Implantable Cardioverter-Defibrillators and Cardiac Resynchronization Therapy in Older Adults With Heart Failure

Differences in the prognostic value of the electrocardiographic pattern after cardiac resynchronization therapy according to age

OBJECTIVES

In this cohort study, we analyzed if a specific pattern in three leads of the electrocardiogram (Rs in V1, Qr in aVL, or rS in I) was associated with outcomes after cardiac resynchronization therapy (CRT) depending on age.

METHODS

Patients with CRT devices were included from January 2012 to April 2019. We divided the sample into 2 groups, those with age ≥ 75 years old and those younger. The primary endpoint was a composite of all-cause death and heart failure (HF) hospitalization at 1 year.

RESULTS

We included 111 patients. Patients older than 75 years (26.1%, n = 29) had a significantly higher rate of hypertension and atrial fibrillation and received less frequently optimal medical therapy. The patterns were observed in 32 (39.0%) younger patients and 11 (37.9%) older patients. Patients who presented any of them had a lower incidence of the primary endpoint in the younger group (0 vs. 14%, p = 0.029), but not in the older group (9.1 vs. 27.8%, p = 0.24). The presence of a basal QRS duration greater than 160 ms was associated with a higher rate of the primary endpoint in the elderly (50 vs. 13%, p = 0.015), but not in the younger group (16.7 vs. 7.1%, p = 0.254).

CONCLUSIONS

The presence of the selected patterns after CRT is associated with a lower incidence of all-cause death and hospitalization for HF in patients younger than 75 years, but not in those older than 75 years. Conversely, baseline QRS duration was associated with worse outcomes in older patients, but not in the younger group.

Upregulation of miR-144-3p alleviates Doxorubicin-induced heart failure and cardiomyocytes apoptosis via SOCS2/PI3K/AKT axis

MicroRNAs (miRs) are implicated in heart failure (HF). Thereby, we aim to uncover the role of miR-144-3p in HF. Doxorubicin (Dox)-induced HF model was constructed in rats and cardiomyocytes H9C2, and the cardiac function was determined using ultrasound cardiogram. Morphology of cardiac tissue was observed using hematoxylin-eosin (H&E) staining. The viability and apoptosis of Dox-treated and transfected cardiomyocytes were determined using Cell Counting Kit-8 (CCK-8) assay and flow cytometry. Relative expressions of the HF-associated miRs (including miR-144-3p), suppressor of cytokine signaling 2 (SOCS2), apoptosis- and phosphoinositide 3-kinase (PI3K)/AKT pathway-related factors (B-cell lymphoma 2, Bcl-2; Bcl-2 associated X protein, Bax; cleaved [C] capsase-3; phosphoinositide 3-kinase, PI3K; phosphorylated-PI3K, p-PI3K; p-AKT; AKT) were measured with quantitative real-time polymerase chain reaction or Western blot. Target gene of miR-144-3p was predicted by Starbase and TargetScan and confirmed with dual-luciferase reporter assay. Dox caused rat cardiac dysfunction, aggravated cardiac injury, decreased cardiomyocytes viability, and the expression of miR-144-3p, Bcl-2, and phosphorylation of both PI3K and AKT yet the upregulated those of Bax and C caspase-3, which was reversed by upregulating miR-144-3p, whereas downregulating miR-144-3p did oppositely. SOCS2 was the target gene of miR-144-3p, Dox promoted SOCS2 expression, which was reversed by upregulating miR-144-3p, while downregulating miR-144-3p did conversely. In addition, silencing SOCS2 reversed the effects of miR-144-3p downregulation in Dox-treated cardiomyocytes. Upregulating miR-144-3p alleviated Dox-induced cardiac dysfunction and cell apoptosis via targeting SOCS2, providing a novel evidence of miR-144-3p in HF.

CE: Guideline-Directed Cardiac Devices for Patients with Heart Failure

ABSTRACT

Heart failure affects over 6.2 million adults in the United States and is expected to affect over 8 million by 2030. The U.S. one-year mortality rate is almost 30% among Medicare beneficiaries. Technological advances have produced several new cardiac devices that are available for therapy and symptom management. This article reviews current device therapies for heart failure and uses a composite case to demonstrate how bedside nurses can help patients understand treatment options related to their disease process and care for them through this experience.

Pro-Con Debate: Are Patients With a Cardiovascular Implantable Electronic Device Suitable to Receive Care in a Free-Standing Ambulatory Surgery Center?

Migration of surgical and other procedures that require anesthesia care from a hospital to a free-standing ambulatory surgery center (ASC) continues to grow. Patients with cardiac implantable electronic devices (CIED) might benefit from receiving their care in a free-standing ASC setting. However, these patients have cardiovascular comorbidities that can elevate the risk of major adverse cardiovascular events. CIEDs are also complex devices and perioperative management varies between devices marketed by various manufacturers and require consultation and ancillary services, which may not be available in a free-standing ASC. Thus, perioperative care of these patients can be challenging. Therefore, the suitability of this patient population in a free-standing ASC remains highly controversial. Although applicable advisories exist, considerable discussion continues with surgeons and other proceduralists about the concerns of anesthesiologists. In this Pro-Con commentary article, we discuss the arguments for and against scheduling a patient with a CIED in a free-standing ASC.

HAT2CH2 Score Predicts Systemic Thromboembolic Events in Elderly After Cardiac Electronic Device Implantation

Background: The HAT₂CH₂ score has been evaluated for predicting new onset atrial fibrillation, but never for adverse systemic thromboembolic events (STE) in elderly. We aimed to evaluate the HAT₂CH₂ score and comparing to atrial high rate episodes (AHRE) ≥24 h for predicting STE in older patients with cardiac implantable electronic devices (CIED) implantation.

Methods: We retrospective enrolled 219 consecutive patients ≥ 65 years of age undergoing CIED implantation. The primary endpoint was subsequent STE. For all patients in the cohort, the CHA₂DS₂-VASc, C₂HEST, mC₂HEST, HAVOC, HAT₂CH₂ scores and AHRE ≥ 24 h were determined. AHRE was defined as > 175 bpm lasting ≥ 30 s. Multivariate Cox regression analysis with time-dependent covariates was used to determine variables associated with independent risk of STE.

Results: The median patient age was 77 years, and 61.2% of the cohort was male. During follow-up (median, 35 months), 16 STE occurred (incidence rate, 2.51/100 patient-years; 95% CI, 1.65–5.48). Multiple Cox regression analysis showed that the HAT₂CH₂ score (HR, 3.405; 95% CI, 2.272–5.104; p < 0.001) was an independent predictor for STE. The optimal HAT₂CH₂ score cutoff value was 3, with the highest Youden index (AUC, 0.907; 95% CI, 0.853–0.962; p < 0.001). The STE rate increased with increasing HAT₂CH₂ score (p < 0.001).

Conclusions: This study is the first to show the prognostic value of the HAT₂CH₂ score for STE occurrence in older patients with CIEDs.