AICD usage for primary prevention at Mercy Hospital: successes, challenges and next steps Mohammad...
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Transcript of AICD usage for primary prevention at Mercy Hospital: successes, challenges and next steps Mohammad...
AICD usage for primary prevention at Mercy Hospital:
successes, challenges and next steps
Mohammad Tahir
PGY-3
Automatic Implantable Cardioverter Defibrillator
• AICD: shock therapy in the event of VT/VF
• Indicated for prevention of suddent cardiac death (SCD)
• Secondary prevention: resuscitation after VT/VF arrest
• Primary prevention: high risk for development of VT/VF
Background• MADIT-I Trial1: mortality benefit in post MI,
NSVT & LVEF <35%
• MADIT-II Trail2: mortality benefit in post MI & LVEF <30%
• ACC/AHA 20023: for LVEF <30% (class IIa)
• SCD-HeFT Trial4: mortality benefit in ischemic & non-ischemic CM, LVEF <35%
1Moss AJ et al. N Engl J Med 1996;335:1933-1940 2Moss AJ et al. N Engl J Med. 2002 Mar 21;346:877-83.3ACC/AHA/NASPE 2002 Guideline Update Circulation 2002;106;2145-2161.4Bardy GH et al. N Engl J Med 2005;352:225-237.
Adapted from: ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities J. Am. Coll. Cardiol. 2008;51;e1-e62; May 15, 2008.
Background (contd…)
• ACC/AHA 2008: LVEF <35%– Post MI (after 40 days), NYHA II/III (class I)– Non-Ischemic NYHA II/III (class I)
• Cost effective: QALY, Hospitalization
ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities J. Am. Coll. Cardiol. 2008;51;e1-e62; May 15, 2008.
Objectives
• To determine the proportion of eligible patients receiving or referred to AICD implantation
• To analyze the factors affecting the referral
Methodology• Retrospective Chart review• IRB Approval: consent waived• Duration: Jan-July 2008 • Data Abstracted on
– Demographics– Duration of CHF– Ischemic/ Non-ischemic Cardiomyopathy, – History of
• coronary artery disease, • diabetes, • hypertension, • chronic kidney disease, • pacemaker implantation, • CABG or PCI
Methodology (contd…)
– Baseline rhythm: sinus rhythm/ atrial fibrillation, – QRS complex duration – Use of medications including
• beta blocker, • ACE inhibitor, • digoxin, • anti-arrhythmic drugs (amiodarone), • anti-coagulation with Coumadin,
– New York Heart Association (NYHA) class for CHF– Pedal edema – Acute myocardial infarction (AMI) during current
hospital admission
Inclusion criteria
• All hospital discharges with a primary or secondary diagnosis of Heart Failure or Cardiomyopathy
• Evidence of LVEF <35%– Echocardiography– Nuclear stress test– MUGA Scan– Left Ventriculography
Exclusion Criteria
• In-hospital death
• AICD previously implanted (in-situ)
• Discharge to hospice services
• Comfort measures only
Data Analysis
• Variables abstracted in MS excel
• Analysis software: SPSS & Epi Info
• Chi-square test: Categorical Variables
• Independent sample t-test: Continuous variables
• Statistical significance: p <0.05.
Results
AICD previously implanted 35
Hospice/comfort care13
Total patients with LVEF ≤ 35% 208
In-Hospital Death 15
Study PopulationN=145
Referred Group77 (53%)
Unreferred Group68 (47%)
Patient refusal for AICD9 (12%)
Re-evaluation after optimization of therapy
8 (10%)
Referred Group(n=77)
Out-patient evaluation for AICD16 (21%)
AICD implanted during hospitalization41 (53%)
AICD deferred in view of risk vs. benefit
3 (4%)
Clinical Variables of ‘referred’ (n=77) and ‘unreferred’ (n=68) groups
Demographic and clinical Characteristics
ReferredGroup(N=77)
UnreferredGroup(N=68)
P-Value
Age in years, Mean ± SD 69.9 ± 14.6 76.0 ± 12.0 <0.01
Sex, females, n (%) 27 (35.1) 28 (41.2) 0.5
Non-White race n (%) 4 (5.2) 4 (1.5) 1.0
NYHA class IV, n(%) 8 (10.4) 3 (4.4) 0.29
NYHA class II / III, n (%) 69 (89.6) 65 (95.6) 0.29
Acute/ exacerbation CHF, n (%) 52 (67.5) 45 (66.1) 0.99
Clinical Variables of ‘referred’ (n=77) and ‘unreferred’ (n=68) groups
Demographic and clinical Characteristics
ReferredGroup(N=77)
UnreferredGroup(N=68)
P-Value
Pedal Edema present, n (%) 20 (26) 17 (25) 0.95
Diabetes, n (%) 33 (42.9) 28 (41.2) 0.97
Hypertension, n (%) 63 (81.8) 57 (83.8) 0.92
Acute Myocardial Infarction, n (%)
11 (14.3) 13 (19.1) 0.58
H/o Coronary artery Disease, n (%)
51 (66.2) 42 (61.8) 0.7
H/O CABG, n (%) 26 (33.8) 24 (35.3) 0.99
Clinical Variables of ‘referred’ (n=77) and ‘unreferred’ (n=68) groups
Demographic and clinical Characteristics
Referred group
(N=77)
Unreferred group (N=68)
P-Value
H/O PCI, n (%) 6 (7.8) 7 (10.3 ) 0.81
H/O Pacemaker Implantation, n (%)
6 (7.8) 9 (13.2) 0.42
CKD stage ≥3,n (%) 20 (26 ) 23 (33.8) 0.4
Beta Blocker at admission, n (%) 51 (66.2) 40 (58.8) 0.45
Beta Blocker at discharge, n (%) 66 (85.7) 56 (82.4) 0.75
Clinical Variables of ‘referred’ (n=77) and ‘unreferred’ (n=68) groups
Demographic and clinical Characteristics
ReferredGroup(N=77)
UnreferreGroup(N=68)
P-Value
Digoxin use at at admission, n (%) 16 (20.8) 11 (16.2) 0.62
Coumadin Use at admission, n (%) 16 (20.8) 19 (27.9) 0.42
Anti-arrythmics use at admission, n (%)
2 (2.6) 1 (1.5) 1.0
ACE inhibitor at discharge, n (%) 56 (72.7) 47 (69.1) 0.77
ACE inhibitor at admission, n (%) 43 (55.8) 37 (54.4) 1.0
Imaging/ EKG variables of ‘referred’ (N=77) and ‘unreferred’ (N=68) groups
CharacteristicReferred
group (N=77)
Unreferredgroup(N=68)
P-Value
LVEF (%), Mean ± SD 25.6 ± 6.3 28.9 ± 6 <0.01
Ischemic Cardiomyopathy, n (%)
50 (65) 42 (62) 0.82
Coronary Angiogram done, n (%)
28 (36.4 ) 12 (17.6 ) 0.02
LVEF on angiogram (%), Mean ± SD
24.6 ± 8.0 19.5 ± 13.6 0.14
Sinus Rhythm 45 (58.4) 36 (52.9) 0.62
Imaging/ EKG variables of ‘referred’ (N=77) and ‘unreferred’ (N=68) groups
CharacteristicReferred
Group(N=77)
UnreferredGroup(N=68)
P-Value
Atrial Fibrillation 23 (29.9) 26 (38.2) 0.38
QRS duration (ms), Mean ± SD
127.2 ± 41.5 120.0 ± 31.5 0.27
LVEDD (mm) Mean ± SD 60.9 ± 8.0 56.9 ± 7.0 <0.01
Severe Aortic Stenosis, n (%)
1 (1.3) 8 (11.8) 0.01
Severe Mitral regurgitation, n (%)
3 (3.9) 5 (7.4) 0.59
Severe Aortic regurgitation, n (%)
1 (1.3) 1 (1.5) 1.0
Limited F/U data
• Cross sectional
• One patient from each group was found to have AICD implanted in the interim period before second hospitalization.
Discussion
• Only 53% of eligible patients had documentation of such discussion
• AICD implantation: 53% of those referred
• Referred Patients: – Younger– Lower EF
Discussion (contd..)
• Most of the patients with severe Aortic Stenosis: in unreferred group– The need of aortic valve replacement
evaluation being of paramount importance.– Not considered immediate candidates– Such documentation was missing.
Discussion (contd..)
• Coronary Angiogram: 36.4 % in referred group vs. 12 % in unreferred group– Patients undergoing coronary angiogram
more likely to have a discussion about the AICD.
– Acute presentation– Consultative assistance
Discussion (contd..)
• Significant difference in the mean LVEDD:– likely an incidental finding– Sicker patients with lower EF.
• Also noted that, recommendations made after procedures such as coronary angiograms were more likely to be followed by the team.
Conclusions
• AICD referral in only 53 %– Need for improvement.
• Hospitalization provides an opportunity:– Greater amount of time spent by patients– Make an in-depth assessment– Involve cardiovascular specialist– Referral/ recommendations.– Likely to be followed as out-patient as in CHF1
1Reibis R, Dovifat C, Dissmann R, et al. Clin Res Cardiol. 2006 Mar;95(3):154-61.
Limitations
• Retrospective review type
• Cross sectional
• Dependence on documented medical information.
Recommendation
• Despite limitations: – A real life patient care outcome report– Insight for the need to improve.
• Creation of ‘centralized recommendation’ from points of diagnostic procedures– Echocardiogram– Radionuclide cardiac imaging– Left ventriculography.
• Importance of medical records documentation• Continued education of all the providers
Acknowledgement
• Dr. Aravind Herle
• Dr. Syed J Noor
• Dr. Khalid J Qazi
• CHS IRB Team
• HIM Staff