Multidisciplinary decision-making in mitral valve disease: the mitral valve heart team

Background

Although decision-making using the heart-team approach is apparently intuitive and has a class I recommendation in most recent guidelines, supportive data is still lacking. The current study aims to demonstrate the individualised clinical pathway for mitral valve disease patients and to evaluate the outcome of all patients referred to the dedicated mitral valve heart team.

Methods

All patients who were evaluated for mitral valve pathology with or without concomitant cardiac disease between 1 January 2016 and 31 December 2016 were prospectively followed and included. Patients were evaluated, and a treatment strategy was determined by the dedicated mitral valve heart team.

Results

One hundred and fifty-eight patients were included; 67 patients were treated surgically (isolated and concomitant surgery), 20 by transcatheter interventions and 71 conservatively. Surgically treated patients had a higher 30-day mortality rate (4.4%), which decreased when specified to a dedicated surgeon (1.7%) and in primary, elective cases (0%). This was also observed for major adverse events within 30 days. Residual mitral regurgitation >grade 2 was more frequent in the catheter-based intervention group (23.5%) compared to the surgical group (4.8%).

Conclusion

In conclusion, the implementation of a multidisciplinary heart team for mitral valve disease is a valuable approach for the selection of patients for different treatment modalities. Our research group will focus on a future comparative study using historical cohorts to prove the potential superiority of the dedicated multidisciplinary heart-team approach.

     

Incidence and outcome of prosthetic valve endocarditis after transcatheter aortic valve replacement in the Netherlands

Background

Transcatheter aortic valve replacement (TAVR) is increasingly being used as an alternative to conventional surgical valve replacement. Prosthetic valve endocarditis (PVE) is a rare but feared complication after TAVR, with reported first-year incidences varying from 0.57 to 3.1%. This study was performed to gain insight into the incidence and outcome of PVE after TAVR in the Netherlands.

Methods

A multicentre retrospective registry study was performed. All patients who underwent TAVR in the period 2010–2017 were screened for the diagnosis of infective endocarditis in the insurance database and checked for the presence of PVE before analysis of general characteristics, PVE parameters and outcome.

Results

A total of 3968 patients who underwent TAVR were screened for PVE. During a median follow-up of 33.5 months (interquartile range (IQR) 22.8–45.8), 16 patients suffered from PVE (0.4%), with a median time to onset of 177 days (IQR 67.8–721.3). First-year incidence was 0.24%, and the overall incidence rate was 0.14 events per 1000 person-years. Overall mortality during follow-up in our study was 31%, of which 25% occurred in hospital. All patients were treated conservatively with intravenous antibiotics alone, and none underwent a re-intervention. Other complications of PVE occurred in 5 patients (31%) and included aortic abscess (2), decompensated heart failure (2) and cerebral embolisation (1).

Conclusion

PVE in patients receiving TAVR is a relatively rare complication and has a high mortality rate.

     

Association between cardiovascular disease and a history of cancer in patients with chest pain on the fast track outpatient clinic

Background

The purpose of this study is to investigate the prevalence of a history of malignancy in patients with chest pain who were referred for computed tomography angiography as well as the long-term survival and cardiovascular outcomes, including coronary artery disease (CAD) and coronary artery calcium (CAC) percentiles of cancer survivors. These data are relevant since it is unknown how cancer survivors, who underwent cardio-toxic therapies, should be monitored.

Methods

We analysed all patients with chest pain, who came to the outpatient clinic and underwent computed tomography angiography. The primary study endpoint was long-term survival. The secondary endpoints included CAD on computed tomography angiogram (CTA), CAC percentiles, suspected and confirmed malignancy on CTA, and other accidental findings on CTA.

Results

Of all 1,892 patients included in the analyses, 133 (7%) had a history of malignancy and 1,759 (93%) did not. Mortality rates were higher for the cancer survivors (6.5% vs 20.9% after ten years, p < 0.001). The multivariable Cox regression model also showed higher mortality for cancer survivors after ten years (adjusted hazard ratio 2.48 [95% confidence interval: 1.58–3.90]). CAD did not differ between both groups. CAC percentiles were higher in cancer survivors (p = 0.037). Cancer survivors had more suspected malignancies (3.8% vs 0.5%; p = 0.001) and also more confirmed malignancies on CTA (3.0% vs 0.1%; p < 0.001).

Conclusions

Cancer survivors have higher mortality rates, no difference in CAD on CTA, higher CAC percentiles and more often malignancy on CTA compared with patients without a cancer history.

     

Improvement in quality of life and angina pectoris: 1-year follow-up of patients with refractory angina pectoris and spinal cord stimulation

Aims

Spinal cord stimulation (SCS) is a treatment for patients with refractory angina pectoris (RAP) who remain symptomatic despite optimal medical therapy and without revascularisation options. Previous studies have shown that SCS improves the quality of life in this patient group and reduces the severity of the angina pectoris. The aim of this prospective, single-arm observational study is to show this effect in a single-centre cohort using a multidisciplinary team approach to the selection process, with a follow-up period of 1 year.

Methods and results

Between July 2010 and March 2017, 87 patients with RAP referred to our centre received SCS. The Seattle Angina Questionnaire (SAQ) and RAND 36-Item Health Survey (RAND-36) were completed at baseline, prior to implantation, and 1 year post-implantation. After 1 year of follow-up there was a statistically significant decrease in the frequency of angina pectoris attacks from more than 4 times a day to 1–2 times a week (p < 0.001). The SAQ showed statistically significant improvement in four of the five dimensions: physical limitation (p < 0.001), angina frequency (p < 0.001), angina stability (p < 0.001) and quality of life (p < 0.001). The RAND-36 showed statistically significant improvement in all nine dimensions: physical functioning (p = 0.001), role/physical (p < 0.001), social functioning (p = 0.03), role/emotional (p < 0.05), bodily pain (p < 0.001), general health (p < 0.001), vitality (p < 0.001), mental health (p = 0.02) and health change (p < 0.001).

Conclusion

This study showed a significant improvement in quality of life and reduction of angina pectoris severity after 1 year of follow-up in patients treated with SCS for RAP.

     

The outcome of pulmonary hypertension and its association with pulmonary artery dilatation

Background

Pulmonary artery (PA) dilatation is often seen in pulmonary hypertension (PH) and is considered a long-term consequence of elevated pressure. The PA dilates over time and therefore may reflect disease severity and duration. Survival is related to the stage of the disease at the time of diagnosis and therefore PA diameter might be used to predict prognosis. This study evaluates the outcome of patients with pulmonary arterial hypertension (PAH) and chronic thrombo-embolic pulmonary hypertension (CTEPH) and investigates whether PA diameter at the time of diagnosis is associated with mortality.

Methods

Patients visiting an outpatient clinic of a tertiary centre between 2004 and 2018 with a cardiac catheterisation confirmed diagnosis of PAH or CTEPH and a CT scan available for PA diameter measurement were included. PA diameter and established predictors of survival were collected (New York Heart Association (NYHA) class, N‑terminal pro-brain natriuretic peptide (NT-proBNP) level and 6‑min walking distance (6MWD)).

Results

In total 217 patients were included (69% female, 71% NYHA class ≥III). During a median follow-up of 50 (22–92) months, 54% of the patients died. Overall survival was 87% at 1 year, 70% at 3 years and 58% at 5 years. The mean PA diameter was 34.2 ± 6.2 mm and was not significantly different among all the diagnosis groups. We found a weak correlation between PA diameter and mean PA pressure ( r = 0.23, p < 0.001). Male sex, higher age, shorter 6MWD and higher NT-proBNP level were independently associated with mortality, but PA diameter was not.

Conclusion

The prognosis of PAH and CTEPH is still poor. Known predictors of survival were confirmed, but PA diameter at diagnosis was not associated with survival in PAH or CTEPH patients.

     

Conservative initial postoperative anticoagulation strategy after HeartMate 3 left ventricular assist device implantation

Introduction

Although anticoagulation therapy is mandated after implantation of a left ventricular assist device (LVAD), postoperative bleedings and reoperations occur relatively frequently and are associated with worse outcomes. We evaluated the use of a conservative postoperative anticoagulation protocol in patients implanted with a HeartMate 3 (HM3) LVAD.

Methods

In a single-centre retrospective analysis of postoperative outcomes after HM3 LVAD implantation, a standard (old) anticoagulation protocol (i.e. early, full-dose anticoagulation with low-molecular weight heparin and overlapping vitamin K antagonist) was compared with a new conservative anticoagulation protocol (i.e. slow initiation of vitamin K antagonists without overlapping heparin). Main outcomes were changes in international normalised ratio (INR), lactate dehydrogenase (LDH), bleeding and/or tamponade events requiring reoperation, length of stay and adverse events.

Results

In total, 73 patients (48 in old vs 25 in new protocol group) were evaluated. Mean age was 56 years (standard deviation 13) and most patients (78%) were males. Changes in INR and LDH in the first 14 days were similar in both groups (p?=?0.50 and p?=?0.997 for interaction, respectively). Number of bleeding/tamponade events requiring reoperation was lower in the new than in the old protocol group (4% vs 33%, p?=?0.005). Postoperative 30-day mortality was similar, and we observed no thromboembolic events. Median (25th–75th percentiles) total length of postoperative hospital stay (27 (25–41) vs 21 (19–27) days, p?<?0.001) and length of intensive care unit stay (5 (2–9) vs 2 (2–5) days, p?=?0.022) were significantly shorter in the new protocol group.

Conclusion

These retrospective data suggest that conservative slow initiation of anticoagulation therapy after HM3 LVAD implantation is associated with less bleeding/tamponade events requiring reoperation, a similar safety profile and a shorter duration of stay than the currently advised standard anticoagulation protocol.

     

The 1‑year safety and efficacy outcomes of Absorb bioresorbable vascular scaffolds for coronary artery disease treatment in diabetes mellitus patients: the ABSORB DM Benelux study

Background

Diabetes mellitus (DM) patients show higher rates of repeat revascularisation even in the era of modern drug-eluting stents (DES). The concept of bioresorbable scaffolds is becoming captivating, as it might allow for repeat interventions, prolonging the time span during which patients can be treated by percutaneous coronary intervention (PCI).

Aims

We intend to evaluate the short- and long-term safety and efficacy of Absorb bioresorbable vascular scaffolds (Absorb BVS) in the treatment of coronary artery disease (CAD) in DM patients for any indication.

Methods

The ABSORB DM Benelux is an international prospective study in DM patients who have undergone PCI with ≥1 Absorb BVS. Major adverse cardiac events (MACE) at 1 year was the primary endpoint, defined as a composite of all-cause death, any myocardial infarction (MI) and ischaemia-driven target vessel revascularisation (TVR). Secondary endpoints were target lesion failure (TLF) and definite or probable scaffold thrombosis (ScT).

Results

Between April 2015 and March 2017, 150 DM patients and 188 non-complex lesions were treated. Device implantation was successful in 100%. MACE occurred in 14 (9.5%) patients, with all-cause death occurring in 4 (2.7%), any MI in 6 (4.1%) and ischaemia-driven TVR in 7 (4.8%) respectively. TLF was reported in 11 (7.5%). Definite and probable ScT was observed in 2 (1.4%).

Conclusion

Absorb BVS for treatment of anatomically low-risk patients with DM show acceptable safety and efficacy outcomes at 1 year. If these promising results are confirmed after a longer follow-up period, new-generation bioresorbable scaffolds combined with refinement of implantation techniques might open new horizons for CAD treatment in DM patients.

     

Retrospective analysis of endocarditis patients to investigate the eligibility for oral antibiotic treatment in routine daily practice

Background

According to the current guidelines of the European Society of Cardiology, patients with left-sided infective endocarditis are treated with intravenous antibiotics for 4–6 weeks, leading to extensive hospital stay and high costs. Recently, the Partial Oral Treatment of Endocarditis (POET) trial suggested that partial oral treatment is effective and safe in selected patients. Here, we investigated if such patients are seen in our daily clinical practice.

Methods

We enrolled 119 adult patients diagnosed with left-sided infective endocarditis in a retrospective, observational study. We identified those that would be eligible for switching to partial oral antibiotic treatment as defined in the POET trial (e.g. stable clinical condition without signs of infection). Secondary objectives were to provide insight into the time until each patient was eligible for partial oral treatment, and to determine parameters of longer hospital stay and/or need for extended intravenous antibiotic treatment.

Results

Applying the POET selection criteria, the condition of 38 patients (32%) was stable enough to switch them to partial oral treatment, of which 18 (47.3%), 8 (21.1%), 9 (23.7%) and 3 patients (7.9%) were eligible for switching after 10, 14, 21 days or 28 days of intravenous treatment, respectively.

Conclusion

One-third of patients who presented with left-sided endocarditis in routine clinical practice were possible candidates for switching to partial oral treatment. This could have major implications for both the patient’s quality of life and healthcare costs. These results offer an interesting perspective for implementation of such a strategy, which should be accompanied by a prospective cost-effectiveness analysis.

     

Development and first results of a dedicated chronic total occlusion programme

Objective

To describe the development and first results of a dedicated chronic total occlusion (CTO) programme in a tertiary medical centre.

Background

Because of the complexity and the increased risk of complications during percutaneous coronary intervention (PCI) for CTO, it is essential that less experienced and evolving CTO centres perform regular quality analyses.

Methods

We therefore performed analyses to describe the results during the first 3 years of a dedicated CTO programme at a high-volume PCI centre. In addition, we discuss the strategies employed to develop such a programme.

Results

A total of 179 consecutive patients undergoing 187 CTO procedures were included in the study. The complexity of the CTO lesions increased from a mean J‑CTO (Japanese Multicentre CTO Registry) score of 1.3 in 2015 to 2.1 in 2017. In the majority of cases, the antegrade wire escalation technique was performed. Final technical success rate was 78.5% in 175 patients with a single CTO and 80.2% of all 187 CTO procedures. No peri-procedural or in-hospital deaths occurred. One peri-procedural myocardial infarction occurred. Cardiac tamponade occurred in 2 cases, both managed by pericardiocentesis. No urgent cardiac surgery was necessary. Survival and revascularisation rates at 30 days and 1 year were excellent.

Conclusion

Following initiation of a dedicated CTO programme, using up-to-date techniques and strategies, procedural and clinical outcome were comparable with current standards in established centres.

     

The Absorb bioresorbable vascular scaffold in real-world practice: long-term follow-up of the AMC Single Centre Real World PCI Registry

Background

Bioresorbable scaffolds have been introduced to overcome the shortcomings of drug-eluting stents. Higher rates of device thrombosis, however, have been reported up to 3 years after implantation of the Absorb bioresorbable vascular scaffold (BVS). In the current article, we therefore report long-term clinical outcomes of the AMC Absorb Registry.

Methods and results

In the AMC Absorb Registry, all patients who underwent a percutaneous coronary intervention with Absorb BVS implantation between 30 August 2012 and 5 August 2013?at the Amsterdam University Medical Centre—Academic Medical Centre were included. The composite endpoint of this analysis was target-vessel failure (TVF). The median follow-up of the study cohort of the AMC Absorb Registry was 1534 days. At the time of the cross-sectional data sweep the clinical status at 4 years was known in 124 of 135 patients (91.9%). At long-term follow-up, the composite endpoint of TVF had occurred in 27 patients. The 4?year Kaplan-Meier estimate of TVF was 19.8%. At 4 years cardiac death had occurred in 4 patients (3.2%) and target-vessel myocardial infarction in 9 (6.9%) patients. Definite scaffold thrombosis occurred in 5 (3.8%) patients. We found 1 case of very late scaffold thrombosis that occurred at 911 days after device implantation in a patient who was not on dual anti-platelet therapy.

Conclusion

In a patient population reflecting routine clinical practice, we found that cases of TVF continued to accrue beyond 2 years after Absorb BVS implantation.

     

Infective endocarditis in the Netherlands: current epidemiological profile and mortality

Introduction

Infective endocarditis (IE) is associated with a high in-hospital and long term mortality. Although progress has been made in diagnostic approach and management of IE, morbidity and mortality of IE remain high. In the latest European guidelines, the importance of the multi-modality imaging in diagnosis and follow up of IE is emphasized.

Aim

The aim was to provide information regarding mortality and adverse events of IE, to determine IE characteristics and to assess current use of imaging in the diagnostic workup of IE.

Methods

This is a prospective observational cohort study. We used data from the EURO-ENDO registry. Seven hospitals in the Netherlands have participated and included patients with IE between April 2016 and April 2018.

Results

A total of 139 IE patients were included. Prosthetic valve endocarditis constituted 32.4% of the cases, cardiac device related IE 7.2% and aortic root prosthesis IE 3.6%. In-hospital mortality was 14.4% (20 patients) and one-year mortality was 21.6% (30 patients). The incidence of embolic events under treatment was 16.5%, while congestive heart failure or cardiogenic shock occurred in 15.1% of the patients. Transthoracic and transoesophageal echocardiography were performed most frequently (97.8%; 81.3%) and within 3 days after IE suspicion, followed by ¹⁸F‑fluorodeoxyglucose positron emission tomography/computed tomography (45.3%) within 6 days and multi-slice computed tomography (42.4%) within 7 days.

Conclusion

We observed a high percentage of prosthetic valve endocarditis, rapid and extensive use of imaging and a relatively low in-hospital and one-year mortality of IE in the Netherlands. Limitations include possible selection bias.

     

Outcome of mechanical circulatory support at the University Medical Centre Utrecht

Background

The prevalence of heart failure (HF) is increasing substantially and, despite improvements in medical therapy, HF still carries a poor prognosis. Mechanical circulatory support (MCS) by a continuous-flow left ventricular assist device (cf-LVAD) improves survival and quality of life in selected patients. This holds especially for the short-term outcome, but experience regarding long-term outcome is growing as the waiting time for heart transplantation is increasing due to the shortage of donor hearts. Here we present our results from the University Medical Centre Utrecht.

Methods

Data of all patients with a cf-LVAD implant between March 2006 and January 2018 were collected. The primary outcome was survival. Secondary outcomes included adverse events defined according to the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) definitions, described per patient year.

Results

A total of 268 patients (69% male, mean age 50?±?13 years) received a cf-LVAD. After a median follow-up of 542 (interquartile range 205–1044) days, heart transplantation had been performed in 82 (31%) patients, the cf-LVAD had been explanted in 8 (3%) and 71 (26%) had died. Survival at 1, 3 and 5 years was 83%, 72% and 57%, respectively, with heart transplantation, cf-LVAD explantation or death as the end-point. Death was most often caused by neurological complications (31%) or infection (20%). Major bleeding occurred 0.51 times and stroke 0.15 times per patient year.

Conclusion

Not only short-term results but also 5?year survival after cf-LVAD support demonstrate that MCS is a promising therapy as an extended bridge to heart transplantation. However, the incidence of several major complications still has to be addressed.

     

Assessment of the MANTA closure device in transfemoral transcatheter aortic valve replacement: a single-centre observational study

Objectives

The present study aims to evaluate the efficacy and safety of the MANTA vascular closure device (VCD) (Teleflex, Morrisville, NC, USA) in transfemoral transcatheter aortic valve replacement (TF-TAVR).

Background

To close the femoral artery in TF-TAVR a VCD is the treatment of choice. Data involving suture-based VCDs have been extensive. Although scarce, results on the MANTA device are promising. There is no consensus yet as to whether the MANTA device is associated with fewer access-site-related vascular/bleeding complications when compared to suture-based VCDs.

Methods

In this prospective single-arm study, performed at a single centre, a total of 73 patients eligible for TF-TAVR were included and consecutively treated with the MANTA device.

Results

Access-site-related vascular complications were seen in 13.7% of patients treated with the MANTA device. In this group of patients only minor vascular complications were observed. Access-site-related bleeding complications were rare (6.8%), and device failure was seen in 13.7% of the patients.

Conclusions

This single-centre study confirms that use of the MANTA device in TF-TAVR is feasible with an acceptable rate of access-site-related complications and no major vascular complications.

     

Safety and efficacy of balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension in the Netherlands

Background

Balloon pulmonary angioplasty (BPA) is an emerging treatment in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and chronic thromboembolic disease (CTED). We describe the first safety and efficacy results of BPA in the Netherlands.

Methods

We selected all consecutive patients with inoperable CTEPH and CTED accepted for BPA treatment who had a six-month follow-up in the St. Antonius Hospital in Nieuwegein and the Amsterdam University Medical Center (UMC) in Amsterdam. Functional class (FC), N?terminal pro-brain natriuretic peptide (NT-proBNP), 6?minute walking test distance (6MWD) and right-sided heart catheterisation were performed at baseline and six months after last BPA. Complications for each BPA procedure were noted.

Results

A hundred and seventy-two BPA procedures were performed in 38 patients (61% female, mean age 65?±?15 years). Significant improvements six months after BPA treatment were observed for functional class (63% FC I/II to 90% FC I/II, p?=?0.014), mean pulmonary artery pressure (?8.9?mm?Hg, p?=?0.0001), pulmonary vascular resistance (?2.8 Woods Units (WU), p?=?0.0001), right atrial pressure (?2.0?mm?Hg, p?=?0.006), stroke volume index (+5.7?ml/m², p?=?0.009) and 6MWD (+48m, p?=?0.007). Non-severe complications occurred in 20 (12%) procedures.

Conclusions

BPA performed in a CTEPH expert centre is an effective and safe treatment in patients with inoperable CTEPH.

     

Survival analysis of patients with rheumatic MS after PBMV compared with MVS in a low-to-middle-income country

Introduction

Rheumatic mitral stenosis continues to be prevalent in developing countries, notably in endemic areas. Over the last few decades, percutaneous balloon mitral valvuloplasty (PBMV) has been established as a lower-cost alternative treatment for mitral stenosis (MS) in low-to-middle-income countries. PBMV has also been suggested to be an effective and safe alternative treatment modality. This study aims to analyse the survival of rheumatic MS patients treated with PBMV compared with those treated with mitral valve surgery (MVS).

Methods

This study was a national, single-centre, longitudinal study using a survival analysis method in 329 consecutive patients suffering from rheumatic heart disease with severe MS who underwent PBMV compared with 142 consecutive patients with similar characteristics who underwent MVS between January 2011 and December 2016. Survival analysis and event-free duration were determined over a median follow-up of 24 months in the PBMV group and 27 months in the MVS group.

Results

The results showed that of the 329 consecutive patients in the PBMV group, 61 patients (18.5) had an event (6 patients died and 55 patients were hospitalised), and of the 142 consecutive patients in the MVS group, 19 patients (13.4%) had an event (5 patients died, and 14 patients were hospitalised). The hazard ratio was 0.631 (95% confidence interval, 0.376–1.058; P = 0.081). Longer short-term survival was found in the MVS group but was not statistically significant. Event-free survival was significantly longer in the MVS group (P = 0.002), by 5 months.

Conclusions

In this study, the efficacy and safety of PBMV was reconfirmed, as PBMV proved to be non-inferior to MVS in survival prognosis, but sustained event-free duration was significantly better in the MVS group than in the PBMV group.

     

Phospholamban cardiomyopathy: a Canadian perspective on a unique population

Introduction

Phospholamban cardiomyopathy is an inherited cardiomyopathy, characterised by a defect in regulation of the sarcoplasmic reticulum Ca²⁺ pump, often presenting with malignant arrhythmias and progressive cardiac dysfunction occurring at a young age.

Methods

Phospholamban R14del mutation carriers and family members were identified from inherited arrhythmia clinics at 13 sites across Canada. Cardiac investigations, including electrocardiograms, Holter monitoring (premature ventricular complexes, PVCs), and imaging results were summarised.

Results

Fifty patients (10 families) were identified (median age 30 years, range 3–71, 46% female). Mutation carriers were more likely to be older, have low-voltage QRS, T‑wave inversion, frequent PVCs, and cardiac dysfunction, compared to unaffected relatives. Increasing age, low-voltage QRS, T‑wave inversion, late potentials, and frequent PVCs were predictors of cardiac dysfunction (p < 0.05 for all). Older carriers (age ≥45 years) were more likely to have disease manifestations than were their younger counterparts, with disease onset occurring at an older age in Canadian patients and their Dutch counterparts.

Discussion

Among Canadian patients with phospholamban cardiomyopathy, clinical manifestations resembled those of their Dutch counterparts, with increasing age a major predictor of disease manifestation. Older mutation carriers were more likely to have electrical and structural abnormalities, and may represent variable expressivity, age-dependent penetrance, or genetic heterogeneity among Canadian patients.

     

Patients who do not complete cardiac rehabilitation have an increased risk of cardiovascular events during long-term follow-up

Background

Cardiac rehabilitation (CR) has favourable effects on cardiovascular mortality and morbidity. Therefore, it might reasonable to expect that incomplete CR participation will result in suboptimal patient outcomes.

Methods

We studied the 914 post-acute coronary syndrome patients who participated in the OPTImal CArdiac REhabilitation (OPTICARE) trial. They all started a ‘standard’ CR programme, with physical exercises (group sessions) twice a week for 12 weeks. Incomplete CR was defined as participation in <75% of the scheduled exercise sessions. Patients were followed-up for 2.7 years, and the incidence of cardiac events was recorded. Major adverse cardiac events (MACE) included all-cause mortality, non-fatal myocardial infarction and coronary revascularisation.

Results

A total of 142 (16%) patients had incomplete CR. They had a higher incidence of MACE than their counterparts who completed CR (11.3% versus 3.8%, adjusted hazard ratio [aHR] 2.86 and 95% confidence interval [CI] 1.47–5.26). Furthermore, the incidence of any cardiac event, including MACE and coronary revascularisation, was higher (20.4% versus 11.0%, aHR 1.54; 95% CI 0.98–2.44). Patients with incomplete CR were more often persistent smokers than those who completed CR (31.7% versus 11.5%), but clinical characteristics were similar otherwise.

Conclusion

Post-ACS patients who did not complete a ‘standard’ 12-week CR programme had a higher incidence of adverse cardiac events during long-term follow-up than those who completed the programme. Since CR is proven beneficial, further research is needed to understand the reasons why patients terminate prematurely.

     

Telemonitoring with an implantable loop recorder in outpatient heart failure care

Introduction

In the care of heart failure patients, telemonitoring is receiving growing attention. The main purpose of this study was to determine the effect of continuous telemonitoring with an implantable loop recorder (ILR, Reveal XT), a novel strategy in the management of stable heart failure patients without a cardiac implantable device. Furthermore, little is known about the incidence of subclinical arrhythmias in this specific group of patients.

Materials and Methods

Stable heart failure patients, New York Heart Association Class II and III, without recent hospitalisation or upcoming intervention, were included. After implantation of the ILR there was regular contact with the research nurse on a pre-specified basis. Clinic visits and telephonic interviews were alternated for a minimum of 1 year. Parallel visits to their treating physician continued according to standard care. The treating physician was blinded for the ILR findings, accept for pre-specified, significant arrhythmic events.

Results

Thirty patients were included and followed for a median duration of 12 months. In 13 patients, data from the loop recorder led to therapeutic changes. One patient received a pacemaker. Eight patients developed atrial fibrillation, all subclinical, with a mean burden of 65.8 ± 173.2 min/day.

Conclusion

The use of an ILR could potentially impact patient management. Additional study is needed in different patient populations (e. g. higher risk groups) to assess if an ILR could also impact on endpoints such as heart failure hospitalisation.

     

A mobile one-lead ECG device incorporated in a symptom-driven remote arrhythmia monitoring program. The first 5,982 Hartwacht ECGs

Background

In recent years many mobile devices able to record health-related data in ambulatory patients have emerged. However, well-organised programs to incorporate these devices are sparse. Hartwacht Arrhythmia (HA) is such a program, focusing on remote arrhythmia detection using the AliveCor Kardia Mobile (KM) and its algorithm.

Objectives

The aim of this study was to assess the benefit of the KM device and its algorithm in detecting cardiac arrhythmias in a real-world cohort of ambulatory patients.

Methods

All KM ECGs recorded in the HA program between January 2017 and March 2018 were included. Classification by the KM algorithm was compared with that of the Hartwacht team led by a cardiologist. Statistical analyses were performed with respect to detection of sinus rhythm (SR), atrial fibrillation (AF) and other arrhythmias.

Results

5,982 KM ECGs were received from 233 patients (mean age 58 years, 52% male). The KM algorithm categorised 59% as SR, 22% as possible AF, 17% as unclassified and 2% as unreadable. According to the Hartwacht team, 498 (8%) ECGs were uninterpretable. Negative predictive value for detection of AF was 98%. However, positive predictive value as well as detection of other arrhythmias was poor. In 81% of the unclassified ECGs, the Hartwacht team was able to provide a diagnosis.

Conclusions

This study reports on the first symptom-driven remote arrhythmia monitoring program in the Netherlands. Less than 10% of the ECGs were uninterpretable. However, the current performance of the KM algorithm makes the device inadequate as a stand-alone application, supporting the need for manual ECG analysis in HA and similar programs.