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Lewis GD, Gosch K, Cohen LP, Nassif ME, Windsor SL, Borlaug BA, Kitzman DW, Shah SJ, Khumri T, Umpierrez G, Lamba S, Sharma K, Khan SS, Kosiborod MN, Sauer AJ. Effect of Dapagliflozin on 6-Minute Walk Distance in Heart Failure With Preserved Ejection Fraction: PRESERVED-HF. Circ Heart Fail 2023; 16:e010633. [PMID: 37869881 PMCID: PMC10655911 DOI: 10.1161/circheartfailure.123.010633] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/08/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Heart failure with preserved ejection fraction is associated with significant functional limitations, yet treatments for improving exercise performance have been elusive. We sought to explore the association between prespecified patient characteristics and changes in 6-minute walk distance that constitute a clinically significant response to dapagliflozin. METHODS We performed a responder analysis to understand patient characteristics associated with clinically meaningful improvement in 6-minute walk test (6MWT) distance ≥15 m among patients randomized to 12 weeks of dapagliflozin versus placebo in the double-blind PRESERVED-HF trial (Effects of Dapagliflozin on Biomarkers, Symptoms and Functional Status in Patients With Preserved Ejection Fraction Heart Failure). RESULTS A total of 289 randomized patients had 6MWT distance completed at baseline and 12 weeks. Patients randomized to dapagliflozin improved walking distance by ≥15 m more frequently than those on placebo (n=64, 44% versus n=48, 34%). After adjusting for baseline covariates, patients randomized to dapagliflozin were more likely to experience a clinically meaningful improvement in 6MWT distance compared with those that received placebo (adjusted odds ratio, 1.66 [95% CI, 1.00-2.75]; P=0.05). Dapagliflozin-treated patients were also less likely to have a ≥15 m reduction in 6MWT distance compared with placebo-treated patients (adjusted odds ratio, 0.56 [95% CI, 0.33-0.94]; P=0.03). These results were consistent across all prespecified subgroups (all P values for interaction were not significant). CONCLUSIONS Compared with those on placebo, patients with heart failure with preserved ejection fraction randomized to dapagliflozin were more likely to experience a clinically meaningful improvement and less likely to experience a deterioration in physical function over 12 weeks as measured by 6MWT distance. Beneficial response to dapagliflozin was consistent across prespecified subgroups. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03030235.
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Affiliation(s)
- Gregory D. Lewis
- Cardiology Division, Massachusetts General Hospital, Boston (G.D.L., L.P.C.)
| | - Kensey Gosch
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (K.G., M.E.N., S.L.W., T.K., M.N.K., A.J.S.)
- University of Missouri-Kansas City School of Medicine (K.G., M.E.N., T.K., M.N.K., A.J.S.)
| | - Laura P. Cohen
- Cardiology Division, Massachusetts General Hospital, Boston (G.D.L., L.P.C.)
| | - Michael E. Nassif
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (K.G., M.E.N., S.L.W., T.K., M.N.K., A.J.S.)
- University of Missouri-Kansas City School of Medicine (K.G., M.E.N., T.K., M.N.K., A.J.S.)
| | - Sheryl L. Windsor
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (K.G., M.E.N., S.L.W., T.K., M.N.K., A.J.S.)
| | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (B.A.B.)
| | - Dalane W. Kitzman
- Department of Internal Medicine, Sections on Cardiovascular Medicine and Geriatrics, Wake Forest University School of Medicine, Winston-Salem, NC (D.W.K.)
| | - Sanjiv J. Shah
- Department of Medicine and Bluhm Cardiovascular Institute, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., S.S.K.)
| | - Taiyeb Khumri
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (K.G., M.E.N., S.L.W., T.K., M.N.K., A.J.S.)
- University of Missouri-Kansas City School of Medicine (K.G., M.E.N., T.K., M.N.K., A.J.S.)
| | | | - Sumant Lamba
- First Coast Cardiovascular Institute, Jacksonville, FL (S.L.)
| | - Kavita Sharma
- Johns Hopkins University School of Medicine, Baltimore, MD (K.S.)
| | - Sadiya S. Khan
- Department of Medicine and Bluhm Cardiovascular Institute, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., S.S.K.)
| | - Mikhail N. Kosiborod
- Cardiology Division, Massachusetts General Hospital, Boston (G.D.L., L.P.C.)
- University of Missouri-Kansas City School of Medicine (K.G., M.E.N., T.K., M.N.K., A.J.S.)
| | - Andrew J. Sauer
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (K.G., M.E.N., S.L.W., T.K., M.N.K., A.J.S.)
- University of Missouri-Kansas City School of Medicine (K.G., M.E.N., T.K., M.N.K., A.J.S.)
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Nassif ME, Windsor SL, Gosch K, Borlaug BA, Husain M, Inzucchi SE, Kitzman DW, McGuire DK, Pitt B, Scirica BM, Shah SJ, Umpierrez G, Austin BA, Lamba S, Khumri T, Sharma K, Kosiborod MN. Dapagliflozin Improves Heart Failure Symptoms and Physical Limitations Across the Full Range of Ejection Fraction: Pooled Patient-Level Analysis From DEFINE-HF and PRESERVED-HF Trials. Circ Heart Fail 2023; 16:e009837. [PMID: 37203441 PMCID: PMC10348645 DOI: 10.1161/circheartfailure.122.009837] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 04/07/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Patients with heart failure (HF) have a high burden of symptoms and physical limitations, regardless of ejection fraction (EF). Whether the benefits of SGLT2 (sodium-glucose cotransporter-2) inhibitors on these outcomes vary across the full range of EF remains unclear. METHODS Patient-level data were pooled from the DEFINE-HF trial (Dapagliflozin Effects on Biomarkers, Symptoms, and Functional Status in Patients With Heart Failure With Reduced Ejection Fraction) of 263 participants with reduced EF (≤40%), and PRESERVED-HF trial (Effects of Dapagliflozin on Biomarkers, Symptoms and Functional Status in Patients With Preserved Ejection Fraction Heart Failure) of 324 participants with preserved EF (≥45%). Both were randomized, double-blind 12-week trials of dapagliflozin versus placebo, recruiting participants with New York Heart Association class II or higher and elevated natriuretic peptides. The effect of dapagliflozin on the change in the Kansas City Cardiomyopathy Questionnaire (KCCQ) Clinical Summary Score (CSS) at 12 weeks was tested with ANCOVA adjusted for sex, baseline KCCQ, EF, atrial fibrillation, estimated glomerular filtration rate, and type 2 diabetes. Interaction of dapagliflozin effects on KCCQ-CSS by EF was assessed using EF both categorically and continuously with restricted cubic spline. Responder analyses, examining proportions of patients with deterioration, and clinically meaningful improvements in KCCQ-CSS were conducted using logistic regression. RESULTS Of 587 patients randomized (293 dapagliflozin, 294 placebo), EF was ≤40, >40-≤60, and >60% in 262 (45%), 199 (34%), and 126 (21%), respectively. Dapagliflozin improved KCCQ-CSS at 12 weeks (placebo-adjusted difference 5.0 points [95% CI, 2.6-7.5]; P<0.001). This was consistent in participants with EF≤40 (4.6 points [95% CI, 1.0-8.1]; P=0.01), >40 to ≤60 (4.9 points [95% CI, 0.8-9.0]; P=0.02) and >60% (6.8 points [95% CI, 1.5-12.1]; P=0.01; Pinteraction=0.79). Benefits of dapagliflozin on KCCQ-CSS were also consistent when analyzing EF continuously (Pinteraction=0.94). In responder analyses, fewer dapagliflozin-treated patients had deterioration and more had small, moderate, and large KCCQ-CSS improvements versus placebo; these results were also consistent regardless of EF (all Pinteractionvalues nonsignificant). CONCLUSIONS In patients with HF, dapagliflozin significantly improves symptoms and physical limitations after 12 weeks of treatment, with consistent and clinically meaningful benefits across the full range of EF. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifiers: NCT02653482 and NCT03030235.
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Affiliation(s)
- Michael E. Nassif
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.E.N., S.L.W., K.G., B.A.A., T.K., M.N.K.)
- University of Missouri-Kansas City (M.E.N., B.A.A., T.K., M.N.K.)
| | - Sheryl L. Windsor
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.E.N., S.L.W., K.G., B.A.A., T.K., M.N.K.)
| | - Kensey Gosch
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.E.N., S.L.W., K.G., B.A.A., T.K., M.N.K.)
| | - Barry A. Borlaug
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.E.N., S.L.W., K.G., B.A.A., T.K., M.N.K.)
- University of Missouri-Kansas City (M.E.N., B.A.A., T.K., M.N.K.)
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (B.A.B.)
| | - Mansoor Husain
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University of Toronto, ON, Canada (M.H.)
| | | | - Dalane W. Kitzman
- Department of Internal Medicine, Sections on Cardiovascular Medicine and Geriatrics, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.)
| | - Darren K. McGuire
- University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas (D.K.M.)
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Benjamin M. Scirica
- Cardiovascular Division, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (B.M.S.)
| | - Sanjiv J. Shah
- Division of Cardiology, Department of Medicine, and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
| | | | - Bethany A. Austin
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.E.N., S.L.W., K.G., B.A.A., T.K., M.N.K.)
| | - Sumant Lamba
- First Coast Cardiovascular Institute, Jacksonville, FL (S.L.)
| | - Taiyeb Khumri
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.E.N., S.L.W., K.G., B.A.A., T.K., M.N.K.)
- University of Missouri-Kansas City (M.E.N., B.A.A., T.K., M.N.K.)
| | - Kavita Sharma
- Johns Hopkins University School of Medicine, Baltimore, MD (K.S.)
| | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.E.N., S.L.W., K.G., B.A.A., T.K., M.N.K.)
- University of Missouri-Kansas City (M.E.N., B.A.A., T.K., M.N.K.)
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Turk A, Khariton Y, Kao A, Khumri T, Sperry B, Magalski A, Austin B, Lawhorn S, Vodnala D, Nassif M, Fendler TJ. Use Of Implantable Pulmonary Artery Pressure Monitoring To Guide Care Of Patients With Ambulatory Heart Failure; The First Three Years In A Real World, Single Center Experience. J Card Fail 2022. [DOI: 10.1016/j.cardfail.2022.03.113] [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: 11/28/2022]
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Sammour Y, Nassif M, Magwire M, Thomas M, Fendler T, Khumri T, Sperry BW, O'Keefe J, Kosiborod M. Effects of GLP-1 receptor agonists and SGLT-2 inhibitors in heart transplant patients with type 2 diabetes: Initial report from a cardiometabolic center of excellence. J Heart Lung Transplant 2021; 40:426-429. [PMID: 33745782 DOI: 10.1016/j.healun.2021.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/10/2021] [Accepted: 02/17/2021] [Indexed: 11/28/2022] Open
Abstract
Type 2 diabetes mellitus (T2D) is a common comorbidity among patients who have undergone heart transplantation. Recently two classes of glucose-lowering medications (sodium-glucose cotransporter type-2 inhibitors [SGLT-2Is] and glucagon-like-peptide-1 receptor agonists [GLP-1RAs]), have been shown to significantly improve cardiovascular outcomes. There is a paucity of data regarding their use in immunosuppressed patients, with many studies specifically excluding this population. We retrospectively evaluated the safety and efficacy of GLP-1RAs and SGLT-2Is in patients who had undergone orthotopic heart transplant at a high-volume center. Among 21 patients, we found significant weight loss, reductions in insulin use, hemoglobin A1c, and low-density lipoprotein-cholesterol. Moreover, both SGLT-2Is and GLP-1RAs were well tolerated with no adverse events leading to discontinuation of either therapy. While larger studies of patients after solid organ transplant are needed, this small hypothesis-generating study demonstrates that SGLT-2Is and GLP-1RAs appear safe and effective therapies among patients with T2D after heart transplant.
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Affiliation(s)
- Yasser Sammour
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Michael Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Melissa Magwire
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Merrill Thomas
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Timothy Fendler
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Taiyeb Khumri
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Brett W Sperry
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - James O'Keefe
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
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Gondi KT, Kao A, Linard J, Austin BA, Everley MP, Fendler TJ, Khumri T, Lawhorn SL, Magalski A, Nassif ME, Sperry BW, Vodnala D, Borkon AM. Single-center utilization of donor-derived cell-free DNA testing in the management of heart transplant patients. Clin Transplant 2021; 35:e14258. [PMID: 33606316 DOI: 10.1111/ctr.14258] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/02/2021] [Accepted: 02/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Gene expression profiling (GEP) and donor-derived cell-free DNA (dd-cfDNA) are useful in acute rejection (AR) surveillance in orthotopic heart transplant (OHT) patients. We report a single-center experience of combined GEP and dd-cfDNA testing for AR surveillance. METHODS GEP and dd-cfDNA are tested together starting at 2 months post-OHT. After 6 months, combined testing was obtained before scheduled endomyocardial biopsy (EMB), and EMB was canceled with a negative dd-cfDNA. This approach was compared to using a GEP-only approach, where EMB was canceled with a negative GEP. We evaluated for frequency of EMB cancellation with dd-cfDNA usage. RESULTS A total of 153 OHT patients over a 13-month period underwent 495 combined GEP/dd-cfDNA tests. 82.2% of dd-cfDNA tests were below threshold. Above threshold results identified high-risk patients who developed AR. 378 combined tests ≥6 months post-OHT resulted in cancellation of 83.9% EMBs as opposed to 71.2% with GEP surveillance alone. There were 2 acute cellular and 2 antibody-mediated rejection episodes, and no significant AR ≥6 months. CONCLUSION Routine dd-cfDNA testing alongside GEP testing yielded a significant reduction in EMB volume by re-classifying GEP (+) patients into a lower risk group, without reduction in AR detection. The addition of dd-cfDNA identified patients at higher risk for AR.
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Affiliation(s)
- Keerthi T Gondi
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Andrew Kao
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Jodie Linard
- Department of Cardiac Transplant, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Bethany A Austin
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Mark P Everley
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Timothy J Fendler
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Taiyeb Khumri
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Stephanie L Lawhorn
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Anthony Magalski
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Michael E Nassif
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Brett W Sperry
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Deepthi Vodnala
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - A Michael Borkon
- Department of Cardiothoracic Surgery, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
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Sammour Y, Nassif M, Thomas M, Magwire M, Khumri T, Sperry B, Austin B, Fendler T, Kao A, Vodnala D, Lawhorn S, Everley M, Magalski A, Kosiborod M. Effects of GLP-1 Receptor Agonists and SGLT-2 Inhibitors in Heart Transplant Patients with Type 2 Diabetes: a Case Series. J Card Fail 2020. [DOI: 10.1016/j.cardfail.2020.09.081] [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: 11/17/2022]
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Kapuria D, Khumri T, Shamim S, Surana P, Khan S, Al-Khalisi N, Aggarwal S, Koh C, Chhabra R. Characterization and timing of gastrointestinal bleeding in continuous flow left ventricular assist device recipients. Heliyon 2020; 6:e04695. [PMID: 32939410 PMCID: PMC7479277 DOI: 10.1016/j.heliyon.2020.e04695] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 07/11/2018] [Accepted: 08/07/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIMS Heart failure is one of the leading causes of morbidity and mortality in the United States. The advent of left ventricular assist devices (LVAD) has improved the survival and quality of life in patients with end stage heart failure. Gastrointestinal bleeding (GIb) remains one of the limitations of LVADs. METHODS A single center, retrospective review of records was performed for patients who underwent LVAD implantation between 2010 and 2015. All patients who survived more than 30 days were followed till March 2016 and are described below. RESULTS A total of 79 patients were included in the study. The rate of GIb was 34.1% (27 patients) with a mean time to bleed of 267 days. Older patients were more likely to bleed. Upper GI bleeding was the source of bleeding in 54% patients. Arteriovenous malformations (AVM) were the source of bleeding in 74% bleeders and 80% of these patients had de novo AVM formation. 14/27 (51%) patients had a re-bleeding event. Thrombotic events were 4.5 times more likely to occur in patients who also had a GI bleed. CONCLUSIONS GI bleeding in LVAD patients is common with the source of bleeding more commonly being in the upper GI tract. GI bleeding may occur as early as 10 days post procedure, despite previous negative screening endoscopies. There is an increased risk of thrombotic events in patients who have experienced a GI bleed.
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Affiliation(s)
- Devika Kapuria
- Department of Internal Medicine, University of Missouri, Kansas City-School of Medicine, USA
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, USA
| | - Taiyeb Khumri
- Department of Cardiology, University of Missouri, Kansas City- School of Medicine, USA
| | - Shariq Shamim
- Department of Cardiology, University of Missouri, Kansas City- School of Medicine, USA
| | - Pallavi Surana
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, USA
| | - Salman Khan
- Department of Internal Medicine, University of Missouri, Kansas City-School of Medicine, USA
| | - Nabil Al-Khalisi
- Department of Radiology, University of Missouri, Kansas City-School of Medicine, USA
| | | | - Christopher Koh
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, USA
| | - Rajiv Chhabra
- Department of Gastroenterology, University of Missouri, Kansas-School of Medicine, USA
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Chan PS, Khumri T, Chung ES, Ghio S, Reid KJ, Gerritse B, Nallamothu BK, Spertus JA. Echocardiographic dyssynchrony and health status outcomes from cardiac resynchronization therapy: insights from the PROSPECT trial. JACC Cardiovasc Imaging 2010; 3:451-60. [PMID: 20466340 DOI: 10.1016/j.jcmg.2009.08.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [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] [Received: 09/04/2008] [Revised: 08/03/2009] [Accepted: 08/10/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study sought to assess the prognostic utility of echocardiographic dyssynchrony for health status improvement after cardiac resynchronization therapy (CRT). BACKGROUND Echocardiographic measures of dyssynchrony have been proposed for patient selection for CRT, but prospective validation studies are lacking. METHODS A prospective cohort of 324 patients from 53 centers with moderate to severe heart failure, left ventricular dysfunction, QRS > or =130 ms, and available echocardiographic and health status information were identified from the PROSPECT (Predictors of Response to Cardiac Re-Synchronization Therapy) trial, which evaluated the prognostic utility of dyssynchrony measures in CRT recipients. The association of 12 echocardiographic dyssynchrony parameters with 6-month improvement in health status, as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), was assessed both as a continuous variable and by responder status (DeltaKCCQ > or =+10 points reflecting moderate to large improvement). RESULTS Of 12 pre-defined dyssynchrony parameters, only 3 were consistently reported: interventricular mechanical delay (IVMD), left ventricular filling time relative to the cardiac cycle (LVFT), and left ventricular pre-ejection interval. After multivariable adjustment, IVMD (+5.18, 95% confidence interval [CI]: +0.76 to +9.60; p = 0.02) and LVFT (+5.19, 95% CI: +0.45 to +0.94; p = 0.03) were independently associated with 6-month improvements in KCCQ. Patients with 6-month improvements in KCCQ had lower subsequent mortality (adjusted hazard ratio [HR] for each 5-point improvement: 0.83; 95% CI: 0.72 to 0.93; p = 0.03). Additionally, IVMD was associated with CRT responder status (for DeltaKCCQ > or =+10 points: odds ratio [OR]: 1.85; 95% CI: 1.12 to 3.05; p = 0.03), whereas LVFT was not (OR: 1.63; 95% CI: 0.85 to 3.11; p = 0.14). Patients classified as health status responders had a 76% lower subsequent risk of all-cause mortality (adjusted HR: 0.24; 95% CI: 0.07 to 0.84; p = 0.03). CONCLUSIONS The presence of pre-implantation IVMD and LVFT was associated with 6-month health status improvement, and IVMD was associated with a significant CRT response. These echocardiographic factors may help clinicians counsel patients regarding their likelihood of symptomatic improvement with CRT. ( PROSPECT Predictors of Response to Cardiac Re-Synchronization Therapy; NCT00253357).
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Affiliation(s)
- Paul S Chan
- Mid America Heart Institute, Kansas City, Missouri 64111, USA.
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