Objectives The purpose of this study was to assess the effect of remote patient monitoring (RPM) on the outcome of chronic heart failure (HF) patients. Background RPM via regularly scheduled ...structured telephone contact between patients and health care providers or electronic transfer of physiological data using remote access technology via remote external, wearable, or implantable electronic devices is a growing modality to manage patients with chronic HF. Methods After a review of the literature published between January 2000 and October 2008 on a multidisciplinary heart failure approach by either usual care (in-person visit) or RPM, 96 full-text articles were retrieved: 20 articles reporting randomized controlled trials (RCTs) and 12 reporting cohort studies qualified for a meta-analysis. Results Respectively, 6,258 patients and 2,354 patients were included in RCTs and cohort studies. Median follow-up duration was 6 months for RCTs and 12 months for cohort studies. Both RCTs and cohort studies showed that RPM was associated with a significantly lower number of deaths (RCTs: relative risk RR: 0.83, 95% confidence interval CI: 0.73 to 0.95, p = 0.006; cohort studies: RR: 0.53, 95% CI: 0.29 to 0.96, p < 0.001) and hospitalizations (RCTs: RR: 0.93, 95% CI: 0.87 to 0.99, p = 0.030; cohort studies: RR: 0.52, 95% CI: 0.28 to 0.96, p < 0.001). The decrease in events was greater in cohort studies than in RCTs. Conclusions RPM confers a significant protective clinical effect in patients with chronic HF compared with usual care.
Abstract Aim We compared the time to initiation of cardiopulmonary resuscitation (CPR) by lay responders and/or first responders alerted either via Short Message Service (SMS) or by using a mobile ...application-based alert system (APP). Methods The Ticino Registry of Cardiac Arrest collects all data about out-of-hospital cardiac arrests (OHCAs) occurring in the Canton of Ticino. At the time of a bystander’s call, the EMS dispatcher sends one ambulance and alerts the first-responders network made up of police officers or fire brigade equipped with an automatic external defibrillator, the so called “traditional” first responders, and − if the scene was considered safe − lay responders as well. We evaluated the time from call to arrival of traditional first responders and/or lay responders when alerted either via SMS or the new developed mobile APP. Results Over the study period 593 OHCAs have occurred. Notification to the first responders network was sent via SMS in 198 cases and via mobile APP in 134 cases. Median time to first responder/lay responder arrival on scene was significantly reduced by the APP-based system (3.5 2.8-5.2) compared to the SMS-based system (5.6 4.2-8.5 min, p 0.0001). The proportion of lay responders arriving first on the scene significantly increased (70% vs. 15%, p<0.01) with the APP. Earlier arrival of a first responder or of a lay responder determined a higher survival rate. Conclusions The mobile APP system is highly efficient in the recruitment of first responders, significantly reducing the time to the initiation of CPR thus increasing survival rates.
Abstract
Aims
Non-invasive imaging of electrical activation requires high-density body surface potential mapping. The nine electrodes of the 12-lead electrocardiogram (ECG) are insufficient for a ...reliable reconstruction with standard inverse methods. Patient-specific modelling may offer an alternative route to physiologically constraint the reconstruction. The aim of the study was to assess the feasibility of reconstructing the fully 3D electrical activation map of the ventricles from the 12-lead ECG and cardiovascular magnetic resonance (CMR).
Methods and results
Ventricular activation was estimated by iteratively optimizing the parameters (conduction velocity and sites of earliest activation) of a patient-specific model to fit the simulated to the recorded ECG. Chest and cardiac anatomy of 11 patients (QRS duration 126–180 ms, documented scar in two) were segmented from CMR images. Scar presence was assessed by magnetic resonance (MR) contrast enhancement. Activation sequences were modelled with a physiologically based propagation model and ECGs with lead field theory. Validation was performed by comparing reconstructed activation maps with those acquired by invasive electroanatomical mapping of coronary sinus/veins (CS) and right ventricular (RV) and left ventricular (LV) endocardium. The QRS complex was correctly reproduced by the model (Pearson’s correlation r = 0.923). Reconstructions accurately located the earliest and latest activated LV regions (median barycentre distance 8.2 mm, IQR 8.8 mm). Correlation of simulated with recorded activation time was very good at LV endocardium (r = 0.83) and good at CS (r = 0.68) and RV endocardium (r = 0.58).
Conclusion
Non-invasive assessment of biventricular 3D activation using the 12-lead ECG and MR imaging is feasible. Potential applications include patient-specific modelling and pre-/per-procedural evaluation of ventricular activation.
Precise knowledge of left atrial appendage (LAA) orifice size is crucial for correct sizing of LAA closure devices. The aim of the present study was to determine the performance of real-time 3D ...transesophageal echocardiography (RT3DTEE) for LAA orifice size assessment, compared with 2D transesophageal echocardiography (2DTEE), and to investigate the impact of atrial fibrillation (AF) on LAA orifice size.
One hundred thirty-seven patients (38 control subjects, 31 with paroxysmal AF, 38 with persistent AF and 30 with permanent AF) underwent 2DTEE and RT3DTEE. Both techniques were used to measure LAA orifice area. Clinically-indicated 64-slice computed tomography (CT) was used as reference technique in 46 patients. Two-dimensional TEE underestimated LAA orifice area, compared with RT3DTEE (1.99±0.94 cm(2) versus 3.05±1.27 cm(2); P<0.001). RT3DTEE showed higher correlation with CT for the assessment of LAA orifice area, compared with 2DTEE (r=0.92; 95% confidence interval, 0.85 to 0.95, versus r=0.72; 95% confidence interval, 0.54 to 0.83, respectively). At Bland-Altman analysis, RT3DTEE and 2DTEE underestimated LAA orifice area, compared with CT. However, RT3DTEE showed smaller bias (0.07 cm(2) versus 0.72 cm(2)) and narrower limits of agreement (-0.71 to 0.85 cm(2) versus -0.58 to 2.02 cm(2)) with CT, compared with 2DTEE. Among AF patients, a progressive increase in RT3DTEE-derived LAA orifice area was observed with increasing frequency of AF (P<0.001). At multivariate analysis, AF and left atrial volume index (P<0.001 for both) were independently associated with RT3DTEE-derived LAA orifice area.
RT3DTEE is more accurate than 2DTEE for the assessment of LAA orifice size. A progressive increase in LAA orifice area is observed with increasing frequency of AF.
Aims
To assess the cost‐effectiveness and the cost utility of remote patient monitoring (RPM) when compared with the usual care approach based upon differences in the number of hospitalizations, ...estimated from a meta‐analysis of randomized clinical trials (RCTs).
Methods and results
We reviewed the literature published between January 2000 and September 2009 on multidisciplinary heart failure (HF) management, either by usual care or RPM to retrieve the number of hospitalizations and length of stay (LOS) for HF and for any cause. We performed a meta‐analysis of 21 RCTs (5715 patients). Remote patient monitoring was associated with a significantly lower number of hospitalizations for HF incidence rate ratio (IRR): 0.77, 95% CI 0.65–0.91, P < 0.001 and for any cause (IRR: 0.87, 95% CI: 0.79–0.96, P = 0.003), while LOS was not different. Direct costs for hospitalization for HF were approximated by diagnosis‐related group (DRG) tariffs in Europe and North America and were used to populate an economic model. The difference in costs between RPM and usual care ranged from €300 to €1000, favouring RPM. These cost savings combined with a quality‐adjusted life years (QALYs) gain of 0.06 suggest that RPM is a ‘dominant’ technology over existing standard care. In a budget impact analysis, the adoption of an RPM strategy entailed a progressive and linear increase in costs saved.
Conclusions
The novel cost‐effectiveness data coupled with the demonstrated clinical efficacy of RPM should encourage its acceptance amongst clinicians and its consideration by third‐party payers. At the same time, the scientific community should acknowledge the lack of prospectively and uniformly collected economic data and should request that future studies incorporate economic analyses.
CRT has been proven to achieve most benefit in patients with left bundle branch block morphology (LBBB). However, ECG criteria to define LBBB significantly differ from each other.
Objective of the ...study was to evaluate the impact of different ECG criteria for LBBB definition on survival, hospitalization for heart failure and reverse remodelling in patients who received cardiac resynchronization therapy (CRT).
Three-hundred-sixteen consecutive patients were included in the analysis. Six different classifications were assessed in baseline ECGs of patients who received a CRT device: a QRS duration of ≥150 ms and LBBB according to AHA/ACC/HRS, ESC 2006, ESC 2009, ESC 2013 and the classification proposed by Strauss and colleagues. In univariate analysis, the ESC 2009 and 2013 and the Strauss classifications were significantly associated with a reduction in cumulative probability for heart failure (HF) and mortality (HR 0.60, 95%CI 0.42–0.86, HR 0.61, 95% CI 0.43–0.87 and HR 0.57, 95% CI 0.40–0.80, respectively). In multivariate analysis, the association with the combined endpoint was confirmed only for ESC 2009 and 2013 classifications and for Strauss. Moreover, the cumulative probability of all-cause death and HF hospitalizations was higher in patients who were negative for all the 5 LBBB classifications.
This study shows that the strength of the association of LBBB to outcome in CRT depends on the ECG classifications used to define LBBB, the simplest criteria (ESC 2009 and 2013) providing the best association with clinical endpoints in CRT.
•The present study shows that using QRS morphology, it can help identify patients that will probably benefit of CRT.•The study also shows that the choice of the correct criteria is associated with the outcome to CRT.•It is imperative to develop a standard on ECG classification to assess the candidacy to CRT.
Aims To investigate the effects of cardiac resynchronization therapy (CRT) on survival in heart failure (HF) patients with permanent atrial fibrillation (AF) and the role of atrio-ventricular ...junction (AVJ) ablation in these patients. Methods and results Data from 1285 consecutive patients implanted with CRT devices are presented: 1042 patients were in sinus rhythm (SR) and 243 (19%) in AF. Rate control in AF was achieved by either ablating the AVJ in 118 patients (AVJ-abl) or prescribing negative chronotropic drugs (AF-Drugs). Compared with SR, patients with AF were significantly older, more likely to be non-ischaemic, with higher ejection fraction, shorter QRS duration, and less often received ICD back-up. During a median follow-up of 34 months, 170/1042 patients in SR and 39/243 in AF died (mortality: 8.4 and 8.9 per 100 person-year, respectively). Adjusted hazard ratios were similar for all-cause and cardiac mortality 0.9 (0.57–1.42), P = 0.64 and 1.00 (0.60–1.66) P = 0.99, respectively. Among AF patients, only 11/118 AVJ-abl patients died vs. 28/125 AF-Drugs patients (mortality: 4.3 and 15.2 per 100 person-year, respectively, P < 0.001). Adjusted hazard ratios of AVJ-abl vs. AF-Drugs was 0.26 95% confidence interval (CI) 0.09–0.73, P = 0.010 for all-cause mortality, 0.31 (95% CI 0.10–0.99, P = 0.048) for cardiac mortality, and 0.15 (95% CI 0.03–0.70, P = 0.016) for HF mortality. Conclusion Patients with HF and AF treated with CRT have similar mortality compared with patients in SR. In AF, AVJ ablation in addition to CRT significantly improves overall survival compared with CRT alone, primarily by reducing HF death.
Few data are available on the assessment of P-wave beat-to-beat morphology variability and its ability to identify patients prone to paroxysmal atrial fibrillation (AF) occurrence. Aim of this study ...was to determine whether electrocardiographic (ECG) parameters resulting from the beat-to-beat analysis of P wave in ECG recorded during sinus rhythm could be indicators of paroxysmal AF susceptibility. ECGs of 76 consecutive patients including 36 patients with history of AF and no overt structural cardiac abnormalities and a control group of 40 healthy patients without history of AF were analyzed. After preprocessing, features based on P waves and RR intervals were extracted from lead II of a 5-minute ECG recorded during sinus rhythm. The discriminative power of the extracted features was assessed. Among extracted features, the most discriminative ones to identify patients with paroxysmal episodes of AF were the mean P-wave duration and the SD of beat-to-beat Euclidean distance between P waves (an indicator of beat-to-beat P-wave morphologic variability). Patients with history of AF presented a significantly longer P-wave duration (125 ± 18 vs 110 ± 8 ms, p <0.001) and higher variability of P-wave morphology over time (beat-to-beat Euclidean distance: 0.11 ± 0.07 vs 0.076 ± 0.02, p <0.01) compared to patients without history of AF. Combination of P-wave duration and standard deviation of beat-to-beat Euclidean distance led to an accuracy of 88% in the discrimination between the 2 groups of patients. In conclusion, combination of P-wave duration and beat-to-beat Euclidean distance between P waves efficiently discriminates patients with history of AF and no overt structural cardiac abnormalities from healthy age-matched subjects, and it might be used as an effective tool to identify patients prone to paroxysmal AF occurrence.
The aim of this study was to evaluate the timing and magnitude of global and regional right ventricular (RV) function by means of speckle tracking-derived strain in normal subjects and patients with ...RV dysfunction.
Peak longitudinal systolic strain (PLSS) and time to PLSS in 6 RV segments (the basal, mid, and apical segments of the RV free wall and septum) were obtained in 100 healthy volunteers and 76 patients with RV dysfunction by tracking speckles inside the myocardium using grayscale images. Global PLSS and time to PLSS were based on the average of the 6 regional values.
There was a significant and close correlation between RV contractility as measured by PLSS and tricuspid annular plane systolic excursion (r = -0.83, P < .001). In normal subjects, PLSS was significantly greater in the free wall than in the septum (-28.7 + or - 4.1% vs -19.8 + or - 3.4%, P < .001), whereas time to PLSS was similar in the different regions of the right ventricle. In patients with RV dysfunction, global and regional PLSS was significantly less than in normal subjects (-13.7 + or - 3.6% vs -24.2 + or - 2.9%, P < .001), and a global PLSS cutoff value of -19% was helpful in distinguishing the two groups. Furthermore, time to PLSS in all of the RV septal segments and dispersion in RV contraction timing were significantly longer. Global PLSS in the patients with RV dysfunction was also significantly less in the presence of moderate to severe pulmonary hypertension (-12.7 + or - 3.6% vs -14.4 + or - 3.4%, P = .038).
Speckle tracking not only makes it possible to quantify global RV function but also illustrates the physiology of RV contraction and the pattern of activation at regional level. Speckle tracking-derived strain could become an important new means of assessing and following up patients with impaired RV function and increased pulmonary pressure.
PDF
