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Sarkar S, Koehler J, Vasudevan N. Ambulatory Risk Stratification for Worsening Heart Failure in Patients with Reduced and Preserved Ejection Fraction Using Diagnostic Parameters Available in Implantable Cardiac Monitors. Diagnostics (Basel) 2024; 14:771. [PMID: 38611683 PMCID: PMC11012110 DOI: 10.3390/diagnostics14070771] [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: 03/13/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Ambulatory risk stratification for worsening heart failure (HF) using diagnostics measured by insertable cardiac monitors (ICM) may depend on the left ventricular ejection fraction (LVEF). We evaluated risk stratification performance in patients with reduced versus preserved LVEF. METHODS ICM patients with a history of HF events (HFEs) were included from the Optum® de-identified Electronic Health Record dataset merged with ICM device-collected data during 2007-2021. ICM measures nighttime heart rate (NHR), heart rate variability (HRV), atrial fibrillation (AF) burden, rate during AF, and activity duration (ACT) daily. Each diagnostic was categorized into high, medium, or low risk using previously defined features. HFEs were HF-related inpatient, observation unit, or emergency department stays with IV diuresis administration. Patients were divided into two cohorts: LVEF ≤ 40% and LVEF > 40%. A marginal Cox proportional hazards model compared HFEs for different risk groups. RESULTS A total of 1020 ICM patients with 18,383 follow-up months and 301 months with HFEs (1.6%) were included. Monthly evaluations with a high risk were 2.3, 4.2, 5.0, and 4.5 times (p < 0.001 for all) more likely to have HFEs in the next 30 days compared to those with a low risk for AF, ACT, NHR, and HRV, respectively. HFE rates were higher for patients with LVEF > 40% compared to LVEF ≤ 40% (2.0% vs. 1.3%), and the relative risk between high-risk and low-risk for each diagnostic parameter was higher for patients with LVEF ≤ 40%. CONCLUSIONS Diagnostics measured by ICM identified patients at risk for impending HFEs. Patients with preserved LVEF showed a higher absolute risk, and the relative risk between risk groups was higher in patients with reduced LVEF.
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Mujanovic A, Dobrocky T, Pfeilschifter W, Remonda L, Caroff J, Behme D, Seiffge DJ, Cereda CW, Kägi G, Leyon J, Piechowiak EI, Costalat V, Wagner J, Chabert E, Meinel TR, Jansen O, Alonso A, Loehr C, Liebeskind DS, Gralla J, Fischer U, Kaesmacher J. Value of intravenous alteplase before thrombectomy among patients with tandem lesions and emergent carotid artery stenting: A subgroup analysis of the SWIFT DIRECT trial. Eur J Neurol 2024:e16256. [PMID: 38409874 DOI: 10.1111/ene.16256] [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: 11/21/2023] [Revised: 01/26/2024] [Accepted: 02/07/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND AND PURPOSE The value of intravenous thrombolysis (IVT) in eligible tandem lesion patients undergoing endovascular treatment (EVT) is unknown. We investigated treatment effect heterogeneity of EVT + IVT versus EVT-only in tandem lesion patients. Additional analyses were performed for patients undergoing emergent internal carotid artery (ICA) stenting. METHODS SWIFT DIRECT randomized IVT-eligible patients to either EVT + IVT or EVT-only. Primary outcome was 90-day functional independence (modified Rankin Scale score 0-2) after the index event. Secondary endpoints were reperfusion success, 24 h intracranial hemorrhage rate, and 90-day all-cause mortality. Interaction models were fitted for all predefined outcomes. RESULTS Among 408 included patients, 63 (15.4%) had a tandem lesion and 33 (52.4%) received IVT. In patients with tandem lesions, 20 had undergone emergent ICA stenting (EVT + IVT: 9/33, 27.3%; EVT: 11/30, 36.7%). Tandem lesion did not show treatment effect modification of IVT on rates of functional independence (tandem lesion EVT + IVT vs. EVT: 63.6% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 65.6% vs. 58.2%; p for interaction = 0.77). IVT also did not increase the risk of intracranial hemorrhage among tandem lesion patients (tandem lesion EVT + IVT vs. EVT: 34.4% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 33.5% vs. 26.3%; p for interaction = 0.15). No heterogeneity was noted for other endpoints (p for interaction > 0.05). CONCLUSIONS No treatment effect heterogeneity of EVT + IVT versus EVT-only was observed among tandem lesion patients. Administering IVT in patients with anticipated emergent ICA stenting seems safe, and the latter should not be a factor to consider when deciding to administer IVT before EVT.
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Affiliation(s)
- Adnan Mujanovic
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Waltraud Pfeilschifter
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Luca Remonda
- Department of Neuroradiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Jildaz Caroff
- Department of Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre Hospital, Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - Daniel Behme
- Department for Neuroradiology, Otto von Guericke University Hospital Magdeburg, University of Magdeburg, Magdeburg, Germany
| | - David J Seiffge
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Carlo W Cereda
- Stroke Center, Neurology, Neurocenter of Southern Switzerland (EOC), Lugano, Switzerland
| | - Georg Kägi
- Department of Neurology, Cantonal Hospital St. Gallen, University of St. Gallen, St. Gallen, Switzerland
| | - Joe Leyon
- Department of Neuroradiology, St. George's University Hospital, London, UK
| | - Eike I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Vincent Costalat
- Department of Neuroradiology, University Hospital Montpellier, Montpellier, France
| | - Judith Wagner
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Department of Neurology, Evangelisches Klinikum Gelsenkirchen, Academic Hospital University Essen-Duisburg, Gelsenkirchen, Germany
| | - Emmanuel Chabert
- Department of Neuroradiology, University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas R Meinel
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, University of Kiel, Kiel, Germany
| | - Angelika Alonso
- Department of Neurology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christian Loehr
- Department of Radiology and Neuroradiology, Klinikum Vest, Recklinghausen, Germany
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
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El-Chami MF, Bockstedt L, Longacre C, Higuera L, Stromberg K, Crossley G, Kowal RC, Piccini JP. Leadless vs. transvenous single-chamber ventricular pacing in the Micra CED study: 2-year follow-up. Eur Heart J 2022; 43:1207-1215. [PMID: 34788416 PMCID: PMC8934700 DOI: 10.1093/eurheartj/ehab767] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [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] [Received: 08/04/2021] [Revised: 08/19/2021] [Accepted: 10/20/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Clinical trials have demonstrated the safety and efficacy of the Micra leadless VVI pacemaker; however, longer-term outcomes in a large, real-world population with a contemporaneous comparison to transvenous VVI pacemakers have not been examined. We compared reinterventions, chronic complications, and all-cause mortality at 2 years between leadless VVI and transvenous VVI implanted patients. METHODS AND RESULTS The Micra Coverage with Evidence Development study is a continuously enrolling, observational, cohort study of leadless VVI pacemakers in the US Medicare fee-for-service population. Patients implanted with a leadless VVI pacemaker between March 9, 2017, and December 31, 2018, were identified using Medicare claims data linked to manufacturer device registration data (n = 6219). All transvenous VVI patients from facilities with leadless VVI implants during the study period were obtained directly from Medicare claims (n = 10 212). Cox models were used to compare 2-year outcomes between groups. Compared to transvenous VVI, patients with leadless VVI had more end-stage renal disease (12.0% vs. 2.3%) and a higher Charlson comorbidity index (5.1 vs. 4.6). Leadless VVI patients had significantly fewer reinterventions [adjusted hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.45-0.85, P = 0.003] and chronic complications (adjusted HR 0.69, 95% CI 0.60-0.81, P < 0.0001) compared with transvenous VVI patients. Adjusted all-cause mortality at 2 years was not different between the two groups (adjusted HR 0.97, 95% CI 0.91-1.04, P = 0.37). CONCLUSION In a real-world study of US Medicare patients, the Micra leadless VVI pacemaker was associated with a 38% lower adjusted rate of reinterventions and a 31% lower adjusted rate of chronic complications compared with transvenous VVI pacing. There was no difference in adjusted all-cause mortality at 2 years.
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Affiliation(s)
- Mikhael F El-Chami
- Emory University School of Medicine, 550 W Peachtree St NE, Atlanta, GA 30308, USA
| | | | - Colleen Longacre
- Medtronic, Inc, 710 Medtronoc PKW NE, Minneapolis, MN 55432, USA
| | - Lucas Higuera
- Medtronic, Inc, 710 Medtronoc PKW NE, Minneapolis, MN 55432, USA
| | - Kurt Stromberg
- Medtronic, Inc, 710 Medtronoc PKW NE, Minneapolis, MN 55432, USA
| | - George Crossley
- Vanderbilt University Medical Center, 1161 21ST Ave S, Nashville, TN 37232, USA
| | - Robert C Kowal
- Medtronic, Inc, 710 Medtronoc PKW NE, Minneapolis, MN 55432, USA
| | - Jonathan P Piccini
- Duke University Medical Center & Duke Clinical Research Institute, 40 Duke Medicine Circle Clinic 2F/2 G, Durham, NC 27710, USA
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