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Ahmed FZ, Sammut-Powell C, Martin GP, Callan P, Cunnington C, Kahn M, Kale M, Weldon T, Harwood R, Fullwood C, Gerritse B, Lanctin D, Soken N, Campbell NG, Taylor JK. Association of a device-based remote management heart failure pathway with outcomes: TriageHF Plus real-world evaluation. ESC Heart Fail 2024. [PMID: 38712903 DOI: 10.1002/ehf2.14821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/08/2024] [Accepted: 04/02/2024] [Indexed: 05/08/2024] Open
Abstract
AIMS Clinical pathways have been shown to improve outcomes in patients with heart failure (HF). Although patients with HF often have a cardiac implantable electronic device, few studies have reported the utility of device-derived risk scores to augment and organize care. TriageHF Plus is a device-based HF clinical pathway (DHFP) that uses remote monitoring alerts to trigger structured telephone assessment for HF stability and optimization. We aimed to evaluate the impact of TriageHF Plus on hospitalizations and describe the associated workforce burden. METHODS AND RESULTS TriageHF Plus was a multi-site, prospective study that compared outcomes for patients recruited between April 2019 and February 2021. All alert-triggered assessments were analysed to determine the appropriateness of the alert and the workload burden. A negative-binomial regression with inverse probability treatment weighting using a time-matched usual care cohort was applied to estimate the effect of TriageHF Plus on non-elective hospitalizations. A post hoc pre-COVID-19 sensitivity analysis was also performed. The TriageHF Plus cohort (n = 443) had a mean age of 68.8 ± 11.2 years, 77% male (usual care cohort: n = 315, mean age of 66.2 ± 14.5 years, 65% male). In the TriageHF Plus cohort, an acute medical issue was identified following an alert in 79/182 (43%) cases. Fifty assessments indicated acute HF, requiring clinical action in 44 cases. At 30 day follow-up, 39/66 (59%) of initially symptomatic patients reported improvement, and 20 (19%) initially asymptomatic patients had developed new symptoms. On average, each assessment took 10 min. The TriageHF Plus group had a 58% lower rate of hospitalizations across full follow-up [incidence relative ratio: 0.42, 95% confidence interval (CI): 0.23-0.76, P = 0.004]. Across the pre-COVID-19 window, hospitalizations were 31% lower (0.69, 95% CI: 0.46-1.04, P = 0.077). CONCLUSIONS These data represent the largest real-world evaluation of a DHFP based on multi-parametric risk stratification. The TriageHF Plus clinical pathway was associated with an improvement in HF symptoms and reduced all-cause hospitalizations.
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Affiliation(s)
- Fozia Zahir Ahmed
- Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Camilla Sammut-Powell
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Glen P Martin
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Paul Callan
- Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Colin Cunnington
- Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Matthew Kahn
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Mita Kale
- Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Toni Weldon
- Department of Cardiology, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Rachel Harwood
- Statistics Department, Research and Innovation, Manchester University NHS Foundation Trust, Manchester, UK
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Catherine Fullwood
- Statistics Department, Research and Innovation, Manchester University NHS Foundation Trust, Manchester, UK
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | | | | | - Niall G Campbell
- Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Joanne K Taylor
- Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Taylor JK, Ahmed FZ. Clinical Pathways Guided by Remotely Monitoring Cardiac Device Data: The Future of Device Heart Failure Management? Arrhythm Electrophysiol Rev 2023; 12:e15. [PMID: 37427299 PMCID: PMC10326671 DOI: 10.15420/aer.2022.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/03/2022] [Indexed: 07/11/2023] Open
Abstract
Research examining the utility of cardiac device data to manage patients with heart failure (HF) is rapidly evolving. COVID-19 has reignited interest in remote monitoring, with manufacturers each developing and testing new ways to detect acute HF episodes, risk stratify patients and support self-care. As standalone diagnostic tools, individual physiological metrics and algorithm-based systems have demonstrated utility in predicting future events, but the integration of remote monitoring data with existing clinical care pathways for device HF patients is not well described. This narrative review provides an overview of device-based HF diagnostics available to care providers in the UK, and describes the current state of play with regard to how these systems fit in with current HF management.
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Affiliation(s)
- Joanne K Taylor
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Fozia Zahir Ahmed
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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3
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Ahmed FZ, Sammut-Powell C, Martin GP, Callan P, Cunnington C, Kale M, Gerritse B, Lanctin D, Soken N, Campbell NG, Taylor JK. Use of a device-based remote management heart failure care pathway is associated with reduced hospitalization and improved patient outcomes: TriageHF Plus real-world evaluation. Eur Heart J 2022. [PMCID: PMC9619664 DOI: 10.1093/eurheartj/ehac544.2814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Heart failure (HF) is a leading cause of hospital admission. However, prompt identification of worsening HF using implantable device data and proactive intervention may reduce hospitalizations. The validated TriageHF algorithm in enabled ICD/CRT devices uses sensor data to risk stratify patients for HF hospitalization in the next 30 days. TriageHF Plus is a novel device-based HF care pathway (DHFP) that uses “high” risk status as the trigger for remote intervention (see Figure 1 for pathway overview). Outcomes after DHFP implementation in a clinical setting have not been examined. Purpose To evaluate the impact of TriageHF Plus clinical pathway on hospitalisation rates. Methods A prospective, multi-center evaluation comparing monthly hospitalization rates for patients enrolled in a DHFP with a concurrent standard of care (SoC) cohort and characterizing staffing resources necessary to implement the DHFP. The DHFP cohort received telephonic assessment and guideline-directed clinical care upon transition to high-risk status. Propensity scores (PS) were applied to DHFP and SoC cohorts to allow unbiased comparison. A negative binomial model was fitted to the monthly number of all-cause hospitalizations with treatment group (DHFP vs. SoC) as a covariate, using PS as weights. Results Between 09/11/2019 and 06/24/2021, 758 patients were included in the study (443 DHFP, 315 SoC). Proportion CRT 76%/ 89% and LVEF <50% 78%/ 66% for DHFP/ SoC, respectively. 196 high risk transmissions prompted telephone assessment, with successful contact in 182; of which, 79 (43%) identified an explanatory acute medical issue. A secondary intervention was undertaken in 44/79 (56%). High risk transmissions took on average 19 minutes per clinical assessment (initial telephone triage and 30 day follow up). The rate of hospitalizations was 58% lower in the DHFP group, compared with SoC, after PS adjustment (IRR 0.42, 95% CI: 0.23, 0.76, p=0.004), see Figure 2. Sensitivity analyses showed Covid-19 had little effect on results. Conclusions This is the first prospective, real-world evaluation of a device-based HF care pathway to report a reduction in hospitalizations and does so with minimal staffing time. Integrated into existing HF services, device-based remote monitoring of HF patients can improve outcomes. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Medtronic
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Affiliation(s)
- F Z Ahmed
- Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - C Sammut-Powell
- University of Manchester, Division of Informatics, Imaging and Data Science , Manchester , United Kingdom
| | - G P Martin
- University of Manchester, Division of Informatics, Imaging and Data Science , Manchester , United Kingdom
| | - P Callan
- Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - C Cunnington
- Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - M Kale
- North Manchester General Hospital , Manchester , United Kingdom
| | - B Gerritse
- Medtronic, Inc. , Minneapolis , United States of America
| | - D Lanctin
- Medtronic, Inc. , Minneapolis , United States of America
| | - N Soken
- Medtronic, Inc. , Minneapolis , United States of America
| | - N G Campbell
- Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - J K Taylor
- University of Manchester, Division of Informatics, Imaging and Data Science , Manchester , United Kingdom
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4
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Sammut‐Powell C, Taylor JK, Motwani M, Leonard CM, Martin GP, Ahmed FZ. Remotely Monitored Cardiac Implantable Electronic Device Data Predict All-Cause and Cardiovascular Unplanned Hospitalization. J Am Heart Assoc 2022; 11:e024526. [PMID: 35943063 PMCID: PMC9496305 DOI: 10.1161/jaha.121.024526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Unplanned hospitalizations are common in patients with cardiovascular disease. The "Triage Heart Failure Risk Status" (Triage-HFRS) algorithm in patients with cardiac implantable electronic devices uses data from up to 9 device-derived physiological parameters to stratify patients as low/medium/high risk of 30-day heart failure (HF) hospitalization, but its use to predict all-cause hospitalization has not been explored. We examined the association between Triage-HFRS and risk of all-cause, cardiovascular, or HF hospitalization. Methods and Results A prospective observational study of 435 adults (including patients with and without HF) with a Medtronic Triage-HFRS-enabled cardiac implantable electronic device (cardiac resynchronization therapy device, implantable cardioverter-defibrillator, or pacemaker). Cox proportional hazards models explored association between Triage-HFRS and time to hospitalization; a frailty term at the patient level accounted for repeated measures. A total of 274 of 435 patients (63.0%) transmitted ≥1 high HFRS transmission before or during the study period. The remaining 161 patients never transmitted a high HFRS. A total of 153 (32.9%) patients had ≥1 unplanned hospitalization during the study period, totaling 356 nonelective hospitalizations. A high HFRS conferred a 37.3% sensitivity and an 86.2% specificity for 30-day all-cause hospitalization; and for HF hospitalizations, these numbers were 62.5% and 85.6%, respectively. Compared with a low Triage-HFRS, a high HFRS conferred a 4.2 relative risk of 30-day all-cause hospitalization (8.5% versus 2.0%), a 5.0 relative risk of 30-day cardiovascular hospitalization (3.6% versus 0.7%), and a 7.7 relative risk of 30-day HF hospitalization (2.0% versus 0.3%). Conclusions In patients with cardiac implantable electronic devices, remotely monitored Triage-HFRS data discriminated between patients at high and low risk of all-cause hospitalization (cardiovascular or noncardiovascular) in real time.
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Affiliation(s)
- Camilla Sammut‐Powell
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and HealthUniversity of Manchester, Manchester Academic Health Science CentreManchesterUnited Kingdom
| | - Joanne K. Taylor
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and HealthUniversity of Manchester, Manchester Academic Health Science CentreManchesterUnited Kingdom
| | - Manish Motwani
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterUnited Kingdom,Department of CardiologyManchester University Hospitals National Health Service Foundation TrustManchesterUnited Kingdom
| | | | - Glen P. Martin
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and HealthUniversity of Manchester, Manchester Academic Health Science CentreManchesterUnited Kingdom
| | - Fozia Zahir Ahmed
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterUnited Kingdom,Department of CardiologyManchester University Hospitals National Health Service Foundation TrustManchesterUnited Kingdom
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5
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Bachtiger P, Park S, Letchford E, Scott F, Barton C, Ahmed FZ, Cole G, Keene D, Plymen CM, Peters NS. Triage-HF plus: 12-month study of remote monitoring pathway for triage of heart failure risk initiated during the Covid-19 pandemic. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The Covid-19 pandemic necessitated rapid adoption of remote monitoring across cardiovascular patient cohorts. Most patients with cardiac implantable electronic devices (CIEDs) are now able to be remotely monitored using either scheduled, patient- or threshold-triggered transmissions. The validated “Triage Heart Failure Risk Score” (Triage-HFRS) is a medical algorithm within company-specific CIEDs that can risk-stratify patients as low-, medium- or high-risk of worsening heart failure (WHF) in the next 30 days based on integrated monitoring of physiological parameters. Building on a previous proof-of-concept of the Triage-HF Plus pathway, we integrated remote data with simple 5-question telephone triage within a clinical pathway to identify WHF during the first year of the Covid-19 pandemic.
Purpose
Prospective evaluation of clinical remote monitoring pathway integrating Triage-HFRS with protocolised telephone triage (Triage-HF Plus pathway).
Methods
Prospective, real-world evaluation of clinical pathway serving a large urban region over a 12-month period, using data from April 2020 to April 2021 (initiated during the first wave of Covid-19 pandemic in the UK). From a population of 435 patients with CIEDs, 87 “high” Triage-HFRS alerts were received and patients contacted for telephone triage assessment. Screening questions were designed to identify episodes of WHF and non-HF events. Intervention was at discretion of the clinical practitioner and in line with guideline-directed practice. A consecutive sample of 115 “medium” risk scores received the same triage.
Results
Successful contact was made with 72 (82.8%) high-risk patients. Classification for high scoring patients confirmed on triage included isolated heart failure (18.3%), heart failure concurrent to medical problem (5.7%), alternative medical problem (10.3%), and recent hospital admission (8.0%); triage reassured absence of acute cause of high score in 40.2%. The sensitivity and specificity for detection of WHF was 87.9% (0.77–0.99) and 59.4% (0.50–0.69) respectively. Positive and negative predictive values were 40.3% and 94.0%, respectively. Overall accuracy was 66.2%.
Conclusions
The Triage-HF Plus pathway served as a useful remote monitoring tool for identifying patients with WHF whose care had been otherwise disrupted by the Covid-19 pandemic, allowing timely intervention and cementing the longer-term role for such models of care delivery. Crucially, in this multimorbid, high-cost population, relevant non-HF issues were also identified. The high negative predictive value further highlights the potential of proactive surveillance over conventional, periodic follow up.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Imperial Health Charity
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Affiliation(s)
- P Bachtiger
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - S Park
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - E Letchford
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - F Scott
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - C Barton
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - F Z Ahmed
- University of Manchester, Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, Manchester, United Kingdom
| | - G Cole
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - D Keene
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - C M Plymen
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - N S Peters
- National Heart and Lung Institute Imperial College, London, United Kingdom
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6
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Ahmed FZ, Sammut-Powell C, Kwok CS, Tay T, Motwani M, Martin GP, Taylor JK. Remote monitoring data from cardiac implantable electronic devices predicts all-cause mortality. Europace 2021; 24:245-255. [PMID: 34601572 PMCID: PMC8824524 DOI: 10.1093/europace/euab160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Indexed: 11/13/2022] Open
Abstract
Aims To determine if remotely monitored physiological data from cardiac implantable electronic devices (CIEDs) can be used to identify patients at high risk of mortality. Methods and results This study evaluated whether a risk score based on CIED physiological data (Triage-Heart Failure Risk Status, ‘Triage-HFRS’, previously validated to predict heart failure (HF) events) can identify patients at high risk of death. Four hundred and thirty-nine adults with CIEDs were prospectively enrolled. Primary observed outcome was all-cause mortality (median follow-up: 702 days). Several physiological parameters [including heart rate profile, atrial fibrillation/tachycardia (AF/AT) burden, ventricular rate during AT/AF, physical activity, thoracic impedance, therapies for ventricular tachycardia/fibrillation] were continuously monitored by CIEDs and dynamically combined to produce a Triage-HFRS every 24 h. According to transmissions patients were categorized into ‘high-risk’ or ‘never high-risk’ groups. During follow-up, 285 patients (65%) had a high-risk episode and 60 patients (14%) died (50 in high-risk group; 10 in never high-risk group). Significantly more cardiovascular deaths were observed in the high-risk group, with mortality rates across groups of high vs. never-high 10.3% vs. <4.0%; P = 0.03. Experiencing any high-risk episode was associated with a substantially increased risk of death [odds ratio (OR): 3.07, 95% confidence interval (CI): 1.57–6.58, P = 0.002]. Furthermore, each high-risk episode ≥14 consecutive days was associated with increased odds of death (OR: 1.26, 95% CI: 1.06–1.48; P = 0.006). Conclusion Remote monitoring data from CIEDs can be used to identify patients at higher risk of all-cause mortality as well as HF events. Distinct from other prognostic scores, this approach is automated and continuously updated.
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Affiliation(s)
- Fozia Zahir Ahmed
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Oxford Rd, Manchester, UK
| | - Camilla Sammut-Powell
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Chun Shing Kwok
- School of Primary, Community and Social Care, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Tricia Tay
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Manish Motwani
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Oxford Rd, Manchester, UK
| | - Glen P Martin
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Joanne K Taylor
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Lewis GA, Dodd S, Clayton D, Bedson E, Eccleson H, Schelbert EB, Naish JH, Jimenez BD, Williams SG, Cunnington C, Ahmed FZ, Cooper A, Rajavarma Viswesvaraiah, Russell S, McDonagh T, Williamson PR, Miller CA. Pirfenidone in heart failure with preserved ejection fraction: a randomized phase 2 trial. Nat Med 2021; 27:1477-1482. [PMID: 34385704 DOI: 10.1038/s41591-021-01452-0] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 06/25/2021] [Indexed: 11/09/2022]
Abstract
In heart failure with preserved ejection fraction (HFpEF), the occurrence of myocardial fibrosis is associated with adverse outcome. Whether pirfenidone, an oral antifibrotic agent without hemodynamic effect, is efficacious and safe for the treatment of HFpEF is unknown. In this double-blind, phase 2 trial ( NCT02932566 ), we enrolled patients with heart failure, an ejection fraction of 45% or higher and elevated levels of natriuretic peptides. Eligible patients underwent cardiovascular magnetic resonance and those with evidence of myocardial fibrosis, defined as a myocardial extracellular volume of 27% or greater, were randomly assigned to receive pirfenidone or placebo for 52 weeks. Forty-seven patients were randomized to each of the pirfenidone and placebo groups. The primary outcome was change in myocardial extracellular volume, from baseline to 52 weeks. In comparison to placebo, pirfenidone reduced myocardial extracellular volume (between-group difference, -1.21%; 95% confidence interval, -2.12 to -0.31; P = 0.009), meeting the predefined primary outcome. Twelve patients (26%) in the pirfenidone group and 14 patients (30%) in the placebo group experienced one or more serious adverse events. The most common adverse events in the pirfenidone group were nausea, insomnia and rash. In conclusion, among patients with HFpEF and myocardial fibrosis, administration of pirfenidone for 52 weeks reduced myocardial fibrosis. The favorable effects of pirfenidone in patients with HFpEF will need to be confirmed in future trials.
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Affiliation(s)
- Gavin A Lewis
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Susanna Dodd
- Department of Health Data Science, University of Liverpool, a Member of Liverpool Health Partners, Liverpool, UK
| | - Dannii Clayton
- Liverpool Clinical Trials Centre, University of Liverpool, Institute of Child Health, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Emma Bedson
- Liverpool Clinical Trials Centre, University of Liverpool, Institute of Child Health, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Helen Eccleson
- Liverpool Clinical Trials Centre, University of Liverpool, Institute of Child Health, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Erik B Schelbert
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Cardiovascular Magnetic Resonance Center, Heart and Vascular Institute, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Josephine H Naish
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | | | | | | | - Fozia Zahir Ahmed
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Anne Cooper
- Salford Royal NHS Foundation Trust, Salford, UK
| | | | | | | | - Paula R Williamson
- Department of Health Data Science, University of Liverpool, a Member of Liverpool Health Partners, Liverpool, UK
| | - Christopher A Miller
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
- Manchester University NHS Foundation Trust, Manchester, UK.
- Wellcome Centre for Cell-Matrix Research, Division of Cell-Matrix Biology & Regenerative Medicine, School of Biology, Faculty of Biology, Medicine & Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
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Guella E, Devereux F, Ahmed FZ, Scott P, Cunnington C, Zaidi A. Novel atrioventricular sequential pacing approach using a transvenous atrial pacemaker and a leadless pacemaker: a case report. Eur Heart J Case Rep 2021; 5:ytab219. [PMID: 34377899 PMCID: PMC8343438 DOI: 10.1093/ehjcr/ytab219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/11/2020] [Accepted: 04/22/2021] [Indexed: 11/24/2022]
Abstract
Background The use of transvenous pacing leads is associated with the risk of developing tricuspid valve (TV) dysfunction. This develops through several mechanisms including the failure of leaflet coaptation or direct damage to the TV or to its sub-valvular apparatus and can result in significant tricuspid regurgitation (TR). Multiple approaches to pacemaker implantation after transvenous lead extraction (TLE) or surgical TV repair have been described. Placement of pacing leads across the TV is generally avoided in such circumstances. Case summary A 66-year-old woman presented with a year-long history of exertional dyspnoea, peripheral oedema, and postural neck pulsations. Her medical history included a dual-chamber pacemaker implantation for sinus node dysfunction 14 years ago. Echocardiography revealed severe lead-related TR. Her case was discussed in our multi-disciplinary team meeting. A decision was made to perform a TLE and implant a leadless pacemaker in an attempt to avoid open-heart surgery if possible. This was reserved as an option in the event of persistent severe TR. Transvenous extraction of the right ventricular lead was performed. The atrial lead was preserved and connected to and AAI device. A Micra AV was implanted allowing for atrioventricular (AV) synchronous pacing. Discussion We present the first case of successful implementation of AV sequential pacing using a dual-pacemaker approach involving the use of an AAI pacemaker and a Micra AV device. This was performed after TLE for severe lead-related TR.
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Affiliation(s)
- Elhosseyn Guella
- Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - Frances Devereux
- Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - Fozia Zahir Ahmed
- Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, UK
| | - Peter Scott
- Cardiology Department, Royal Bolton Hospital, Minerva Road, Farnworth, Bolton BL4 0JR, UK
| | - Colin Cunnington
- Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, UK
| | - Amir Zaidi
- Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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Kwok CS, Mayer J, Kazi SI, Makiela L, Keay AAR, Bennett S, Ahmed FZ, Patwala A, Phan TT. Do all patients with implantable cardioverter defibrillator need a generator change? A health service evaluation of patients who underwent generator changes from a single tertiary center. Indian Pacing Electrophysiol J 2020; 20:257-260. [PMID: 32866597 PMCID: PMC7691778 DOI: 10.1016/j.ipej.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/29/2020] [Accepted: 08/17/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The patient characteristics, therapy received and outcomes after one or more implantable cardioverter defibrillator (ICD) generator changes from contemporary practice is not well known. METHODS We conducted a health service evaluation of patients who underwent ICD implantation and generator change. Patients who had generator changes from February 2016 to October 2019 were identified from our database and electronic records were reviewed for patient characteristics, number of generator changes, receipt of therapy and death. RESULTS Our database included 88 patients with a generator change. A total of 22 patients (25.0%) received dual chamber ICD, 10 patients (11.4%) received single chamber ICD, 54 patients (61.3%) received cardiac resynchronization therapy defibrillator and 2 patients (2.3%) received subcutaneous ICD. A second generator change occurred in 18 patients and a third generator changes was performed in 6 patients. There were 29 deaths and a follow up period of 9.4 ± 2.9 years. From implant to initial generator change 39 patients had appropriate antitachycardia pacing (ATP), 6 patient had inappropriate ATP, 29 patients had appropriate shocks and 5 patients had an inappropriate shock. Between the 1st and 2nd generator change and the 2nd and 3rd there were no cases of inappropriate ATP or shock. Overall, 42 patients out of the 88 had appropriate therapy (47.7%) and 7 patients had inappropriate therapy (8.0%). CONCLUSIONS Most patients with ICDs do not receive therapy and a minority have inappropriate therapy which typically occur before the first generator change as we observed no inappropriate therapy beyond the first generator change.
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Affiliation(s)
- Chun Shing Kwok
- Royal Stoke University Hospital, Stoke-on-Trent, UK; Keele University, Stoke-on-Trent, UK
| | - Joseph Mayer
- Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - Lec Makiela
- Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | | | - Fozia Zahir Ahmed
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | | | - Thanh T Phan
- Royal Stoke University Hospital, Stoke-on-Trent, UK.
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10
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Ahmed FZ, Crosbie C, Kahn M, Motwani M. Protecting the most vulnerable during COVID-19 and beyond: a case report on the remote management of heart failure patients with cardiac implantable electronic devices. Eur Heart J Case Rep 2020; 4:1-6. [PMID: 33089059 PMCID: PMC7499530 DOI: 10.1093/ehjcr/ytaa249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/07/2020] [Accepted: 07/07/2020] [Indexed: 01/15/2023]
Abstract
Background Heart failure (HF) patients with cardiac implantable electronic devices (CIEDs) represent an important cohort. They are at increased risk of hospitalization and mortality. We outline how remote-only management strategies, which leverage transmitted health-related data, can be used to optimize care for HF patients with a CIED during the COVID-19 pandemic. Case summary An 82-year-old man with HF, stable on medical therapy, underwent cardiac resynchronization therapy implantation in 2016. Modern CIEDs facilitate remote monitoring by providing real-time physiological data (thoracic impedance, heart rate and rhythm, etc.). The 'Triage Heart Failure Risk Score' (Triage-HFRS), available on Medtronic CIEDs, integrates several monitored physiological parameters into a risk prediction model classifying patients as low, medium, or high risk of HF events within 30 days. In November 2019, the patient was enrolled in an innovative clinical pathway (Triage-HF Plus) whereby any 'high' Triage-HF risk status transmission prompts a phone call-based virtual consultation. A high-risk alert was received via remote transmission on 11 March, triggering a phone call assessment. Upon reporting increasing breathlessness, diuretics were initiated. The prescription was remotely issued and delivered to the patient's home. This approach circumvented the need for all face-to-face reviews, delivering care in an entirely remote manner. Discussion The challenges posed by COVID-19 have prompted us to think differently about how we deliver care for patients, both now and following the pandemic. Contemporary CIEDs facilitate the ability to remotely monitor HF patients by providing rich physiological data that can help identify individuals at elevated risk of decompensation using automated device-generated alerts.
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Affiliation(s)
- Fozia Zahir Ahmed
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK.,Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Carol Crosbie
- Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Wythenshawe, UK
| | - Matthew Kahn
- Department of Cardiology, Fairfield General Hospital, Pennine Acute Hospitals NHS Trust, Bury, UK
| | - Manish Motwani
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK.,Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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11
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Ahmed FZ, Blomstrom Lundqvist C, Bloom H, Cooper C, Ellis C, Goette A, Greenspon A, Love C, Johansen JB, Philippon F, Tarakji K, Holbrook R, Sherfesee L, Xia Y, Krahn A. P549CIED infection risk score validation using US health claims data. Europace 2020. [DOI: 10.1093/europace/euaa162.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
This work was supported by Medtronic
Background/Introduction: The increasing number of cardiac implantable electronic device (CIED) infections has led to increased interest in the identification of patients who may benefit from additional infection prevention measures.
Purpose
The purpose of this evaluation was to validate the predictive value of the Prevention of Arrhythmia Device Infection Trial (PADIT) risk score to identify patients at increased risk of CIED infection using a U.S. health claims data set.
Methods
A retrospective analysis using the Optum® Clinformatics® claims database was conducted to create a dataset of index procedures which either did or did not result in an infection. The study population included both commercial and Medicare Advantage patients aged ≥18 years with at least one record of a CIED procedure between January 2011 and September 2014. Major CIED infections, defined as an infection associated with system removal, invasive procedure without system removal, or death attributable to infection, were identified through diagnosis and procedure codes. The dataset was randomized (stratified by PADIT score, which included prior procedures, age, depressed renal function, immunocompromised, and procedure type) into a Development Dataset (60%) and a Validation dataset (40%). A frailty model allowing multiple procedures per patient was fit using the Development Dataset, with PADIT score as the only predictor, excluding patients with prior infection. Prior CIED infection, which was not available in the original PADIT data, was examined for additional predictive value.
Results
The data extraction resulted in a dataset of 53,554 index procedures among 51,583 patients, with 30,950 patients randomized to the Development Dataset. The distribution of procedures was pacemakers (52%), ICD (20%), CRT (12%), and Revision/Upgrade (16%), while prior procedures were none (62%), 1 (37%), and 2 (1%). Among patients with no history of prior CIED infection, the frailty model showed that a 1 unit increase in the PADIT score predicts higher infection risk (20%) in the U.S. claims data set (Table 1). Prior CIED infection was associated with strong additional predictive value (HR 4.77, p < 0.0001) after adjusting for PADIT score.
Conclusion
In the largest external validation of a CIED risk score, the PADIT risk score predicts increased CIED infection risk, identifying higher risk patients that can benefit from targeted interventions to reduce the risk of CIED infection. Prior CIED infection brings additional predictive value to the PADIT score.
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Affiliation(s)
- F Z Ahmed
- Manchester University NHS Foundation Trust, Manchester, United Kingdom of Great Britain & Northern Ireland
| | | | - H Bloom
- The Emory Clinic, Brookhaven, United States of America
| | - C Cooper
- Orlando Immunology Consultants, Orlando, United States of America
| | - C Ellis
- Vanderbilt University, Nashville, United States of America
| | - A Goette
- Saint Vincenz Hospital Paderborn, Paderborn, Germany
| | - A Greenspon
- Thomas Jefferson University Hospital, Philadelphia, United States of America
| | - C Love
- Johns Hopkins, Baltimore, United States of America
| | | | | | - K Tarakji
- Cleveland Clinic, Cleveland, United States of America
| | - R Holbrook
- Medtronic, Mounds View, United States of America
| | - L Sherfesee
- Medtronic, Mounds View, United States of America
| | - Y Xia
- Medtronic, Mounds View, United States of America
| | - A Krahn
- University of British Colombia, Vancouver, Canada
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12
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Ahmed FZ, Taylor JK, Green C, Moore L, Goode A, Black P, Howard L, Fullwood C, Zaidi A, Seed A, Cunnington C, Motwani M. Triage-HF Plus: a novel device-based remote monitoring pathway to identify worsening heart failure. ESC Heart Fail 2019; 7:107-116. [PMID: 31794140 PMCID: PMC7083434 DOI: 10.1002/ehf2.12529] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 08/08/2019] [Accepted: 09/06/2019] [Indexed: 11/23/2022] Open
Abstract
Aims Remote monitoring of patients with physiological data derived from cardiac implanted electronic devices (CIEDs) offers potential to reconfigure clinical services. The ‘Heart Failure Risk Score' (HFRS) uses input from integrated device physiological monitoring to risk‐stratify patients as low‐risk, medium‐risk, or high‐risk of a heart failure event in the next 30 days. This study aimed to evaluate a novel clinical pathway utilizing a combination of CIED risk‐stratification and telephone triage to identify patients with worsening heart failure (WHF). Methods and results A prospective, single‐centre, real‐world evaluation of the ‘Triage‐HF Plus' clinical pathway (HFRS in combination with telephone triage) over a 27 month period. One hundred and fifty‐seven high‐risk HFRS transmissions were referred for telephone triage assessment. Interventions were at the discretion of the clinical assessor acting in accordance with clinical guidelines. An additional 3month consecutive sample of low and medium HFRS transmissions (control group) were also contacted for telephone triage assessment (n = 98). Successful telephone contact was made in 127 (81%) of referred high‐risk HFRS cases: 71 (55.9%) were confirmed to have WHF requiring intervention; 19 (14.9%) had an alternative acute medical problem; one patient had been recently discharged from hospital with WHF; and 36 (28.0%) had no apparent cause for the high score. In the control group, only one patient had symptoms of WHF. The sensitivity and specificity of CIED‐based remote monitoring to identify WHF 98.6% (92.5–100.0%) and 63.4% (55.2–71.0%), respectively. Conclusions The Triage‐HF Plus clinical pathway is a potentially useful remote monitoring tool for patients with heart failure and in situ CIEDs.
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Affiliation(s)
- Fozia Zahir Ahmed
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK.,Department of Cardiology, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Joanne K Taylor
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK.,Department of Cardiology, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.,Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Caroline Green
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Lucy Moore
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Angelic Goode
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
| | - Paula Black
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
| | - Lesley Howard
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
| | - Catherine Fullwood
- Manchester Academic Health Science Centre, Research and Innovation, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.,Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Amir Zaidi
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Alison Seed
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
| | - Colin Cunnington
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK.,Department of Cardiology, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Manish Motwani
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK.,Department of Cardiology, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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13
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Lewis GA, Schelbert EB, Naish JH, Bedson E, Dodd S, Eccleson H, Clayton D, Jimenez BD, McDonagh T, Williams SG, Cooper A, Cunnington C, Ahmed FZ, Viswesvaraiah R, Russell S, Neubauer S, Williamson PR, Miller CA. Pirfenidone in Heart Failure with Preserved Ejection Fraction-Rationale and Design of the PIROUETTE Trial. Cardiovasc Drugs Ther 2019; 33:461-470. [PMID: 31069575 PMCID: PMC6689029 DOI: 10.1007/s10557-019-06876-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The PIROUETTE (PIRfenidOne in patients with heart failUre and preserved lEfT venTricular Ejection fraction) trial is designed to evaluate the efficacy and safety of the anti-fibrotic pirfenidone in patients with chronic heart failure and preserved ejection fraction (HFpEF) and myocardial fibrosis. HFpEF is a diverse syndrome associated with substantial morbidity and mortality. Myocardial fibrosis is a key pathophysiological mechanism of HFpEF and myocardial fibrotic burden is strongly and independently associated with adverse outcome. Pirfenidone is an oral anti-fibrotic agent, without haemodynamic effect, that leads to regression of myocardial fibrosis in preclinical models. It has proven clinical effectiveness in pulmonary fibrosis. METHODS The PIROUETTE trial is a randomised, double-blind, placebo-controlled phase II trial evaluating the efficacy and safety of 52 weeks of treatment with pirfenidone in patients with chronic HFpEF (symptoms and signs of heart failure, left ventricular ejection fraction ≥ 45%, elevated natriuretic peptides [BNP ≥ 100 pg/ml or NT-proBNP ≥ 300 pg/ml; or BNP ≥ 300 pg/ml or NT-proBNP ≥ 900 pg/ml if in atrial fibrillation]) and myocardial fibrosis (extracellular matrix (ECM) volume ≥ 27% measured using cardiovascular magnetic resonance). The primary outcome measure is change in myocardial ECM volume. A sub-study will investigate the relationship between myocardial fibrosis and myocardial energetics, and the impact of pirfenidone, using 31phosphorus magnetic resonance spectroscopy. DISCUSSION PIROUETTE will determine whether pirfenidone is superior to placebo in relation to regression of myocardial fibrosis and improvement in myocardial energetics in patients with HFpEF and myocardial fibrosis (NCT02932566). CLINICAL TRIAL REGISTRATION clinicaltrials.gov (NCT02932566) https://clinicaltrials.gov/ct2/show/NCT02932566.
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Affiliation(s)
- Gavin A Lewis
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
- Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK
| | - Erik B Schelbert
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Cardiovascular Magnetic Resonance Center, Heart and Vascular Institute, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Josephine H Naish
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Emma Bedson
- Clinical Trials Research Centre, 2nd Floor - Institute in the Park, Alder Hey Children's NHS Foundation Trust, University of Liverpool, Member of Liverpool Health Partners, Liverpool, L12 2AP, UK
| | - Susanna Dodd
- Department of Biostatistics, University of Liverpool, Member of Liverpool Health Partners, Block F, Waterhouse Bld, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Helen Eccleson
- Clinical Trials Research Centre, 2nd Floor - Institute in the Park, Alder Hey Children's NHS Foundation Trust, University of Liverpool, Member of Liverpool Health Partners, Liverpool, L12 2AP, UK
| | - Dannii Clayton
- Clinical Trials Research Centre, 2nd Floor - Institute in the Park, Alder Hey Children's NHS Foundation Trust, University of Liverpool, Member of Liverpool Health Partners, Liverpool, L12 2AP, UK
| | - Beatriz Duran Jimenez
- Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK
| | | | - Simon G Williams
- Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK
| | - Anne Cooper
- Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - Colin Cunnington
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
- Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK
| | - Fozia Zahir Ahmed
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
- Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK
| | - Rajavarma Viswesvaraiah
- Stockport NHS Foundation Trust, Stepping Hill Hospital, Poplar Grove, Hazel Grove, Stockport, SK2 7JE, UK
| | - Stuart Russell
- East Cheshire NHS Trust, Victoria Road, Macclesfield, SK10 3BL, UK
| | - Stefan Neubauer
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Paula R Williamson
- Department of Biostatistics, University of Liverpool, Member of Liverpool Health Partners, Block F, Waterhouse Bld, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Christopher A Miller
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
- Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK.
- Wellcome Centre for Cell-Matrix Research, Division of Cell-Matrix Biology and Regenerative Medicine, School of Biology, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, M13 9PT, UK.
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14
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Ahmed FZ, Arumugam P. 18F-FDG PET/CT now endorsed by guidelines across all types of CIED infection: Evidence limited but growing. J Nucl Cardiol 2019; 26:971-974. [PMID: 29188432 DOI: 10.1007/s12350-017-1119-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 01/28/2023]
Affiliation(s)
- Fozia Zahir Ahmed
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK
| | - Parthiban Arumugam
- Nuclear Medicine Centre, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK.
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15
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Ahmed FZ, Fullwood C, Zaman M, Qamruddin A, Cunnington C, Mamas MA, Sandoe J, Motwani M, Zaidi A. Correction: Cardiac implantable electronic device (CIED) infections are expensive and associated with prolonged hospitalisation: UK Retrospective Observational Study. PLoS One 2019; 14:e0213682. [PMID: 30840705 PMCID: PMC6402672 DOI: 10.1371/journal.pone.0213682] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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16
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Ahmed FZ, Fullwood C, Zaman M, Qamruddin A, Cunnington C, Mamas MA, Sandoe J, Motwani M, Zaidi A. Cardiac implantable electronic device (CIED) infections are expensive and associated with prolonged hospitalisation: UK Retrospective Observational Study. PLoS One 2019; 14:e0206611. [PMID: 30601808 PMCID: PMC6314621 DOI: 10.1371/journal.pone.0206611] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 10/16/2018] [Indexed: 12/05/2022] Open
Abstract
Background There are limited reports outlining the financial cost of treating cardiac implantable electronic device (CIED) infection outside the United States. This study aimed to determine the average treatment cost of CIED infection in a large UK tertiary referral centre and compared costs of different treatment pathways that are recognised in the management of CIED infection (early versus delayed re-implantation). Methods We retrospectively analysed cost and length of stay (LOS) data for consecutive patients undergoing infected CIED extraction with cardiac resynchronization therapy (CRT-D [with defibrillator], CRT-P [with pacemaker]), implantable cardioverter-defibrillators (ICDs) and permanent pacemakers (PPMs). Results Between January 2013 and March 2015, complete data was available for 84 patients (18 [21.4%] CRT-D, 24 [28.6%] ICDs and 42 [50.0%] PPMs). When all cases were considered the cost of infection ranged from £5,139 (PPM) to £24,318 (CRT-D). Considering different treatment strategies; 41 (48.8%) underwent CIED extraction and re-implantation during the same admission (early re-implant strategy (ER). 43 (51.2%) underwent extraction, but were then discharged home to be re-admitted for day-case re-implantation (delayed re-implant strategy (DR)). Median LOS was significantly shorter in DR compared to ER (5.0 vs. 18.0 days, p<0.001). The total cost of CIED infection episode was similar for both treatment strategies (median £14,241.48 vs. £14,741.70 including wearable defibrillator (Lifevest) and outpatient antibiotics costs, ER vs. DR; p = 0.491). Conclusion CIED infections are expensive and associated with significant health-economic burden. When all device types were considered, a DR strategy is associated with reduced LOS without an increased cost penalty.
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Affiliation(s)
- Fozia Zahir Ahmed
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
- Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
- * E-mail:
| | - Catherine Fullwood
- Manchester Academic Health Science Centre, Research and Innovation, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Mahvash Zaman
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Ahmed Qamruddin
- Department of Microbiology, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Colin Cunnington
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
- Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Jonathan Sandoe
- Department of Medical Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Biomedical & Clinical Sciences, University of Leeds, Leeds, United Kingdom
| | - Manish Motwani
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Amir Zaidi
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
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17
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Zaidi A, Ali M, Cunnington C, Motwani M, Allen S, Ahmed FZ. 22Cied lead extraction in the elderly has low risk. Europace 2017. [DOI: 10.1093/europace/eux283.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Johnstone EM, Black P, Hassan S, Goode A, Green C, Cassidy C, Ahmed FZ, Seed A. 52HF-RADD - heart failure risk according to device diagnostics: a prospective observational study. Europace 2017. [DOI: 10.1093/europace/eux283.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Zaidi A, Ali M, Cunnington C, Motwani M, Allen S, Ahmed FZ. 84Single-centre experience of cied lead extraction using cook medical evolution system. Europace 2017. [DOI: 10.1093/europace/eux283.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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Ahmed FZ, Cunnington C, Motwani M, Zaidi AM. Totally Leadless Dual-Device Implantation for Combined Spontaneous Ventricular Tachycardia Defibrillation and Pacemaker Function: A First Report. Can J Cardiol 2017; 33:1066.e5-1066.e7. [PMID: 28754393 DOI: 10.1016/j.cjca.2017.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/20/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022] Open
Abstract
Subcutaneous implantable cardioverter defibrillators (S-ICDs) provide effective defibrillation, while also reducing the risk of long-term lead problems. However, S-ICDs do not offer bradycardia or antitachycardia pacing and therefore use has been limited. Combined implantation of an S-ICD with a leadless pacemaker (LP) has been proposed to overcome this limitation. Although a handful of combined S-ICD/LP implantations have been reported for Nanostim (St Jude Medical, St Paul, MN) as well as Micra LP (Medtronic, Minneapolis, MN) systems, none have documented delivery of appropriate shock therapies for spontaneous ventricular tachycardia. We report the first case of effective defibrillation for spontaneous ventricular tachycardia in a patient with combined Micra LP and S-ICD.
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Affiliation(s)
- Fozia Zahir Ahmed
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom.
| | - Colin Cunnington
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Manish Motwani
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Amir Masood Zaidi
- Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
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Ahmed FZ, Motwani M, Cunnington C, Kwok CS, Fullwood C, Oceandy D, Fitchet A, Goode GK, Luckie M, Zaidi AM, Khattar R, Mamas MA. One-Month Global Longitudinal Strain Identifies Patients Who Will Develop Pacing-Induced Left Ventricular Dysfunction over Time: The Pacing and Ventricular Dysfunction (PAVD) Study. PLoS One 2017; 12:e0162072. [PMID: 28095413 PMCID: PMC5240943 DOI: 10.1371/journal.pone.0162072] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/17/2016] [Indexed: 11/25/2022] Open
Abstract
Background Predicting which individuals will have a decline in left ventricular (LV) function after pacemaker implantation remains an important challenge. We investigated whether LV global longitudinal strain (GLS), measured by 2D speckle tracking strain echocardiography, can identify patients at risk of pacing-induced left ventricular dysfunction (PIVD) or pacing-induced cardiomyopathy (PICMP). Methods Fifty-five patients with atrioventricular block and preserved LV function underwent dual-chamber pacemaker implantation and were followed with serial transthoracic echocardiography for 12 months for the development of PIVD (defined as a reduction in LV ejection fraction (LVEF) ≥5 percentage points at 12 months) or PICMP (reduction in LVEF to <45%). Results At 12 months, 15 (27%) patients developed PIVD; of these, 4 patients developed PICMP. At one month, GLS was significantly lower in the 15 patients who subsequently developed PIVD, compared to those who did not (n = 40) (GLS -12.6 vs. -16.4 respectively; p = 0.022). When patients with PICMP were excluded, one month GLS was significantly reduced compared to baseline whereas LVEF was not. One-month GLS had high predictive accuracy for determining subsequent development of PIVD or PICMP (AUC = 0.80, optimal GLS threshold: <−14.5, sensitivity 82%, specificity 75%); and particularly PICMP (AUC = 0.86, optimal GLS threshold: <−13.5, sensitivity 100%, specificity 71%). Conclusions GLS is a novel predictor of decline in LV systolic function following pacemaker implantation, with the potential to identify patients at risk of PIVD before measurable changes in LVEF are apparent. GLS measured one month after implantation has high predictive accuracy for identifying patients who later develop PIVD or PICMP.
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Affiliation(s)
- Fozia Zahir Ahmed
- Cardiovascular Institute, Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
- Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, Manchester, United Kingdom
- * E-mail:
| | - Manish Motwani
- Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Colin Cunnington
- Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Chun Shing Kwok
- Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care, University of Keele, Keele, United Kingdom
- University Hospital North Midlands, Stoke-on-Trent, United Kingdom
| | - Catherine Fullwood
- Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
- Department of Biostatistics, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Delvac Oceandy
- Cardiovascular Institute, Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Alan Fitchet
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool, United Kingdom
| | - Grahame Kevin Goode
- Department of Cardiology, Salford Royal Foundation Trust, Stott Lane, Salford, United Kingdom
| | - Matthew Luckie
- Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Amir Masood Zaidi
- Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Rajdeep Khattar
- Department of Cardiology, Royal Brompton Hospital and Cardiovascular Biomedical Research Unit, Imperial College, London, United Kingdom
| | - Mamas Andreas Mamas
- Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care, University of Keele, Keele, United Kingdom
- University Hospital North Midlands, Stoke-on-Trent, United Kingdom
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Affiliation(s)
- Shilpa Manupati
- Department of Stroke Medicine, Abertawe Bro Morgannwg University Health Board, Port Talbot, UK
| | - Fozia Zahir Ahmed
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Abstract
Owing to expanding clinical indications, cardiac implantable electronic devices (CIEDs) are being increasingly used. Despite improved surgical techniques and the use of prophylactic antimicrobial therapy, the rate of CIED-related infection is also increasing. Infection is a potentially serious complication, with clinical manifestations ranging from surgical site infection and local symptoms in the region of the generator pocket to fulminant endocarditis. The utility of radionuclide imaging as a stand-alone noninvasive diagnostic imaging test in patients with suspected endocarditis has been less frequently examined. This article summarizes the recent advances in radionuclide imaging for evaluation of patients with suspected cardiovascular infections.
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Affiliation(s)
- Fozia Zahir Ahmed
- Department of Cardiology, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
| | - Jackie James
- Department of Nuclear Medicine, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
| | - Matthew J Memmott
- Department of Nuclear Medicine, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
| | - Parthiban Arumugam
- Department of Nuclear Medicine, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK.
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Ahmed FZ, James J, Cunnington C, Motwani M, Fullwood C, Hooper J, Burns P, Qamruddin A, Al-Bahrani G, Armstrong I, Tout D, Clarke B, Sandoe JAT, Arumugam P, Mamas MA, Zaidi AM. Early diagnosis of cardiac implantable electronic device generator pocket infection using ¹⁸F-FDG-PET/CT. Eur Heart J Cardiovasc Imaging 2015; 16:521-30. [PMID: 25651856 PMCID: PMC4407104 DOI: 10.1093/ehjci/jeu295] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 11/25/2014] [Indexed: 01/07/2023] Open
Abstract
AIMS To examine the utility of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) in the early diagnosis of cardiac implantable electronic device (CIED) generator pocket infection. METHODS AND RESULTS A total of 86 patients with CIEDs were evaluated with (18)F-FDG PET/CT imaging: 46 with suspected generator pocket infection and 40 without any history of infection. (18)F-FDG activity in the region of the generator pocket was expressed as a semi-quantitative ratio (SQR)-defined as the maximum count rate around the CIED divided by the mean count rate between normal right and left lung parenchyma. All patients underwent standard clinical management, independent of the PET/CT result. Patients with suspected generator pocket infection that required CIED extraction (n = 32) had significantly higher (18)F-FDG activity compared with those that did not (n = 14), and compared with controls (n = 40) [SQR: 4.80 (3.18-7.05) vs. 1.40 (0.88-1.73) vs. 1.10 (0.98-1.40), respectively; P < 0.001]. On receiver operator characteristic analysis, SQR had a high diagnostic accuracy (area under curve = 0.98) for the early identification of patients with confirmed infection (i.e. those ultimately needing extraction)-with an optimal SQR cut-off value of >2.0 (sensitivity = 97%; specificity = 98%). CONCLUSION This study highlights the potential benefits of evaluating patients with suspected CIED generator pocket infection using (18)F-FDG PET/CT. In this study, (18)F-FDG PET/CT had a high diagnostic accuracy in the early diagnosis of CIED generator pocket infection, even where initial clinical signs were underwhelming.
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Affiliation(s)
- Fozia Zahir Ahmed
- Cardiovascular Institute, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK Department of Cardiology, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Jacqueline James
- Department of Nuclear Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Colin Cunnington
- Department of Cardiology, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Manish Motwani
- Department of Cardiology, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Catherine Fullwood
- Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK Department of Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Jacquelyn Hooper
- Department of Cardiology, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Phillipa Burns
- Department of Microbiology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Ahmed Qamruddin
- Department of Microbiology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Ghada Al-Bahrani
- Department of Nuclear Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Ian Armstrong
- Department of Nuclear Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Deborah Tout
- Department of Nuclear Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Bernard Clarke
- Cardiovascular Institute, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK Department of Cardiology, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Jonathan A T Sandoe
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, and University of Leeds, Leeds, UK
| | - Parthiban Arumugam
- Department of Nuclear Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Mamas A Mamas
- Cardiovascular Institute, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK Department of Cardiology, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Amir M Zaidi
- Department of Cardiology, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Ahmed FZ, Zaidi AM. The evolution of lead extraction. Eur Heart J 2015; 36:67. [PMID: 25734201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
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Attar MN, Ahmed FZ, Moore RK. Recurrent collapses following permanent pacemaker implantation. Neth Heart J 2011; 20:86-7. [PMID: 21984451 DOI: 10.1007/s12471-011-0204-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- M N Attar
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, Lancashire, UK, FY3 8NR,
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