Cardiac Resynchronisation Therapy and Heart Failure: Persepctive from 5P Medicine

Association between frailty and adverse outcomes after cardiac resynchronization therapy: a systematic review and meta-analysis

AIM

To synthesize evidence, using data from published studies, on the association of frailty with the outcomes after cardiac resynchronization therapy (CRT).

METHODS

The systematic search of PubMed, Web of Science, Scopus, and Embase databases was done to identify observational studies (cohort/case-control/cross-sectional) that used an objective method for frailty assessment and had presented adjusted effect sizes. STATA version 15.0 was used to conduct analysis, which was based on random effects model.

RESULTS

Fifteen studies were included. Frailty was found to be associated with an increased risk of in-hospital mortality (odds ratio (OR) 6.96, 95% confidence interval (CI) 5.48, 8.85). The effect of frailty on the response to CRT was not statistically significant (OR 0.55, 95% CI 0.19, 1.59). The pooled effect size indicated that frailty was associated with somewhat bigger but not statistically significant increase in the risk of complications (OR 1.70, 95% CI 0.93, 3.12). The risks of mortality and decompensated heart failure on long-term follow up were higher in frail patients (Hazard ratio (HR) 1.75, 95% CI 1.40, 2.17 and HR 3.03, 95% CI 1.33, 6.90, respectively) compared to patients without frailty. The risk of readmission was higher in frail patients, however, it did not achieve statistical significance (HR 2.63, 95% CI 0.89, 7.75).

CONCLUSION

Frail CRT patients could be at higher risks of mortality, decompensated heart failure, and may have potentially higher rates of complications. Integrating frailty assessment into pre-CRT evaluation and customizing interventions for frail patients might be an essential steps towards enhancing outcomes in this population.

Smart Pacemaker: A Review

Since the first pacemaker was implanted, nearly 60 years have passed. Since then, pacemaker technology has made major advancements that have increased both its safety and effectiveness in treating people with bradyarrhythmias. The repeated stimulation of cells in specialized "pacemaker" regions of the mammalian heart and the transmission of stimulus via the ventricles serve as evidence that the electrical function of the mammalian heart is necessary for a regular mechanical (pump) role. The development of action potentials in individual cardiac cells is linked to myocardial electrical activity and the heart's regular cooperative electrical functioning. A container or pulse initiator that houses the battery and electronics, as well as lines that connect to the myocardium to deliver a depolarizing pulse and detect intrinsic cardiac stimulation, are all parts of a pacemaker. Defibrillators could be used with artificial hearts that have electrical pacemakers integrated into them in order to treat arrhythmia, heart failure, and cardiac arrest. Modern pacemakers have units for supporting patients with other disorders like "heart failure," which happens when the heart does not pump as forcefully as it should. While many pacemakers are effective in treating different types of arrhythmias (irregular heartbeats), they also have units for treating them.

Cost-Effectiveness of Cardiac Resynchronization Therapy in Patients with Heart Failure in Thailand

Background

Cardiac resynchronization therapy (CRT) improves symptoms and survival in patients with heart failure (HF). However, the CRT devices are costly and can impose a significant burden to the relatively constrained health budgets of middle-income countries such as Thailand. The aim of this study was to analyze the cost-effectiveness of CRT in combination with optimal medical therapy (OMT) relative to patients with OMT alone.

Methods

A two-component model was used to analyze lifetime costs and quality-adjusted life-years (QALYs) from a healthcare perspective. Clinical inputs were mostly obtained from meta-analysis of landmark trials. All cost-related data, risk of non-cardiovascular death and readmission rate were based on Thai HF data. Costs and QALYs were discounted at 3%. Findings were reported as an incremental cost-effectiveness ratio (ICER). A variety of sensitivity analyses were also performed.

Results

CRT plus OMT costs more than OMT (123,279 vs 11,165 THB or 3,972.90 vs 359.81 USD), and is more effective (3.57 QALYs vs 2.49 QALYs), yielding an ICER of 104,325 THB per QALY (3,362.07 USD per QALY). CRT was cost-effective at the Thai willingness to pay threshold of 160,000 THB per QALY (5,156.30 USD per QALY). The results were sensitive to cost of CRT maintenance.

Conclusion

The use of CRT was associated with a cost-effectiveness ratio below generally accepted benchmarks for therapeutic interventions of 160,000 THB per QALY (5,156.30 USD per QALY). This suggests that the clinical benefits of CRT can be achieved at a reasonable cost in Thai HF patients.

Patients are expecting to learn more: A longitudinal study of patients with heart failure undergoing device implantation

OBJECTIVE

To explore the educational expectations and experiences of patients with heart failure in relation to device implantation.

METHODS

In this longitudinal study, patients at six Swedish and Icelandic hospitals answered instruments about their knowledge expectations, before the device implantation, and about the knowledge they had received at two weeks, six months and 12 months after the procedure. Predictors for fulfillment of knowledge expectations were assessed with linear mixed model analysis.

RESULTS

Patients (N = 133, mean age 69.8 (±9.7) years, 80 % men) had high knowledge expectations, which for 83 % of them were unfulfilled. Predictors for fulfillment of knowledge expectations were access to knowledge from healthcare professionals (β 0.74, 95 % CI: 0.42-1.10), educational level (β -0.30, 95 % CI: -0.52 to -0.07) and knowledge expectations (β -1.03, 95 % CI: -1.30 to -0.80). Healthcare professionals were the main information source (89 %), 74 % of patients received written information, and 19 % had used the Internet.

CONCLUSIONS

Patients receive less knowledge than they expect, and individual factors and communication with healthcare professionals are related to their experience. Face-to-face is the most common method of delivering education.

PRACTICE IMPLICATIONS

Healthcare professionals should assess patients' expectations for information and consider implementing more diversity in their educational practices.