Frieder Braunschweig

Long-term benefits of biventricular pacing in congestive heart failure : Results from the multisite stimulation in cardiomyopathy (MUSTIC) study

OBJECTIVES The main objective of this study was to assess if the benefits of biventricular (BiV) pacing observed during the crossover phase were sustained over 12 months. BACKGROUND MUltisite STimulation In Cardiomyopathies (MUSTIC) is a randomized controlled study intended to evaluate the effects of BiV pacing in patients with New York Heart Association (NYHA) class III heart failure and intraventricular conduction delay. METHODS Of 131 patients included, 42/67 in sinus rhythm (SR) and 33/64 in atrial fibrillation (AF) were followed up longitudinally at 9 and 12 months by 6-min walked distance, peak oxygen uptake (peak VO(2)), quality of life by the Minnesota score, NYHA class, echocardiography, and left ventricular ejection fraction by radionuclide technique. RESULTS At 12 months, all SR and 88% of AF patients were programmed to BiV pacing. Compared with baseline, the 6-min walked distance increased by 20% (SR) (p = 0.0001) and 17% (AF) (p = 0.004); the peak VO(2) by 11% (SR) and 9% (AF); quality of life improved by 36% (SR) (p = 0.0001) and 32% (AF) (p = 0.002); NYHA class improved by 25% (SR) (p = 0.0001) and 27% (AF) (p = 0.0001). The ejection fraction improved by 5% (SR) and 4% (AF). Mitral regurgitation decreased by 45% (SR) and 50% (AF). CONCLUSIONS The clinical benefits of BiV pacing appeared to be significantly maintained over a 12-month follow-up period.

Long-term improvements in quality of life by biventricular pacing in patients with chronic heart failure: results from the Multisite Stimulation in Cardiomyopathy study (MUSTIC).

To assess the impact of biventricular pacing on quality of life over 12 months of follow-up, 76 patients in the MUSTIC trial were evaluated by 2 instruments: The Minnesota Living with Heart Failure Questionnaire and the Karolinska Quality of Life Questionnaire. MUSTIC is a randomized, controlled study to evaluate the effects of biventricular pacing in patients in New York Heart Association class III heart failure with intraventricular conduction delay. Following a single, blind, crossover comparison of 3 months of biventricular pacing to inactive pacing (sinus rhythm group) or ventricular-inhibited pacing (atrial fibrillation group), 85% of patients preferred and were programmed to biventricular pacing and were followed for 12 months. In parallel with clinical improvements, substantial benefits in quality of life for most broad domains of quality of life and cardiovascular symptoms were found during biventricular pacing already within the crossover phase with a maintained benefit over the 12-month follow-up. Biventricular pacing improved quality of life in patients with heart failure and intraventricular conduction delays. The benefits were sustained over 12 months of follow-up.

What are the costs of heart failure

Heart failure , a syndrome associated with increasing prevalence, high mortality, and frequent hospital admissions, imposes a significant economic burden on western healthcare systems that is expected to further increase in the future due to the ageing population. Hospitalizations are responsible for the largest part of treatment costs and, thus, the main target for strategies aiming at cost reduction. Current literature suggests that evidence-based therapy with drugs, devices, and modern disease management programmes improves clinical outcomes of the large population of heart failure patients in a largely cost-effective manner. However, comprehensive knowledge about the cost of treatment is important to guide clinicians in the responsible allocation of todays limited health-care resources. This review provides information about the total cost of heart failure and the contribution of different treatment components to the overall costs.

Reduction of hospital days by biventricular pacing.

The health care costs for heart failure are substantial. Studies indicate that hospital treatment constitutes 65–75% of these. The aim of this study was to assess total and heart failure related hospital days as well as safety and efficacy of biventricular pacing in 16 patients with severe heart failure and delayed intraventricular conduction (QRS duration <150 ms). They were implanted with a biventricular pacemaker and followed by NYHA class, 6‐min walk test and quality of life for a mean of 291±76 days. Total number of hospital days and the need for hospitalisations were monitored. Thirteen responders improved by at least one functional class. After 6 months of pacing the 6‐min walk test improved from 375±83 m to 437±73 m (P<0.001) and Minnesota Living with Heart Failure quality of life score from 41±19 to 24±17 (P<0.001) compared to baseline. The need for hospital care decreased significantly after biventricular pacing. The total number of hospital days in all patients was 253 the year before compared to 45 the year after biventricular pacing (P<0.01). For heart failure related hospital days the corresponding figures were 183 and 39 days, respectively (P<0.01). Biventricular pacing improved 13/16 patients with severe heart failure and wide QRS complexes in this open study. The improvement resulted in a reduced need for hospital care.

Can monitoring of intrathoracic impedance reduce morbidity and mortality in patients with chronic heart failure? Rationale and design of the Diagnostic outcome Trial in Heart Failure (DOT-HF)

Chronic heart failure is associated with frequent hospitalisations which are often due to volume‐overload decompensation. Monitoring of intrathoracic impedance, measured from an implanted device, can detect increases in pulmonary fluid retention early and facilitate timely treatment interventions.

Lifetime cost-effectiveness of prophylactic implantation of a cardioverter defibrillator in patients with reduced left ventricular systolic function: results of Markov modelling in a European population

AIMS Current European guidelines recommend prophylactic implantation of cardioverter defibrillators (ICDs) in patients with a reduced left ventricular ejection fraction (LVEF) who are not in NYHA class IV and have reasonable life expectancy. Cost and benefit implications of this recommendation have not been reported from a European perspective. METHODS AND RESULTS Markov modelling estimated lifetime costs and effects [life years (LY) and quality-adjusted LY (QALY) gained] of prophylactic ICD implantation vs. conventional treatment, among patients with a reduced LVEF. Efficacy was estimated from a meta-analysis of mortality rates in the six primary prevention trials with inclusion criteria matching ACC/AHA/ESC Class I or IIa recommendations. Direct medical costs were estimated using Belgian national references. Costs and effects were discounted at 3 and 1.5% per annum, respectively. Probabilistic sensitivity and scenario analyses estimated the uncertainty around the incremental cost-effectiveness ratio. An ICD implantation increased the lifetime direct costs by euro 46,413. Estimated mean LY/QALY gained were 1.88/1.57, respectively. Probabilistic analysis estimated mean lifetime cost per QALY gained as euro 31,717 (95% CI: euro 19,760-euro 61,316). Cost-effectiveness was influenced most by ICD efficacy, time to replacement, utility, and patient age at implantation. CONCLUSION In a European healthcare setting, prophylactic ICD implantation may be cost-effective if current guidelines for patients with a reduced LVEF are followed.

Women have better long-term prognosis than men after cardiac resynchronization therapy

AIMS Cardiac resynchronization therapy (CRT) improves prognosis in patients with moderate-to-severe heart failure, reduced left ventricular ejection fraction, and wide QRS complexes. However, CRT may be under-utilized in women and data on long-term follow-up are still scarce. The aim was to investigate long-term mortality and hospitalization and prognostic impact of gender after CRT. METHODS AND RESULTS Data on 619 consecutive patients (19% women) that received CRT at a single centre between 1998 and 2008 were collected from electronic medical records and national death and hospitalization registries up to 2010. The primary endpoint was death of any cause and the secondary endpoint was combined death of any cause or heart failure hospitalization. Over a mean follow-up of 1320 ± 786 days, 215 (35%) patients reached the primary endpoint and 437 (71%) the secondary endpoint. Overall, 1-, 5-, and 10-year survivals were 91, 63, and 39%, respectively. Female gender was the only independent predictor of all-cause mortality; hazard ratio (HR) 0.44 [95% confidence interval (CI), 0.21-0.90; P= 0.025]. Women also had a trend towards lower risk for the secondary endpoint, HR 0.68 (95% CI, 0.45-1.04; P= 0.072). CONCLUSION In this registry analysis, patients with CRT had similarly high short-term survival to those in controlled trials, and this favourable prognosis was sustained over the long term.Women had lower all-cause mortality than men.

Acute Kidney Injury Following Coronary Artery Bypass Surgery and Long-term Risk of Heart Failure

Background— Acute kidney injury (AKI) after coronary artery bypass grafting (CABG) is common and increases the risk of postoperative complications and mortality. There is little information on the association between AKI after CABG and long-term risk of incident heart failure (HF). Methods and Results— All patients (n=24 018) undergoing primary, isolated CABG in Sweden between 2000 and 2008 with complete information on pre- and postoperative serum creatinine values, and no prior hospitalization for HF were included. The postoperative increase in serum creatinine was used to define different stages of AKI: stage 1, 0.3 to 0.5 mg/dL; stage 2, 0.5 to 1 mg/dL; stage 3, >1 mg/dL. Hazard ratios with 95% confidence intervals were calculated for first hospitalization for HF for each stage of AKI using Cox proportional hazards regression. Twelve percent of the study population developed AKI. During a mean follow-up of 4.1 years, there were 1325 cases (5.5%) of incident HF. Hazard ratios with 95% confidence interval for HF in AKI stage 1, 2, and 3 were 1.60 (1.34–1.92), 1.87 (1.54–2.27), and 1.98 (1.53–2.57), respectively, after multivariable adjustment for age, sex, diabetes mellitus, estimated glomerular filtration rate, left ventricular ejection fraction, and myocardial infarction before surgery or during follow-up. Conclusions— AKI is associated with increased long-term risk of HF after CABG. Patients with AKI after CABG should be followed closely to detect early changes in cardiac function.

Effects of biventricular pacing on myocardial blood flow and oxygen consumption using carbon-11 acetate positron emission tomography in patients with heart failure

Effects of biventricular pacing on myocardial blood flow and oxygen consumption using carbon-11 acetate positron emission tomography in patients with heart failure

Impact of extending device longevity on the long-term costs of implantable cardioverter-defibrillator therapy: a modelling study with a 15-year time horizon

AIMS To determine the long-term costs of extending device longevity in four patient populations requiring a single-chamber implantable cardioverter-defibrillator (ICD) or requiring cardiac resynchronization therapy with defibrillation (CRT-D) device over a 15-year time window. METHODS AND RESULTS We considered patient populations with an accepted indication for a single-chamber ICD for prevention of sudden cardiac death in the context of preserved (Population A) or impaired (Population B) left ventricular function; or with indication for a CRT-D device in the context of heart failure in New York Heart Association class II (Population C) or III (Population D). Expected patient survival and a cost analysis, including the cost of complications, was undertaken from a hospital perspective. Extended device longevity of 5 vs. 9 years for ICDs (Populations A and B); 4 vs. 7 years for CRT-Ds (Populations C and D) were considered. Over a 15-year time horizon, total, yearly, and per diem savings, per patient, from extending ICD longevity to 9 years were €10 926.91, €728.46, and €1.99 for Population A, and €7661.32, €510.75, and €1.40 for Population B. Total, yearly, and per diem savings from extending CRT-D longevity to 7 years were €13 630.38, €908.69, and €2.49 for Population C, and €10 968.29, €731.22, and €2.00 for Population D. Avoidance of a generator replacement amounted up to 46.6-62.5% of the saving. CONCLUSION Extending device longevity has an important effect on the long-term cost of device therapy, both for ICD and CRT-D. This has important implications for device choice.