology and Pneumology, Göttingen, Germany; DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | | | - Aleksandra Kirova
- University Medical Center Göttingen, Dept. of Cardiology and Pneumology, Göttingen, Germany
| | - Stephan E Lehnart
- University Medical Center Göttingen, Dept. of Cardiology and Pneumology, Göttingen, Germany; DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Lars Lüthje
- University Medical Center Göttingen, Dept. of Cardiology and Pneumology, Göttingen, Germany
| | - Christian Röver
- University Medical Center Göttingen, Dept. of Medical Statistics, Göttingen, Germany
| | - Joachim Seegers
- University Medical Center Göttingen, Dept. of Cardiology and Pneumology, Göttingen, Germany; Division of Cardiology, Dept. of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Samuel Sossalla
- University Medical Center Göttingen, Dept. of Cardiology and Pneumology, Göttingen, Germany; Division of Cardiology, Dept. of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Albert Dunnink
- University Medical Center Utrecht, Dept. of Medical Physiology, Utrecht, Netherlands
| | - Rajevaa Sritharan
- University Medical Center Göttingen, Dept. of Cardiology and Pneumology, Göttingen, Germany
| | - Anton E Tuinenburg
- University Medical Center Utrecht, Dept. of Cardiology, Utrecht, Netherlands
| | | | - Marc A Vos
- University Medical Center Utrecht, Dept. of Medical Physiology, Utrecht, Netherlands
| | - Sofieke C Wijers
- University Medical Center Utrecht, Dept. of Medical Physiology, Utrecht, Netherlands; University Medical Center Utrecht, Dept. of Cardiology, Utrecht, Netherlands
| | - Tim Friede
- DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany; University Medical Center Göttingen, Dept. of Medical Statistics, Göttingen, Germany
| | - Markus Zabel
- University Medical Center Göttingen, Dept. of Cardiology and Pneumology, Göttingen, Germany; DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany.
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4
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Du Pre BC, Van Laake LW, Meine M, Van der Heijden JF, Doevendans PA, Vos MA, Van Veen TAB. Analysis of 24-h Rhythm in Ventricular Repolarization Identifies QT Diurnality As a Novel Clinical Parameter Associated with Previous Ventricular Arrhythmias in Heart Failure Patients. Front Physiol 2017; 8:590. [PMID: 28861002 PMCID: PMC5559512 DOI: 10.3389/fphys.2017.00590] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/31/2017] [Indexed: 12/13/2022] Open
Abstract
Introduction: Cardiac repolarization abnormalities are among the major causes of ventricular arrhythmias and sudden cardiac death. In humans, cardiac repolarization duration has a 24-h rhythm. Animal studies show that this rhythm is regulated by 24-h rhythms in ion channel function and that disruption of this rhythm leads to ventricular arrhythmias. We hypothesized that 24-h rhythms in QT duration can be used as a predictor for sudden cardiac death and are associated with ventricular arrhythmias. Secondly, we assessed a possible mechanistic explanation by studying the putative role of hERG channel dysfunction. Materials and Methods: In 2 retrospective studies, measures of the 24-h variation in the QT and QTc intervals (QT and QTc diurnality, QTd and QTcd, respectively) have been derived from Holter analyses and compared between groups: 1) 39 post-infarct patients with systolic heart failure (CHF: EF < 35%), of which 14 with, and 25 without a history of ventricular arrhythmias and 2) five patients with proven (LQTS2) and 16 with potential (Sotalol-induced) hERG channel dysfunction vs. 22 controls. Results: QTd was two-fold higher in CHF patients with a history of ventricular arrhythmias (38 ± 15 ms) compared to CHF patients without VT (16 ± 9 ms, p = 0.001). QTd was significantly increased in LQT2 patients (43 ± 24 ms) or those treated with Sotalol (30 ± 10 ms) compared to controls (21 ± 8 ms, p < 0.05 for both). Discussion: QT diurnality presents a novel clinical parameter of repolarization that can be derived from Holter registrations and may be useful for identification of patients at risk for ventricular arrhythmias.
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Affiliation(s)
- Bastiaan C Du Pre
- Division of Heart and Lungs, Department of Medical Physiology, University Medical Center UtrechtUtrecht, Netherlands.,Division of Heart and Lungs, Department of Cardiology, University Medical Center UtrechtUtrecht, Netherlands
| | - Linda W Van Laake
- Division of Heart and Lungs, Department of Cardiology, University Medical Center UtrechtUtrecht, Netherlands
| | - Matthias Meine
- Division of Heart and Lungs, Department of Cardiology, University Medical Center UtrechtUtrecht, Netherlands
| | - Jeroen F Van der Heijden
- Division of Heart and Lungs, Department of Cardiology, University Medical Center UtrechtUtrecht, Netherlands
| | - Pieter A Doevendans
- Division of Heart and Lungs, Department of Cardiology, University Medical Center UtrechtUtrecht, Netherlands
| | - Marc A Vos
- Division of Heart and Lungs, Department of Medical Physiology, University Medical Center UtrechtUtrecht, Netherlands
| | - Toon A B Van Veen
- Division of Heart and Lungs, Department of Medical Physiology, University Medical Center UtrechtUtrecht, Netherlands
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5
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Kuschyk J, Rudic B, Borggrefe M, Akin I. [Current impact of cardiac implantable electronic devices]. Herz 2017; 42:151-161. [PMID: 28229200 DOI: 10.1007/s00059-017-4548-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Sudden cardiac death and chronic heart failure are among the main contributors to persisting high mortality rates in Germany. In addition to removal of causal factors and guideline-conform pharmacological therapy, therapy with cardiac implantable electronic devices (CIED) is of undisputed importance. Subcutaneous defibrillators have the advantage that they do not have intracardiac electrodes but still have the same efficacy and safety. For patients with a wide QRS complex and reduced ejection fraction, cardiac resynchronization has led to a reduction of morbidity and mortality. For patients with a normal QRS complex, cardiac contractility modulation had been shown to improve the quality of life, exercise capacity and left ventricular function. As a procedure for autonomic modulation in patients with reduced cardiac strength, the data for baroreceptor stimulation are the most convincing.
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Affiliation(s)
- J Kuschyk
- I. Medizinische Klinik, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland. .,Deutsches Zentrum für Herz-Kreislauf-Erkrankungen (DZHK), Mannheim, Deutschland.
| | - B Rudic
- I. Medizinische Klinik, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.,Deutsches Zentrum für Herz-Kreislauf-Erkrankungen (DZHK), Mannheim, Deutschland
| | - M Borggrefe
- I. Medizinische Klinik, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.,Deutsches Zentrum für Herz-Kreislauf-Erkrankungen (DZHK), Mannheim, Deutschland
| | - I Akin
- I. Medizinische Klinik, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.,Deutsches Zentrum für Herz-Kreislauf-Erkrankungen (DZHK), Mannheim, Deutschland
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6
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ICD risk stratification studies – EU-CERT-ICD and the European perspective. J Electrocardiol 2016; 49:831-836. [DOI: 10.1016/j.jelectrocard.2016.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Indexed: 11/19/2022]
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7
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Sprenkeler DJ, Rivaud MR, Vos MA. Do women have less repolarization reserve compared to men? Heart Rhythm 2016; 14:96-97. [PMID: 27737803 DOI: 10.1016/j.hrthm.2016.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Indexed: 11/26/2022]
Affiliation(s)
- David J Sprenkeler
- Department of Medical Physiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mathilde R Rivaud
- Department of Medical Physiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc A Vos
- Department of Medical Physiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands.
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8
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Orosz A, Csajbók É, Czékus C, Gavallér H, Magony S, Valkusz Z, Várkonyi TT, Nemes A, Baczkó I, Forster T, Wittmann T, Papp JG, Varró A, Lengyel C. Increased Short-Term Beat-To-Beat Variability of QT Interval in Patients with Acromegaly. PLoS One 2015; 10:e0125639. [PMID: 25915951 PMCID: PMC4411033 DOI: 10.1371/journal.pone.0125639] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 03/24/2015] [Indexed: 12/23/2022] Open
Abstract
Cardiovascular diseases, including ventricular arrhythmias are responsible for increased mortality in patients with acromegaly. Acromegaly may cause repolarization abnormalities such as QT prolongation and impairment of repolarization reserve enhancing liability to arrhythmia. The aim of this study was to determine the short-term beat-to-beat QT variability in patients with acromegaly. Thirty acromegalic patients (23 women and 7 men, mean age±SD: 55.7±10.4 years) were compared with age- and sex-matched volunteers (mean age 51.3±7.6 years). Cardiac repolarization parameters including frequency corrected QT interval, PQ and QRS intervals, duration of terminal part of T waves (Tpeak-Tend) and short-term variability of QT interval were evaluated. All acromegalic patients and controls underwent transthoracic echocardiographic examination. Autonomic function was assessed by means of five standard cardiovascular reflex tests. Comparison of the two groups revealed no significant differences in the conventional ECG parameters of repolarization (QT: 401.1±30.6 ms vs 389.3±16.5 ms, corrected QT interval: 430.1±18.6 ms vs 425.6±17.3 ms, QT dispersion: 38.2±13.2 ms vs 36.6±10.2 ms; acromegaly vs control, respectively). However, short-term beat-to-beat QT variability was significantly increased in acromegalic patients (4.23±1.03 ms vs 3.02±0.80, P<0.0001). There were significant differences between the two groups in the echocardiographic dimensions (left ventricular end diastolic diameter: 52.6±5.4 mm vs 48.0±3.9 mm, left ventricular end systolic diameter: 32.3±5.2 mm vs 29.1±4.4 mm, interventricular septum: 11.1±2.2 mm vs 8.8±0.7 mm, posterior wall of left ventricle: 10.8±1.4 mm vs 8.9±0.7 mm, P<0.05, respectively). Short-term beat-to-beat QT variability was elevated in patients with acromegaly in spite of unchanged conventional parameters of ventricular repolarization. This enhanced temporal QT variability may be an early indicator of increased liability to arrhythmia.
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Affiliation(s)
- Andrea Orosz
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Éva Csajbók
- 1st Department of Internal Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Csilla Czékus
- 1st Department of Internal Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Henriette Gavallér
- 2nd Department of Internal Medicine and Cardiology Center, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Sándor Magony
- 1st Department of Internal Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Zsuzsanna Valkusz
- 1st Department of Internal Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Tamás T. Várkonyi
- 1st Department of Internal Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Attila Nemes
- 2nd Department of Internal Medicine and Cardiology Center, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - István Baczkó
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Tamás Forster
- 2nd Department of Internal Medicine and Cardiology Center, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Tibor Wittmann
- 1st Department of Internal Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Julius Gy. Papp
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Szeged, Hungary
- MTA-SZTE Research Group of Cardiovascular Pharmacology, Hungarian Academy of Sciences, Szeged, Hungary
| | - András Varró
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Szeged, Hungary
- MTA-SZTE Research Group of Cardiovascular Pharmacology, Hungarian Academy of Sciences, Szeged, Hungary
| | - Csaba Lengyel
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Szeged, Hungary
- 1st Department of Internal Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
- * E-mail:
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9
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Abstract
Heart rate turbulence (HRT) is a baroreflex-mediated biphasic reaction of heart rate in response to premature ventricular beats. Heart rate turbulence is quantified by: turbulence onset (TO) reflecting the initial acceleration of heart rate following premature beat and turbulence slope (TS) describing subsequent deceleration of heart rate. Abnormal HRT identifies patients with autonomic dysfunction or impaired baroreflex sensitivity due to variety of disorders, but also may reflect changes in autonomic nervous system induced by different therapeutic modalities such as drugs, revascularization, or cardiac resynchronization therapy. More importantly, impaired HRT has been shown to identify patients at high risk of all-cause mortality and sudden death, particularly in postinfarction and congestive heart failure patients. It should be emphasized that abnormal HRT has a well-established role in stratification of postinfarction and heart failure patients with relatively preserved left ventricular ejection fraction. The ongoing clinical trials will document whether HRT can be used to guide implantation of cardioverter-defibrillators in this subset of patients, not covered yet by ICD guidelines. This review focuses on the current state-of-the-art knowledge regarding clinical significance of HRT in detection of autonomic dysfunction and regarding the prognostic significance of this parameter in predicting all-cause mortality and sudden death.
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Affiliation(s)
- Iwona Cygankiewicz
- Department of Electrocardiology, Medical University of Lodz, Sterling Regional Center for Heart Diseases, 91-425 Lodz, Poland.
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10
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Disertori M, Quintarelli S, Mazzola S, Favalli V, Narula N, Arbustini E. The need to modify patient selection to improve the benefits of implantable cardioverter-defibrillator for primary prevention of sudden death in non-ischaemic dilated cardiomyopathy. Europace 2013; 15:1693-701. [PMID: 23946316 DOI: 10.1093/europace/eut228] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Left ventricular ejection fraction (LVEF) ≤35% is a major determinant for implantable cardioverter-defibrillator (ICD) therapy for primary prevention of sudden death (SD) in patients with non-ischaemic dilated cardiomyopathy (DCM). However, as a risk marker for SD, low LVEF has limited sensibility and specificity. Selecting patients according to the current guidelines shows that most DCM patients do not actually benefit from ICD implantation and may suffer collateral effects and that many patients who are at risk of SD are not identified because a large proportion of SD patients exhibit only mildly depressed LVEF. Identifying patients who are at risk of SD on the sole basis of LVEF appears to be an over-simplification which does not maximize the benefit of ICD therapy. Owing to the complexity of the substrates underlying SD, multiple risk factors used in combination could probably predict the risk of SD better than any individual risk marker. Among non-invasive tests, microvolt T-wave alternans and cardiac magnetic resonance with late gadolinium enhancement may contribute to a better SD risk stratification by their high negative predictive value. Genetics may further contribute because approximately one-third of DCM patients have evidence of familial disease, and mutations in some known disease genes, including LMNA, have been associated with a high risk of SD. In this review, we critically analyse the current indications for ICD implantation and we explore existing knowledge about potentially predicting markers for selecting DCM patients who are at high and low risk of SD.
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Affiliation(s)
- Marcello Disertori
- Healthcare Research and Innovation Program, IRCS-FBK, 38123, Trento, Italy
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11
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Wijers SC, van der Kolk BYM, Tuinenburg AE, Doevendans PAF, Vos MA, Meine M. Implementation of guidelines for implantable cardioverter-defibrillator therapy in clinical practice: Which patients do benefit? Neth Heart J 2013; 21:274-83. [PMID: 23572330 PMCID: PMC3661880 DOI: 10.1007/s12471-013-0407-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Based on multiple large clinical trials conducted over the last decades guidelines for implantable cardioverter-defibrillator (ICD) implantations have been evolving. The increase in primary prophylactic ICD implantations challenges us to be critical towards the indications in certain patient populations. METHODS We retrospectively collected patient characteristics and rates of appropriate and inappropriate ICD therapy, appropriate and inappropriate ICD shock and mortality of all patients who received an ICD in the University Medical Center Utrecht (UMCU) over the years 2006-2011. RESULTS A total of 1075 patients were included in this analysis (74 % male, mean age 61 ± 13 years, left ventricular ejection fraction 30 ± 13 %); 61 % had a primary indication and 58 % had ischaemic heart disease. During a mean follow-up period of 31 ± 17 months, 227 of the patients (21 %) received appropriate ICD therapy (149 (14 %) patients received an appropriate ICD shock). Females, patients with a primary prophylactic indication and patients with non-ischaemic heart disease experienced significantly less ICD therapy. Only a few patients (54, 5 %) received inappropriate ICD therapy; 33 (3 %) patients received an inappropriate ICD shock. Fifty-five patients died within one year after ICD implantation and were therefore, in retrospect, not eligible for ICD implantation. CONCLUSION Our study confirms the benefit of ICD implantation in clinical practice. Nevertheless, certain patients experience less benefit than others. A more patient-tailored risk stratification based on electrophysiological parameters would be lucrative to improve clinical benefit and cost-effectiveness.
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Affiliation(s)
- S C Wijers
- Department of Medical Physiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands,
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12
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Beat-to-beat variability of repolarization as a new biomarker for proarrhythmia in vivo. Heart Rhythm 2012; 9:1718-26. [DOI: 10.1016/j.hrthm.2012.05.016] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Indexed: 11/20/2022]
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13
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Wijers SC, Vos MA, Meine M. Microvolt T-wave alternans in an unselected heart failure population: pros and cons. Eur J Heart Fail 2012; 14:344-7. [PMID: 22431405 DOI: 10.1093/eurjhf/hfs032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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