Sérgio Barra

Implantable cardioverter-defibrillators in the elderly: rationale and specific age-related considerations

Despite the increasingly high rate of implantation of cardioverter-defibrillators (ICD) in elderly patients, data supporting their clinical and cost-effectiveness in this age stratum are ambiguous and contradictory. We comprehensively reviewed the state-of-the-art data regarding the applicability, safety, clinical- and cost-effectiveness of the ICD in elderly patients, and analysed which patients in this age stratum are more likely to get a survival benefit from this therapy. Although peri-procedural risk may be slightly higher in the elderly, this procedure is still relatively safe in this age group. In terms of correcting potentially life-threatening arrhythmias, the effectiveness of ICD therapy is comparable in older and younger individuals. However, the assumption of persistent ICD benefit in the elderly population is questionable, as any advantage of the device on arrhythmic death may be largely attenuated by a higher total non-arrhythmic mortality. While septuagenarians and octogenarians have higher annual all-cause mortality rates, ICD therapy may remain effective in highly selected patients at high risk of arrhythmic death and with minimum comorbidities despite advanced age. ICD intervention among the elderly, as a group, may not be cost-effective, but the procedure may reach cost-effectiveness in those expected to live >5-7 years after implantation. Biological age rather than chronological age per se should be the decisive factor in making a decision on ICD selection for survival benefit.

The Role of Echocardiography in Thromboembolic Risk Assessment of Patients with Nonvalvular Atrial Fibrillation

Echocardiography is a widely used and versatile technique that can provide comprehensive information concerning thromboembolic risk in patients with atrial fibrillation. The authors review the potential contributions of echocardiography to thromboembolic risk stratification and to decreasing the thromboembolic risk associated with procedures such as cardioversion and ablation. Unsolved questions and new possibilities that have arisen from the development of strain and strain rate imaging are also discussed.

LR-PED rule: low risk pulmonary embolism decision rule - a new decision score for low risk pulmonary embolism.

INTRODUCTION When accurately diagnosed, non-massive Pulmonary embolism (PE) has a low mortality rate. However, some patients initially considered to be low risk show progressive deterioration. This research aims at developing a preliminary score that allows detection of low risk patients potentially eligible for outpatient treatment. MATERIALS AND METHODS Retrospective cohort study involving 142 asymptomatic/mildly symptomatic and hemodynamically stable patients with PE and no clinical/echocardiographic signs of right ventricular dysfunction. Collected data: risk factors, analytic/gasometric parameters, admission echocardiogram, thoracic CT angiography. Patients followed for 6months. Primary endpoint: 1-month all-cause mortality. Secondary endpoints: Intrahospital and 6-month all-cause mortality. A score designed for identification of very low risk patients eligible for outpatient treatment was developed and its prognostic accuracy compared to that of the Geneva and simplified PESI models. RESULTS A score for predicting 1-month mortality (Low Risk Pulmonary Embolism Decision [LR-PED] rule) was obtained using Binary Logistic Regression, including: age, atrial fibrillation at admission, previous heart failure, admission heart rate, creatinine, glycaemia, troponin I and C-reactive protein at admission. ROC curve analysis assessed its overall accuracy for predicting 1-month, intrahospital and 6-month mortality (AUC=0.756, 0.763 and 0.854, respectively). Compared to Geneva and simplified PESI, the LR-PED rule showed higher sensitivity and negative predictive value for the detection of the lowest risk patients. The net reclassification improvement index revealed significant successful upward risk reclassification by the LR-PED model of patients reaching primary or secondary outcomes. CONCLUSIONS LR-PED rule seems more attractive than Geneva or simplified PESI in its ability to identify patients at very low mortality risk who would be potentially eligible for outpatient treatment. Prospective validation of this score in larger cohorts is mandatory before its potential implementation.

Decreased Glomerular Filtration Rate and Markers of Left Atrial Stasis in Patients with Nonvalvular Atrial Fibrillation

Background: It is currently unknown if the increased risk of stroke in subjects with chronic kidney disease and atrial fibrillation (AF) is due to the presence of left atrial stasis or to any other vascular or systemic conditions. Methods: This was a retrospective study of 372 subjects undergoing evaluation during an AF episode. The following markers of left atrial stasis were sought on transesophageal echocardiogram: left atrial or left atrial appendage thrombus (LAAT), dense spontaneous echocardiographic contrast (DSEC), and low flow velocities (LFV) in the left atrial appendage. Subgroup comparisons were performed according to the level of estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration equation as follows: ≥90, 45–89.9, and <45 ml/min/1.73 m2. Results: LAAT was found in 11.6%, DSEC in 29.0%, and LFV in 14.9% of cases. A significant increase in the prevalence of DSEC was observed in the lower categories of eGFR: 37.8% in eGFR <45 ml/min, 30.7% in eGFR 45–89.9 ml/min, and 17.0% in eGFR ≥90 ml/min (p = 0.009; γ for trend = 0.297, p = 0.002). The same was observed when assessing left atrial abnormality, i.e. the presence of at least one of the former transesophageal echocardiogram changes. On multivariate analysis, clinical parameters from CHADS2 (congestive heart failure, hypertension, age ≥75, diabetes mellitus and stroke) and CHA2DS2-VASc (age 65–74, history of vascular disease, and female gender along with the clinical variables from CHADS2) were predictors of transesophageal echocardiogram changes and an additive predictive value was found for eGFR. Conclusions: Our results suggest an association between compromised renal function as assessed through eGFR and markers of left atrial stasis in patients with AF. The increased risk of stroke in this population may be due to thromboembolism.

Cardioverter-defibrillator implantation and generator replacement in the octogenarian

AIMS Increase in life expectancy has led to increased rate of implantable cardioverter-defibrillator (ICD) implantation in patients in their 80s, but there are no current formal recommendations to guide physicians when elderly patients with ICDs require elective unit replacement (EUR). This study aims at assessing survival and rates of ICD therapies in patients who have had ICD implantation or EUR above the age of 80, focusing on the latter. METHODS AND RESULTS Retrospective analysis of a prospectively kept database of all ICD-related procedures carried out in a single tertiary centre. Patients 80 years of age or older submitted to ICD implantation (n = 42) or EUR (n = 34) between November 1991 and May 2012 were included. Using collected baseline and outcome data from this cohort, we assessed survival of these patients and the rates of ICD therapies. Median additional years of life after ICD implantation and ICD EUR in patients who died before data retrieval was 2.5 and 1.2, respectively, and while 65% of deceased patients after ICD implantation died in the first 3 years after the procedure, 50% of deceased post-ICD EUR patients died within the first year. Mortality rates at 1 and 2 years post-EUR were 23.1 and 38.1%, respectively. Furthermore, ventricular tachycardia occurred in a small minority of patients after EUR (16.7%) and no ventricular fibrillation-triggered ICD therapies were reported in both groups. CONCLUSION In octogenarians who are due for an ICD EUR, careful thought should be given to the current clinical status, comorbidities, and general frailty prior to considering them for the procedure. A survival benefit from ICD EUR in this age stratum is not likely.

Cardiovascular Risk Assessment of Pulmonary Embolism With the GRACE Risk Score

Despite the existence of several risk scores, the accurate prediction of the prognosis in pulmonary embolism (PE) remains a challenge. The Global Registry of Acute Coronary Events (GRACE) risk score has a high diagnostic performance for adverse outcomes in acute coronary syndrome. We aimed to assess the applicability and extend the use of the GRACE risk score to PE. A case-control study of 206 consecutive patients admitted with PE was performed. The GRACE, Geneva, Simplified Pulmonary Embolism Severity Index, Shock Index, and European Society of Cardiology risk scores were tested for the prediction of the primary end point: all-cause 30-day mortality. Comparisons between GRACE and the other risk scores were performed using receiver operating characteristic area under the curve and the integrated discrimination improvement index. All-cause 30-day mortality was observed in 18.9% of the patients. Unlike the other classifications, no adverse outcomes were observed in patients classified as low risk using the GRACE risk score (100% negative predictive value for GRACE risk score ≤113). The GRACE score showed greater discriminative performance than the Geneva score (area under the curve 0.623, 95% confidence interval [CI] 0.53 to 0.71), Shock Index (area under the curve 0.639, 95% CI 0.55 to 0.73), European Society of Cardiology (area under the curve 0.662, 95% CI 0.57 to 0.76), and Simplified Pulmonary Embolism Severity Index (area under the curve 0.705, 95% CI 0.61 to 0.80), although statistical significance was not reached. The integrated discrimination improvement index suggested a more appropriate risk classification with the GRACE score. In conclusion, our results have demonstrated that the GRACE risk score can accurately predict 30-day mortality in patients admitted for acute PE. Compared to previously proposed PE prediction rules, the GRACE risk score presented improved overall risk classification.

Importance of Manchester Triage in acute myocardial infarction: impact on prognosis

Background Fast and effective diagnosis of patients with acute myocardial infarction (AMI) in the Emergency Department (ED) is needed. Manchester Triage (MT) is based on identification of the patients main complaint, establishing, through decision flowcharts, a target-time for first observation. This study aimed to evaluate the impact of MT on short-term mortality in AMI and detect potential improvements, and to analyse high-risk groups: diabetic patients, women and older patients. Methods 332 consecutive patients (69.0+13.6 years mean age; 34.9% women) with final diagnosis of AMI were assessed in the ED using MT. Data were analysed according to demographics and risk groups, as well as several AMI parameters, admission duration and intrahospital mortality (IHM). Independent predictors of mortality were determined. Results 82.8% of patients met the ideal goal of ≤10 min target-time for a first observation (ITTFO). This was higher (95%) in typical presentations (‘chest pain’), versus 52% in other flowcharts; p<0.01. Patients ≥70 years old were less frequently screened with ITTFO ≤10 min (76.2% vs 90.0% in those under 70; p=0.001) or the ‘chest pain’ flowchart (66.9% vs 77.5%; p=0.031). IHM was 13.3%. Triage with ≤10 min ITTFO and the ‘chest pain’ algorithm seems to predict a lower mortality (0.33 OR; 95% CI 0.17 to 0.63; p=0.0005 and 0.49 OR; 95% CI 0.24 to 1.03; p=0.056). Conclusion MT proved to be an effective system. Patients with typical AMI presentation, ST elevation myocardial infarction and less than 70 years old are protected by MT, with lower ITTFO and better short-term survival.

Importance of Implantable Cardioverter‐Defibrillator Back‐Up in Cardiac Resynchronization Therapy Recipients: A Systematic Review and Meta‐Analysis

Background It remains to be determined whether patients receiving cardiac resynchronization therapy (CRT) benefit from the addition of an implantable cardioverter‐defibrillator (ICD). Methods and Results We performed a literature search looking for studies of patients implanted with CRTs. Comparisons were performed between patients receiving CRT‐defibrillator (CRT‐D) versus CRT‐pacemaker (CRT‐P). The primary outcome was all‐cause mortality. Data were pooled using a random‐effects model. The relative risk (RR) and hazard ratio (HR, when available) were used as measurements of treatment effect. Nineteen entries were entitled for inclusion, comprising 12 378 patients (7030 receiving CRT‐D and 5348 receiving CRT‐P) and 29 799 patient‐years of follow‐up. Those receiving CRT‐D were younger, were more often males, had lower NYHA class, lower prevalence of atrial fibrillation, higher prevalence of ischemic heart disease, and were more often on beta‐blockers. Ten studies showed significantly lower mortality rates with the CRT‐D device, while the remaining 9 were neutral. The pooled data of studies revealed that CRT‐D patients had significantly lower mortality rates compared with CRT‐P patients (mortality rates: CRT‐D 16.6% versus CRT‐P 27.1%; RR=0.69, 95% CI 0.62–0.76; P<0.00001). The number needed to treat to prevent one death was 10. The observed I2 values showed moderate heterogeneity among studies (I2=48%). The benefit of CRT‐D was more pronounced in ischemic cardiomyopathy (HR=0.70, 95% CI 0.59–0.83, P<0.001, I2=0%), but a trend for benefit, albeit of lower magnitude, could also be seen in non‐ischemic dilated cardiomyopathy (HR=0.79, 95% CI 0.61–1.02, P=0.07, I2=36%). Conclusions The addition of the ICD associates with a reduction in the risk of all‐cause mortality in CRT patients. This seems to be more pronounced in patients with ischemic cardiomyopathy.

A Review on State-of-the-Art Data Regarding Safe Early Discharge Following Admission for Pulmonary Embolism: What Do We Know?

Although most patients with acute pulmonary embolism (PE) remain hospitalized during initial therapy, some may be suitable for partial or complete outpatient management, which may have a significant impact on healthcare costs.

Which method of left atrium size quantification is the most accurate to recognize thromboembolic risk in patients with non-valvular atrial fibrillation?

BackgroundLeft atrial (LA) size is a predictor of cardiovascular outcomes in patients in sinus rhythm, whereas conflicting results have been found in atrial fibrillation (AF). This study aims to: (1) Evaluate the accuracy of LA size to identify surrogate markers of an increased thromboembolic risk in patients with AF; (2) Assess the best method to evaluate LA size in this setting.MethodsCross-sectional study enrolling 500 consecutive patients undergoing transthoracic and transesophageal echocardiography evaluation during a non-valvular AF episode. LA size was measured on transthoracic echocardiography using several methods: anteroposterior diameter, area in four-chamber view, and volumes by the ellipsoid, single- and biplane area-length formulas. Surrogate markers of stroke were evaluated by transesophageal echocardiography: LA appendage (LAA) thrombus, LAA low flow velocities, dense spontaneous echocardiographic contrast and LA abnormality.ResultsExcept for non-indexed anteroposterior diameter, increased LA size quantified by all the other methods showed a moderate to high discriminatory power to identify all the surrogate markers of stroke. A higher accuracy was observed for indexed LA area in four-chamber view (LAA thrombus: AUC = 0.708, CI95% 0.644- 0.772, p<0.001; LAA low flow velocities: AUC = 0.733, CI95% 0.674- 0.793, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.693, CI95% 0.638- 0.748, p<0.001; LA abnormality: AUC = 0.705, CI95% 0.654-0.755, p<0.001), indexed single-plane area-length volume (LAA thrombus: AUC = 0.701, CI95% 0.633-0.770, p<0.001; LAA low flow velocities: AUC = 0.726, CI95% 0.660-0.792, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.673, CI95% 0.611-0.736, p<0.001; LA abnormality: AUC = 0.687, CI95% 0.629-0.744, p<0.001), and indexed biplane area-length volume (LAA thrombus: AUC = 0.707, CI95% 0.626-0.788, p<0.001; LAA low flow velocities: AUC = 0.737, CI95% 0.664-0.810, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.651, CI95% 0.578-0.724, p<0.001; LA abnormality: AUC = 0.683, CI95% 0.617-0.749, p<0.001), without significant difference between them. Indexed LA area in four-chamber view and indexed area-length volumes also were independent predictors of surrogate markers of stroke.ConclusionsLeft atrium enlargement is associated with an increased prevalence of surrogate markers of stroke in patients with non-valvular AF. Indexed LA area in four-chamber view and indexed area-length volumes displayed the strongest association.