Martin H Ruwald1, Suneet Mittal2, Anne-Christine Ruwald3, Mehmet K Aktas4, James P Daubert5, Scott McNitt4, Amin Al-Ahmad6, Christian Jons7, Valentina Kutyifa4, Jonathan S Steinberg2, Paul Wang8, Arthur J Moss4, Wojciech Zareba4. 1. Heart Research Follow-up Program, University of Rochester Medical Center, Rochester, New York; Department of Cardiology, Gentofte Hospital, Hellerup, Denmark. Electronic address: mruwald@hotmail.com. 2. Arrhythmia Institute, Valley Health System of New York and New Jersey, New York, New York and Ridgewood, New Jersey. 3. Heart Research Follow-up Program, University of Rochester Medical Center, Rochester, New York; Department of Cardiology, Gentofte Hospital, Hellerup, Denmark. 4. Heart Research Follow-up Program, University of Rochester Medical Center, Rochester, New York. 5. Cardiology Division, Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina. 6. Texas Cardiac Arrhythmia Institute, Austin, Texas. 7. Department of Cardiology, Gentofte Hospital, Hellerup, Denmark. 8. Division of Cardiovascular Medicine, Stanford University, Stanford, California.
Abstract
BACKGROUND: A high percentage of biventricular pacing is required for optimal outcome in patients treated withcardiac resynchronization therapy (CRT), but the influence of ectopic beats on the success of biventricular pacing has not been well established. OBJECTIVES: This study sought to determine if increased ectopic beats reduce the chance of high biventricular pacing percentage and are associated with subsequent adverse outcomes. METHODS: From the MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy), 801 patients with an implanted CRT-defibrillator device with data available on biventricular pacing percentage and pre-implantation 24-h Holter recordings were included. Using logistic regression, we estimated the influence of ectopic beats on the percentage of biventricular pacing. Reverse remodeling was measured as reductions in atrial and left ventricular end-systolic volumes (LVESV) at 1 year. Cox models were used to assess the influence of ectopic beats on the outcomes of heart failure (HF) or death, ventricular tachyarrhythmias (VTAs), and death. RESULTS: In the pre-implantation Holter recording, ectopic beats accounted for a mean 3.2 ± 5.5% of all beats. The probability of subsequent low biventricular pacing percentage (<97%) was increased 3-fold (odds ratio: 3.37; 95% confidence interval: 1.74 to 6.50; p < 0.001) in patients with 0.1% to 1.5% ectopic beats and 13-fold (odds ratio: 13.42; 95% confidence interval: 7.02 to 25.66; p < 0.001) in patients with >1.5% ectopic beats compared with those with <0.1% ectopic beats. Patients with ≥0.1% ectopic beats had significantly less reverse remodeling (percent reduction in LVESV 31 ± 15%) than patients with <0.1% ectopic beats (percent reduction in LVESV 39 ± 14%; p < 0.001). The risk of HF/death and VTA was increased significantly in those with 0.1% to 1.5% ectopic beats (hazard ratio: 3.13 and 1.84, respectively) and for >1.5% ectopic beats (hazard ratio: 2.38 and 2.74, respectively). CONCLUSIONS: Relatively low frequencies of ectopic beats (≥0.1%) dramatically increase the probability of low biventricular pacing (<97%), with reduced CRT efficacy by less reverse remodeling and higher risk of HF/death and VTA. This supports pre-implantation Holter monitoring of patients selected for CRT for optimal outcome. (MADIT-CRT: Multicenter Automatic Defibrillator Implantation With Cardiac Resynchronization Therapy; NCT00180271).
RCT Entities:
BACKGROUND: A high percentage of biventricular pacing is required for optimal outcome in patients treated with cardiac resynchronization therapy (CRT), but the influence of ectopic beats on the success of biventricular pacing has not been well established. OBJECTIVES: This study sought to determine if increased ectopic beats reduce the chance of high biventricular pacing percentage and are associated with subsequent adverse outcomes. METHODS: From the MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy), 801 patients with an implanted CRT-defibrillator device with data available on biventricular pacing percentage and pre-implantation 24-h Holter recordings were included. Using logistic regression, we estimated the influence of ectopic beats on the percentage of biventricular pacing. Reverse remodeling was measured as reductions in atrial and left ventricular end-systolic volumes (LVESV) at 1 year. Cox models were used to assess the influence of ectopic beats on the outcomes of heart failure (HF) or death, ventricular tachyarrhythmias (VTAs), and death. RESULTS: In the pre-implantation Holter recording, ectopic beats accounted for a mean 3.2 ± 5.5% of all beats. The probability of subsequent low biventricular pacing percentage (<97%) was increased 3-fold (odds ratio: 3.37; 95% confidence interval: 1.74 to 6.50; p < 0.001) in patients with 0.1% to 1.5% ectopic beats and 13-fold (odds ratio: 13.42; 95% confidence interval: 7.02 to 25.66; p < 0.001) in patients with >1.5% ectopic beats compared with those with <0.1% ectopic beats. Patients with ≥0.1% ectopic beats had significantly less reverse remodeling (percent reduction in LVESV 31 ± 15%) than patients with <0.1% ectopic beats (percent reduction in LVESV 39 ± 14%; p < 0.001). The risk of HF/death and VTA was increased significantly in those with 0.1% to 1.5% ectopic beats (hazard ratio: 3.13 and 1.84, respectively) and for >1.5% ectopic beats (hazard ratio: 2.38 and 2.74, respectively). CONCLUSIONS: Relatively low frequencies of ectopic beats (≥0.1%) dramatically increase the probability of low biventricular pacing (<97%), with reduced CRT efficacy by less reverse remodeling and higher risk of HF/death and VTA. This supports pre-implantation Holter monitoring of patients selected for CRT for optimal outcome. (MADIT-CRT: Multicenter Automatic Defibrillator Implantation With Cardiac Resynchronization Therapy; NCT00180271).
Authors: Anne-Christine Ruwald; Mehmet K Aktas; Martin H Ruwald; Valentina Kutyifa; Scott McNitt; Christian Jons; Suneet Mittal; Jonathan S Steinberg; James P Daubert; Arthur J Moss; Wojciech Zareba Journal: Ann Noninvasive Electrocardiol Date: 2017-09-20 Impact factor: 1.468
Authors: Mehmet K Aktas; Suneet Mittal; Valentina Kutyifa; Scott McNitt; Bronislava Polonsky; Jonathan Steinberg; Arthur J Moss; Wojciech Zareba Journal: Ann Noninvasive Electrocardiol Date: 2015-02-16 Impact factor: 1.468