Lack of improvement in quality of life after cardiac resynchronization therapy is a potent determinant of unfavorable outcomes independently from functional and echocardiographic response

R. Lenarczyk, E. Jedrzejczyk-Patej, O. Kowalski, B. Sredniawa, P. Pruszkowska, A. Sokal, M. Szulik, M. Mazurek, J. Kowalczyk, Z. Kalarus
2013 European Heart Journal  
Resynchronisation therapy 581 response to CRT than patients with intrinsic BBB. Baseline RV pacing and haemodynamic parameters predicted haemodynamic response but QRS duration had no predictive value. Purpose: The aim of this substudy was to evaluate the prognostic values of device-based diagnostic parameters as predictors of malignant ventricular arrhythmias in patients undergoing Cardiac Resynchronization Therapy (CRT). Methods: Study population consisted of 96 CRT-D recipients participating
more » ... n the TRUST CRT Trial. Inclusion criteria included Heart Failure (HF) in NYHA≥3 class, QRS ≥120msec, left ventricular Ejection Fraction (EF) ≤35% and significant mechanical dyssynchrony. Patients were divided into those with (n=31, 92 arrhythmias) and without (n=65) appropriate ICD interventions within the median followup of 12.03±6.7 months. Daily monitored device-based diagnostic parameters -day and night Heart Rate (HR), Thoracic Impedance (TI), heart rate variability and physical activity were screened for significant changes within 4 time windows: within 10, 7, 3 days and 1 day prior to the first and to all appropriate ICD interventions. Results: Only 6 arrhythmias (6.5%) in 4 patients (13%) showed temporal relationship to HF exacerbation. There was a consistent pattern of changes in three out of five monitored factors prior to arrhythmia: a gradual increase of daily HR (103.43% of reference within 10-day window, 103.6% in 7-days, 104.6% in 3 days and 105.55% one day before, all P<0.05 vs. reference). Similarly varied night HR (104.75% in 3 days, 107.65% one day, all P<0.05). On the contrary, intrathoracic impedance was decreasing significantly (97.8% in 10 days, 97.7% in 7-days, 97.34% in 3 days and 96.81% in 1 day, all P<0.05). Changes in devicemonitored parameters showed only moderate sensitivity, but high specificity, the combination of three parameters had better predictive performance (sensitivity 42%, specificity 86%), which improved further after excluding patients with atrial fibrillation. The predictive model combining changes in HR and TI together with EF and NTproBNP (AUC 0.7, 95% CI 0.63-0.77; P<0.05) was more prognostic in forecasting day-by-day risk than model involving EF and NTproBNP alone (difference in AUC 0.05, 95% CI 0.0005-0.09; P=0.04). Conclusions: Daily device-measured parameters show reproducibly significant variations prior to ventricular arrhythmia. Combination of multiple parameters improves their predictive performance, whereas presence of atrial fibrillation diminishes it. Predictive value of these variables is additive to baseline risk factors.
doi:10.1093/eurheartj/eht309.p3166 fatcat:7s3h35mcwveldjvkbn2yxdtyky