Arrhythmias, devices and role of Electrophysiologists in heart failure management

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Arrhythmias, devices and role of
Electrophysiologists in heart failure management

• Dr Anthony Chow
• The Heart Hospital UCLH London

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Heart Failure

• Europe1
• Prevalence 3.9
• Incidence 11.6 in over 85 years
• Commonest cause for hospital admission in UK
• 78 of HF patients have at least 2 hospital
  admissions/year2
• Cost of HF in the U.S. is estimated to be between
  10 billion and 38 billion annually3
• Prognosis with severe heart failure 10-50
  mortality at 1 year, 5-year survival rate for all
  NYHA class 504

1 Cowie et al Eur Heart J 1999 2 English M and
Mastream M. Crit Care Nurse 1995181-6. 3
Havranek EP, Abraham WT, The Healthcare Economics
of Heart Failure 1998 1410-18. 4 American
Heart Association, 2001 Heart and Stroke
Statistical Update.
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Prognosis

• Severe heart failure
• 10-50 mortality at 1 year
• 5-year survival rate for all NYHA classes
  estimated at 50
• (AHA, 2001 Heart and Stroke Statistical
  Update).

Cowie et al. Eur Heart J 199920421-8
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Sudden Cardiac Death

• Incidence 60,000 sudden cardiac deaths per year
  in UK
• Only 2 - 15 reach the hospital
• Half of these die before discharge
• High recurrence rate
• Most thought to be arrhythmic in nature

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VT suppression with Amiodarone in CHF
N674
Singh et al NEJM 199533377-82
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ICD ATP therapy
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Shock
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Meta analysis of Secondary prevention Trials
(AVID,CASH, CIDS)
RRR28 Plt0.006
RRR50 Plt0.001
Connelly et al EHJ 2000212017-78
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Incremental Cost Effectiveness AnalysisCost per
Life-Year Saved (U.S. 1,000)
Expensive
Borderline Cost Effective
Cost per Life-Year Saved (U.S. 1,000)
Cost Effective
Highly Cost Effective
ICD1
CABG1 (ChronicCAD, MildAngina, 3 VD)
PTCA1 (ChronicCAD, SevereAngina, 2 VD)
Hyper-tension2 (Mild, Men, Age 40)
Captopril1 (Post-MI, EF 40)
Cardiac Transplant1 (CHF)
Peritoneal Dialysis2
PTCA1 (ChronicCAD, MildAngina, 1 VD, LAD)
1Kupersmith J. Prog Cardiovasc Dis.
199537(5)307-346. 2Kuppermann M. Circulation.
1990 81(1)91-100.
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CCF and LBBB
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Wide QRS Proportional Mortality Increase
QRS Duration (msec)

• Vesnarinone Study1
• NYHA Class II-IV patients
• 3,654 ECGs
• Relative risk of widest QRS group 5x greater
  than narrowest

lt90
90-120
120-170
170-220
gt220
1 Gottipaty V, Krelis S, et al. ACC 1999
Abstr847-4.
Adapted from Gottipaty et al.
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Biventricular Pacing ( CRT )
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MIRACLE Hospitalisation for worsening heart
failure
Patients At Risk
Abraham WT, et al. MIRACLE Trial Results ACC
2001.
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MIRACLE Total Days Hospitalized for Heart Failure
? 77
p 0.012
Control N225
CRT N228
Abraham WT, et al. MIRACLE Trial Results AHA
2001.
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CARE-HF Mortality and Cardiovascular
hospitalisations
N 813 2.5y/FU
RRR 37
Cleland et al NEJM 2005
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CARE-HF all cause Mortality
RRR 36
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Baseline Unpaced
Synchronised pacing
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MADIT II Survival by Treatment Group
Hazards ratio 0.69 CI 0.51-0.93 P0.016
Mortality 14.2
19.8
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Secondary Endpoint All cause mortality
DCM 44 IHD 56
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Published CRT complication rates
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Difficult anatomy
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Unusual anatomy
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Device Implant Rates Increasing
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ICD New/M pop
Average 48 UK Target 100 Highest 73 Lowest 26
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CRT New/M pop
Average 56 UK Target none yet set Highest
136 Lowest11
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The Heart Hospital Device Implants
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8 year Heart Hospital experience

• Retrospective analysis of all CRT related
  procedures between 2000-2008
• 402 patients
• Mean age 64.9 years
• 44 Dilated Cardiomyopathy,
• 35 Ischaemic cardiomyopathy,
• 13 Hypertrophic Cardiomyopathy
• 6 Other Cardiomyopathy (ARVC, LVNC etc)
• 2 Adult Congenital Heart disease

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Device type400 CRT implants 2000-2008
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Procedure type
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Complication type
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CRT complications

• The overall incidence of acute complications
  related to CRT devices was 12.1
• The most common complication was inability to
  implant the left ventricular lead (4.5)

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ICD patients

• Electrical Storms
• Approx 50 secondary prevention patients will use
  ICD within 3 years
• Storms occur in 10-20
• Inappropriate therapies
• Occurs in 10-20 of patients

Exener DV, Sergio L et al Circ 2001, Dunbar et
al, Am J Crit Care 2005 Credner et al, J Am Coll
Cardiol 1998, Gradaus R et al, PACE 2003
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F/U 3920m Plt0.001
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EP specialists in CHF management

• Identify and stratify patients for SCD risk
• Assess suitability of patients for device therapy
  
• Identify those that would benefit from CRT
• Troubleshooting device problems
• Manage chronic device complications
• Create centres for training and education

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PM New/M pop Average 460 UK Target 700 Highest
795 Lowest 285
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UK 2006 41,020 devices implanted
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