Predicting the Future

Passman, Rod; Goldberger, Jeffrey J.

doi:10.1161/circulationaha.111.023879

Cited by 32 publications

(9 citation statements)

References 59 publications

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“…10, 12 Current guidelines discourage ICD implantation in patients expected to survive less than a year, although risk assessment at the time of CRT device selection remains practically challenging particularly for patients under-represented in clinical trials. 13 An improved understanding of contemporary patterns of CRT device implantation (CRT-D vs. CRT-P), including predictors of implant type, may identify opportunities to align effective device therapies with patients most likely to benefit.…”

Section: Introductionmentioning

confidence: 99%

National Trends in the Use of Cardiac Resynchronization Therapy With or Without Implantable Cardioverter-Defibrillator

et al. 2016

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Background Candidates for cardiac resynchronization therapy (CRT) receive either a biventricular pacemaker (CRT-P) or a biventricular pacemaker with an implantable-cardioverter defibrillator (ICD; CRT-D). Optimal device selection remains challenging as the benefit of ICD therapy may not be uniform, particularly in patients at competing risk of non-sudden death. Methods and Results In this serial cross-sectional study using the National Inpatient Sample database, we identified 311,086 admissions associated with CRT implant between 2006-2012. CRT-D was the most common device-type (86.1%), including in patients ≥75 years old with 5 or more Elixhauser comorbidities (75.5%). Multivariate predictors of CRT-D implant included demographic, clinical, and geographic factors: prior ventricular arrhythmia (rate ratio [RR], 1.14; 95% CI, 1.13-1.14), ischemic heart disease (RR, 1.11; 95% CI, 1.10-1.11), male gender (RR, 1.10; 95% CI, 1.09-1.10), black race (RR, 1.06; 95% CI: 1.04-1.07), and Northeast geographic region (RR, 1.06; 95% CI, 1.04-1.09). There was significant inter-hospital variation in the use of CRT-D (10-90 percentile range, 72.9% to 98.0% CRT-D). Conclusions The majority of patients in this contemporary US cohort underwent implantation of CRT-D. Predictors of CRT-D implant included demographic, clinical, and geographic factors. In patient subgroups predicted to have an attenuated benefit from ICD therapy (older adults with multiple comorbidities), CRT-D remained the dominant device type. An improved understanding of the determinants of device selection may aid in decision-making and ultimately better align patient risk with device benefit at the time of CRT implantation.

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Section: Introductionmentioning

confidence: 99%

National Trends in the Use of Cardiac Resynchronization Therapy With or Without Implantable Cardioverter-Defibrillator

et al. 2016

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“…Numerous clinical and demographic variables have been associated with an increased risk of arrhythmic death, and many electrophysiological approaches have been proposed and evaluated in an attempt to better identify the patient population at highest risk of future arrhythmic death (1,2). However, despite multiple large clinical trials performed during the last 30 years, left ventricular ejection fraction (LVEF) remains the only parameter clinically used to distinguish high- and low-risk groups.…”

mentioning

confidence: 99%

Regional Myocardial Sympathetic Denervation Predicts the Risk of Sudden Cardiac Arrest in Ischemic Cardiomyopathy

Fallavollita

Heavey

Luísi

et al. 2014

Journal of the American College of Cardiology

359

293

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Objectives The PAREPET (Prediction of ARrhythmic Events with Positron Emission Tomography) study sought to test the hypothesis that quantifying inhomogeneity in myocardial sympathetic innervation could identify patients at highest risk for sudden cardiac arrest (SCA). Background Left ventricular ejection fraction (LVEF) is the only parameter identifying patients at risk of SCA who benefit from an implantable cardiac defibrillator (ICD). Methods We prospectively enrolled 204 subjects with ischemic cardiomyopathy (LVEF ≤35%) eligible for primary prevention ICDs. Positron emission tomography (PET) was used to quantify myocardial sympathetic denervation (11C-meta-hydroxyephedrine [11C-HED]), perfusion (13N-ammonia) and viability (insulin-stimulated 18F-2-deoxyglucose). The primary endpoint was SCA defined as arrhythmic death or ICD discharge for ventricular fibrillation or ventricular tachycardia >240 beats/min. Results After 4.1 years follow-up, cause-specific SCA was 16.2%. Infarct volume (22 ± 7% vs. 19 ± 9% of left ventricle [LV]) and LVEF (24 ± 8% vs. 28 ± 9%) were not predictors of SCA. In contrast, patients developing SCA had greater amounts of sympathetic denervation (33 ± 10% vs. 26 ± 11% of LV; p = 0.001) reflecting viable, denervated myocardium. The lower tertiles of sympathetic denervation had SCA rates of 1.2%/year and 2.2%/year, whereas the highest tertile had a rate of 6.7%/year. Multivariate predictors of SCA were PET sympathetic denervation, left ventricular end-diastolic volume index, creatinine, and no angiotensin inhibition. With optimized cut-points, the absence of all 4 risk factors identified low risk (44% of cohort; SCA <1%/year); whereas ≥2 factors identified high risk (20% of cohort; SCA ~12%/year). Conclusions In ischemic cardiomyopathy, sympathetic denervation assessed using 11C-HED PET predicts cause-specific mortality from SCA independently of LVEF and infarct volume. This may provide an improved approach for the identification of patients most likely to benefit from an ICD. (Prediction of ARrhythmic Events With Positron Emission Tomography [PAREPET]; NCT01400334)

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“…1 The dire consequence of not identifying an individual who is otherwise doing well clinically but will succumb to a sudden arrhythmic death that is potentially either preventable or treatable has driven the search for a strategy that will identify these individuals. It has also been recognized that risk stratification is needed in patients who are currently classified into a high-risk group based on a depressed left ventricular ejection fraction, but who may never have an arrhythmic event.…”

mentioning

confidence: 99%

“…The challenges and potential approaches to improve risk stratification have been extensively discussed. [1][2][3] In this issue of Circulation: Cardiovascular Imaging, Hachamovitch et al 4 have taken on these challenges directly with their study designed to evaluate whether 123 I-mIBG imaging has a role as a gatekeeper for ICD use.…”

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confidence: 99%