To assess survival and to construct a baseline mortality risk score in primary prevention implantable cardioverter defibrillator (ICD) patients with non-ischaemic or ischaemic heart disease. Since... Show moreTo assess survival and to construct a baseline mortality risk score in primary prevention implantable cardioverter defibrillator (ICD) patients with non-ischaemic or ischaemic heart disease. Since 1996, data of all consecutive patients who received an ICD system in the Leiden University Medical Center were collected and assessed at implantation. For the current study, all 1036 patients [age 63 (SD 11) years, 81% male] with a primary indication for defibrillator implantation were evaluated and followed for 873 (SD 677) days. During follow-up, 138 patients (13%) died. Non-ischaemic and ischaemic patients demonstrated similar survival but exhibited different factors that influence risk for mortality. A risk score, consisting of simple baseline variables could stratify patients in low, intermediate, and high risk for mortality. In non-ischaemic patients, annual mortality was 0.4% (95% CI 0.0-2.2%) in low risk and 9.4% (95% CI 6.6-13.1%) in high risk patients. In ischaemic patients, mortality was 1.0% (95% CI 0.2-3.0%) in low risk and 17.8% (95% CI 13.6-22.9%) in high risk patients. Utilization of an easily applicable baseline risk score can create an individual patient-tailored estimation on mortality risk to aid clinicians in daily practice. Show less
Atary, J.Z.; Borleffs, C.J.W.; Liem, S.S.; Bax, J.J.; Hoeven, B.L. van der; Bootsma, M.; ... ; Schalij, M.J. 2010
Aims To assess the number of patients in daily clinical practice that meets criteria for implantation of an implantable cardioverter defibrillator (ICD) following acute myocardial infarction (AMI)... Show moreAims To assess the number of patients in daily clinical practice that meets criteria for implantation of an implantable cardioverter defibrillator (ICD) following acute myocardial infarction (AMI) when treated according to an aggressive treatment protocol. Methods and results Patients were treated according to the MISSION! protocol. The protocol encompasses pre-hospital, in-hospital, and outpatient clinical framework for the acute and chronic treatment of AMI patients and the decision making regarding primary prevention of sudden cardiac death (SCD). A total of 676 consecutive AMI patients (78% male, mean age 59 +/-\12 years) treated according to the MISSION! protocol were included in this analysis. Left ventricular ejection fraction at 3 months was 54 +/- 10%. Only 39 (6%) patients met criteria for implantation of an ICD<1 year post-MI. These patients suffered more extensive infarctions as indicated by higher peak troponin T values ( mean 14.5 +/- 8.3 vs. 6.5 +/- 14.7 mu g/L; P < 0.001) and had more left anterior descending artery related infarctions (79 vs. 46%; P < 0.001). Cumulative first appropriate therapy rate was 15% at 3 years follow-up. No SCD was observed in the study population. Conclusion Aggressive treatment of AMI patients and close monitoring after the index event according to a standardized protocol, results in only a small number of patients becoming candidate for prophylactic ICD implantation. An easy-to-use protocol combining aggressive reperfusion, optimal medication, and a risk stratification algorithm tailored to fit within routine practice may help to maintain ICD implantation rates within manageable proportions. Show less
Rees, J.B. van; Borleffs, C.J.W.; Welsenes, G.H.; Velde, E.T. van der; Erven, L. van; Bax, J.J.; Schalij, M.J. 2010
Objectives This study aimed to assess the prevalence of different types of atrial fibrillation (AF) and their prognostic importance in implantable cardioverter-defibrillator (ICD) patients.... Show moreObjectives This study aimed to assess the prevalence of different types of atrial fibrillation (AF) and their prognostic importance in implantable cardioverter-defibrillator (ICD) patients. Background The prevalence of AF has taken epidemic proportions in the population with cardiovascular disease. The prognostic importance of different types of AF in ICD patients remains unclear. Methods Data on 913 consecutive patients (79% men, mean age 62 +/- 13 years) receiving an ICD at the Leiden University Medical Center were prospectively collected. Among other characteristics, the existence and type of AF (paroxysmal, persistent, or permanent) were assessed at implantation. During follow-up, the occurrence of appropriate or inappropriate device therapy as well as mortality was noted. Results At implantation, 73% of patients had no history of AF, 9% had a history of paroxysmal AF, 7% had a history of persistent AF, and 11% had permanent AF. During 833 +/- 394 days of follow-up, 117 (13%) patients died, 228 (25%) patients experienced appropriate device discharge, and 139 (15%) patients received inappropriate shocks. Patients with permanent AF exhibited more than double the risk of mortality, ventricular arrhythmias triggering device discharge, and inappropriate device therapy. Patients with paroxysmal or persistent AF did not show a significant increased risk of mortality or appropriate device therapy but demonstrated almost 3 times the risk of inappropriate device therapy. Conclusions In the population currently receiving ICD treatment outside the setting of clinical trials, a large portion has either a history of AF or permanent AF. Both types of AF have prognostic implications for mortality and appropriate as well as inappropriate device discharge. (J Am Coll Cardiol 2010; 55: 879-85) (C) 2010 by the American College of Cardiology Foundation Show less
Background-Cardiac resynchronization therapy for heart failure with left bundle branch block reduces left ventricular (LV) conduction delay, contraction asynchrony, and LV end-systolic volume (... Show moreBackground-Cardiac resynchronization therapy for heart failure with left bundle branch block reduces left ventricular (LV) conduction delay, contraction asynchrony, and LV end-systolic volume ("reverse remodeling"). Up to one third of patients do not improve, and the electric requirements for reverse remodeling are unclear. We hypothesized that reverse remodeling is predicted by the left bundle branch block ventricular activation sequence, the paced activation sequence, and interactions between these 2 conditions. Methods and Results-Twelve-lead ECGs during left bundle branch block and cardiac resynchronization therapy were analyzed in 202 consecutive patients (New York Heart Association class III to IV heart failure, ejection fraction <= 35%) for predictors of reverse remodeling (>= 10% reduction in end-systolic volume) at 6 months. Greater longest baseline LV activation time predicted increased odds of reverse remodeling (odds ratio [confidence interval] = 1.30 [1.11, 1.52] per 10-ms increase), whereas higher QRS scores for LV scar predicted reduced reverse remodeling (odds ratio [confidence interval] = 0.49 [0.27, 0.88] for each 1-point increase from 0 to 4; 0.92 [0.83, 1.01] for each 1-point increase >4). After cardiac resynchronization therapy, increasing R amplitudes in leads V-1 through V-2 (odds ratio [confidence interval] = 2.76 [1.01, 7.51] for each 1 x increase over [baseline R x 4.5]) and left-->right frontal axis shift (odds ratio [confidence interval] = 2.00 [0.99, 4.02]), indicators of ventricular activation wavefront fusion, were positive predictors of reverse remodeling. Predicted probability of reverse remodeling ranged from <20% for patients with adverse predictors to 99% for those with positive predictors. Conclusions-Ventricular activation with the use of the ECG accurately predicts LV reverse remodeling during cardiac resynchronization therapy. Greater longest baseline LV activation time and smaller scar volume combined with wavefront fusion on the paced ECG, anticipate higher probability of reverse remodeling. (Circulation. 2010; 121: 626-634.) Show less
Background-Left ventricular (LV) fibrosis is important for the response to cardiac resynchronization therapy (CRT). Calibrated integrated backscatter derived by 2D echocardiography quantifies... Show moreBackground-Left ventricular (LV) fibrosis is important for the response to cardiac resynchronization therapy (CRT). Calibrated integrated backscatter derived by 2D echocardiography quantifies myocardial ultrasound reflectivity, which may provide a surrogate of LV fibrosis. The aim of the study was first, to investigate the relation of myocardial ultrasound reflectivity assessed with calibrated integrated backscatter on CRT response, and second, to explore the "myocardial ultrasound reflectivity-CRT response" relation in patients with ischemic and nonischemic heart failure (HF). Methods and Results-One hundred fifty-nine patients with HF referred for CRT underwent an extensive echocardiographic evaluation at baseline and at 6-month follow-up. LV dyssynchrony was derived from speckle-tracking analysis. Calibrated integrated backscatter was obtained from the parasternal long-axis view. The mean value of calibrated integrated backscatter of the anteroseptal and posterior wall was used to estimate myocardial ultrasound reflectivity. CRT response was defined as reduction >= 15% of LV end-systolic volume. At baseline, LV dyssynchrony was significantly larger in responders as compared with nonresponders (188 +/- 96 ms versus 115 +/- 68 ms, P<0.001), and CRT responders showed less myocardial ultrasound reflectivity as compared with nonresponders (-20.8 +/- 3.0 dB versus -17.0 +/- 3.0 dB, P<0.001). In multivariable logistic regression analysis, independent predictors for CRT response were LV dyssynchrony, renal function, and myocardial ultrasound reflectivity. Importantly, myocardial ultrasound reflectivity provided an incremental value to CRT response (chi(2) change=40, P<0.001). Considering patients with ischemic HF, the only independent predictor of CRT response was myocardial ultrasound reflectivity, whereas in patients with nonischemic HF, independent predictors of LV reverse remodeling were myocardial ultrasound reflectivity, LV dyssynchrony, and renal function. Conclusions-Assessment of myocardial ultrasound reflectivity is important in the prediction of CRT response in ischemic and nonischemic patients. (Circ Cardiovasc Imaging. 2010;3:86-93.) Show less
