BackgroundIt is unclear whether an implantable cardioverter-defibrillator (ICD) is generally beneficial in survivors of out-of-hospital cardiac arrest (OHCA).ObjectiveWe studied the association ...between ICD implantation prior to discharge and survival in patients with cardiac aetiology or initial shockable rhythm in OHCA.DesignWe conducted a retrospective cohort study in the Swedish Registry for Cardiopulmonary Resuscitation. Treatment associations were estimated using propensity scores. We used gradient boosting, Bayesian additive regression trees, neural networks, extreme gradient boosting and logistic regression to generate multiple propensity scores. We selected the model yielding maximum covariate balance to obtain weights, which were used in a Cox regression to calculate HRs for death or recurrent cardiac arrest.ParticipantsAll cases discharged alive during 2010 to 2020 with a cardiac aetiology or initial shockable rhythm were included. A total of 959 individuals were discharged with an ICD, and 2046 were discharged without one.ResultsAmong those experiencing events, 25% did so within 90 days in the ICD group, compared with 52% in the other group. All HRs favoured ICD implantation. The overall HR (95% CI) for ICD versus no ICD was 0.38 (0.26 to 0.56). The HR was 0.42 (0.28 to 0.63) in cases with initial shockable rhythm; 0.18 (0.06 to 0.58) in non-shockable rhythm; 0.32 (0.20 to 0.53) in cases with a history of coronary artery disease; 0.36 (0.22 to 0.61) in heart failure and 0.30 (0.13 to 0.69) in those with diabetes. Similar associations were noted in all subgroups.ConclusionAmong survivors of OHCA, those discharged with an ICD had approximately 60% lower risk of death or recurrent cardiac arrest. A randomised trial is warranted to study this further.
To evaluate the role of baseline 12‑lead ECG in predicting the syncope mechanism during continuous monitoring using an implantable loop recorder (ILR).
Consecutive patients with syncope implanted ...with an ILR were enrolled. Baseline 12‑lead ECG were related to ECG diagnosis derived from ILR tracings recorded at the time of syncope recurrence.
In total 300 patients with a mean age of 66 ± 16 years were included, 49% (146/300) received an ILR-guided diagnosis during follow-up. Patients with abnormal baseline ECG more frequently received an ILR-guided diagnosis compared to those with normal baseline ECG 59% vs. 44%, p = 0.018. For a diagnosis of arrhythmic syncope, the corresponding frequencies were 45% vs. 26%, p = 0.001.
Patients with bifascicular block significantly more common received an ILR-guided diagnosis 76% (25/33) compared to those with normal baseline ECG 44% (90/205), p ≪ 0.001. In this subgroup, 96% (24/25) were diagnosed with arrhythmic syncope, 23 of which were due to bradyarrhythmia. Bifascicular block occurred almost exclusively among those ≥60 years (31/33). After logistic regression the adjusted OR for arrhythmic syncope was significant for bifascicular block 5.5 (95%CI 2.3–13.2), p ≪ 0.001. PPV for bifascicular block in predicting arrhythmic syncope was 73% and NPV 73%.
A baseline 12‑lead ECG with bifascicular block was a strong predictor for syncope during follow-up, most often due to bradyarrhythmia caused by intermittent complete heart block. No other ECG findings were associated with the ILR outcome. We find it reasonable to consider permanent pacing instead of an ILR for patients with bifascicular block and unexplained syncope.
•Bifascicular block at baseline ECG was a strong predictor for syncope.•Bifascicular block was found almost exclusively among those above 60 years of age.•Rational to consider permanent pacing for patients with bifascicular block and syncope•No other 12‑lead ECG findings were associated with the ILR outcome.
Abstract
Background
Patients with chronic right ventricular (RV) pacing are at an increased risk of heart failure. Previous studies have indicated that cardiac resynchronization therapy (CRT) is ...underused in this setting, and that there may be sex‐based differences in both CRT use and clinical outcome.
Objective
To evaluate sex‐based differences in CRT use and clinical outcome for patients with new‐onset heart failure post RV pacing.
Methods
Data from the Swedish pacemaker registry was matched with data from the national death and disease registries. Patients with de novo pacemaker implant due to AV block during the period 2005–2020 were included. New‐onset heart‐failure within two years post‐implant was evaluated, primary outcome was all‐cause mortality.
Results
In all, 30183 patients (37% female) were included. Women were on average 3 years older, but had less comorbidities than men. Median follow‐up time was 4.5 2.0–8.0 years. Women had better age‐ and comorbidity‐adjusted survival (HR 0.78 0.73–0.84,
p
< .001). For the 3560 patients (12.4% men and 10.7% women,
p
< .001) who were diagnosed with new‐onset heart failure, 5‐year mortality was similar for men and women (50% vs. 48%,
p
= .29). However, women were less likely to receive CRT‐upgrade (3.8% vs. 9.1%,
p
< .001), and those who did were almost ten years younger than the men.
Conclusion
Women with pacemaker due to AV block are older but have less comorbidities than men. They are less likely to develop new‐onset heart failure, but also less likely to receive a CRT upgrade if they do develop heart failure. Increased awareness of the positive effects of CRT upgrade and potential sex‐ and age‐based discrimination is warranted.
Prior studies have suggested that the benefit from primary preventive defibrillator treatment for patients with non-ischemic cardiomyopathy primarily, treated with cardiac resynchronization therapy, ...may be age-dependent. We aimed to compare age-stratified mortality rates and mode of death in patients with non-ischemic cardiomyopathy who are treated with either primary preventive Cardiac Resynchronization Therapy-defibrillator (CRT-D) or CRT-pacemaker (CRT-P).
All patients with non-ischemic cardiomyopathy and CRT-P or primary preventive CRT-D who were implanted in Sweden during the period 2005-2020 were included. Propensity scoring was used to create a matched cohort. Primary outcome was all-cause mortality within five years.
4027 patients were included, 2334 with CRT-P and 1693 with CRT-D. Crude 5-year mortality was 635 (27%) vs. 246 (15%), p < 0.001. In Cox regression analysis, adjusted for clinically relevant covariables, CRT-D was independently associated with higher five-year survival (0.72 0.61-0.85, p < 0.001). Cardiovascular mortality was similar between groups (62% vs. 64%, p = 0.64), but death from heart failure was more common in the CRT-D group (46% vs. 36%, p = 0.007). In the matched cohort (n = 2414), five-year mortality was 21% (24% versus 16%, p < 0.001). In age-stratified analyses, CRT-P was associated with higher mortality in age-groups <60 years and 70-79 years, but there was no difference in age groups 60-69 years or 80-89 years.
In this nationwide registry-based study, patients with CRT-D have better five-year survival compared to patients with CRT-P. The interaction between age and mortality reduction not consistent, but patients with CRT-D aged <60 years had the largest absolute mortality reduction.
Abstract
Aims
Prior studies have suggested that the benefit from primary preventive defibrillator treatment for patients with nonischemic cardiomyopathyy, treated with cardiac resynchronization ...therapy, may be age-dependent. We aimed to compare age-stratified mortality rates and mode of death in patients with nonischemic cardiomyopathy who are treated with either primary preventive cardiac resynchronization therapy with defibrillator (CRT-D) or CRT with pacemaker (CRT-P).
Methods and results
All patients with nonischemic cardiomyopathy and CRT-P or primary preventive CRT-D who were implanted in Sweden during the period 2005–2020 were included. Propensity scoring was used to create a matched cohort. Primary outcome was all-cause mortality within 5 years. In all, 4027 patients were included: 2334 with CRT-P and 1693 with CRT-D. Crude 5-year mortality was 635 (27%) vs. 246 (15%), P < 0.001. In Cox regression analysis, adjusted for clinically relevant covariables, CRT-D was independently associated with higher 5-year survival 0.72 (0.61–0.85), P < 0.001. Cardiovascular mortality was similar between groups (62 vs. 64%, P = 0.64), but death from heart failure was more common in the CRT-D group (46 vs. 36%, P = 0.007). In the matched cohort (n = 2414), 5-year mortality was 21% (24 vs. 16%, P < 0.001). In age-stratified analyses, CRT-P was associated with higher mortality in age groups <60 years and 70–79 years, but there was no difference in age groups 60–69 years or 80–89 years.
Conclusion
In this nationwide registry-based study, patients with CRT-D had better 5-year survival compared to patients with CRT-P. The interaction between age and mortality reduction was not consistent, but patients with CRT-D aged <60 years had the largest absolute mortality reduction.
Graphical Abstract
Graphical Abstract
CRT, cardiac resynchronization therapy; ICD, implantable cardioverter defibrillator.
Studies have shown that the risk of new-onset heart failure (HF) is higher post-implant for patients receiving right ventricular pacing.
This study aimed to investigate incidence, risk factors and ...implications for long-term prognosis of new-onset HF in patients after pacemaker-implant.
Patients without preexisting HF who received a pacemaker in Sweden during the period 2005-2020 were identified via the nationwide Pacemaker Registry. Data was crossmatched with the population registry and national disease registries. Primary outcome was new-onset HF within 5 years, and a risk score for this was developed and validated..
In all, 65579 patients met the inclusion criteria (10351 single chamber ventricular and 55228 dual chamber pacemakers). 13792 (21.0%) patients were diagnosed with HF within five years post-implant. Of these, 6244 (45.3%) were hospitalized for HF. Patients with new-onset heart failure were more likely to die within five years (41.2% vs. 19.7%, p<0.0001). Risk factors for new-onset HF included increasing age, male sex, hypertension, diabetes, atrial fibrillation, chronic lung- and kidney disease, ischemic heart disease, and AV block. In a combined score using these variables, patients in the highest risk-score quartile had a hazard ratio of 5.36 4.91-5.86 (p<0.001) and an absolute risk of 32% for developing HF.
Pacemaker therapy is associated with >20% risk of new-onset HF within five years, and we identified nine risk factors associated with the diagnosis of new-onset HF. The proposed score based on these variables can be used to identify patients at high risk for new-onset heart failure.
Risk factors and incidence of new-onset heart failure for patients treated with traditional pacemaker and right ventricular pacing. Display omitted
The use of direct oral anticoagulants (DOACs) in patients undergoing elective direct current (DC) cardioversion of non-acute atrial fibrillation (AF) can potentially shorten the time from initiation ...of anticoagulation treatment to cardioversion, compared with warfarin. The safety of this strategy needs to be investigated. Data from subgroup analysis from clinical trials with DOAC do not clarify whether 4-week treatment with DOAC is sufficient to prevent thromboembolism (TE) after cardioversion. The aim of this retrospective study was to assess the incidence of TE in anticoagulant naive patients converted after one month's pre-treatment with dabigatran.
We scrutinized the medical records of 631 patients where dabigatran had been used prior to elective DC cardioversion. Transoesophageal echocardiography was rarely performed. Thromboembolism within 30 days of cardioversion was the primary endpoint. A total of 570 patients were naive to OAC when dabigatran was initiated. The mean age in this group was 64.2 ± 11 years and 31.7% were women. The mean CHA2DS2-VASc score was 2.0 ± 1.5. The dose of dabigatran was 150 mg b.i.d. in 94% of the patients. The median time from initiation of dabigatran to cardioversion was 32.0 ± 15 days. In 91% cardioversion resulted in sinus rhythm. During the 30-day follow-up, three TE occurred for an incidence of 0.53% (0.18-1.54).
In this retrospective study from clinical material, we found a low incidence of TE when dabigatran was used as TE prophylaxis in association with elective cardioversion. These results indicate that dabigatran is a safe alternative strategy to warfarin during cardioversion in patients with AF.
ObjectivesInappropriate shocks are unpleasant and painful. We hypothesise that remote monitoring and careful attention to known and incident atrial fibrillation (AF) can reduce inappropriate shocks ...to a very low level in clinical praxis.MethodsAltogether 259 patients with implantable cardioverter defibrillator implanted for secondary (S, n=113) and primary (P, n=146) prevention were followed via remote monitoring. At implant, 42S (37%) and 54P (37%) patients had known AF.ResultsInappropriate shocks, all but five due to AF, occurred in 7S (6.2%) and 11P (7.5%), and there were only inappropriate shocks in 5/7S and in 8/11P. They occurred in four of 42S (9.5%) with and in three of 71S (4.2%) without known AF, and in seven of 54P (13%) with and in four of 92P (4.3%) without known AF. The median time from shock to action was 5 and 1 day, respectively. Actions were medication with amiodarone, β blockers, β blockers+amiodarone or β blockers+digoxin (n=5), β blockers+insertion of an atrial lead (n=1), replacement of a fractured lead (n=2), reprogramming in combination with β blockers, digoxin or amiodarone (n=4), reprogramming (n=2) and none (n=4). After action, four further inappropriate shocks occurred during more than 2 years of follow-up, all due to AF.ConclusionsInappropriate shocks occurred at a low rate and most often because of AF known at implant. Remote monitoring enabled rapid action, after which few inappropriate shocks occurred over more than 2 years. Attention to known and incident AF was the most important action to reduce inappropriate shocks.
BackgroundStudies have shown that the risk of new-onset heart failure (HF) is higher post-implant for patients receiving right ventricular pacing.ObjectiveThis study aimed to investigate incidence, ...risk factors and implications for long-term prognosis of new-onset HF in patients after pacemaker-implant.MethodsPatients without preexisting HF who received a pacemaker in Sweden during the period 2005-2020 were identified via the nationwide Pacemaker Registry. Data was crossmatched with the population registry and national disease registries. Primary outcome was new-onset HF within 5 years, and a risk score for this was developed and validated..ResultsIn all, 65579 patients met the inclusion criteria (10351 single chamber ventricular and 55228 dual chamber pacemakers). 13792 (21.0%) patients were diagnosed with HF within five years post-implant. Of these, 6244 (45.3%) were hospitalized for HF. Patients with new-onset heart failure were more likely to die within five years (41.2% vs. 19.7%, p<0.0001). Risk factors for new-onset HF included increasing age, male sex, hypertension, diabetes, atrial fibrillation, chronic lung- and kidney disease, ischemic heart disease, and AV block. In a combined score using these variables, patients in the highest risk-score quartile had a hazard ratio of 5.36 4.91-5.86 (p<0.001) and an absolute risk of 32% for developing HF.ConclusionPacemaker therapy is associated with >20% risk of new-onset HF within five years, and we identified nine risk factors associated with the diagnosis of new-onset HF. The proposed score based on these variables can be used to identify patients at high risk for new-onset heart failure
PDF
