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- Bakos, Zoltan, et al.
(författare)
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Cardiovascular drug utilization post-implant is related to clinical outcome in heart failure patients receiving cardiac resynchronization therapy
- 2017
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Ingår i: Cardiology Journal. - 1898-018X. ; 24:4, s. 374-384
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: In select patients with heart failure, cardiac resynchronization therapy (CRT) is the most common complementary treatment besides medical treatment. We aimed to assess the association between post CRT-implant changes in cardiovascular medication and cardiovascular mortality and heart failure hospitalization.METHODS: 211 patients on optimal medical therapy eligible for CRT were retrospectively included in this study (72 ± 7 years, 80% male, 66% left bundle branch block [LBBB], 48% dilated cardiomyopathy [DCMP]) and investigated at baseline and after 6 months . Follow-up with medication, biochemical markers and echocardiography was performed and 3-year mortality data was collected.RESULTS: At 6 months post-implant the cohort was divided into two groups; 157 patients had low dosage furosemide treatment (up to 40 mg) and 54 patients were treated with high dosage (> 40 mg). A composite endpoint of heart failure hospitalization and all-cause mortality was evaluated at 30 months (881 ± 267 days) after the 6-month visit. In multivariate Cox regression analysis, patients in the high dose diuretics group had a higher risk of the primary endpoint (HR 1.9 [1.1-3.4], p = 0.033), but treatment with high dose diuretics was not associated with improved clinical symptoms (r = 0.031, p = 0.64).CONCLUSIONS: High dosage of loop-diuretics was associated with worse medium-term clinical outcome in CRT treated patients. It is unclear whether there is a direct causality between these associations, or if higher prescribed dosage of loop-diuretics is just a marker of more severe disease. Higher dose loop diuretics do not necessarily improve the symptoms and may be harmful to the patient. Prospective trials are warranted to further elucidate these findings.
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- BAKOS, ZOLTAN
(författare)
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Complementary strategies to improve positive response and outcome in patients with advanced heart failure undergoing CRT therapy
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- AbstractCardiac resynchronization therapy (CRT) has improved quality of life and survival in select heart faillure patients, however 30-40% of patients do not show objective benefit from the treatment. At the same time there is little evidence about the long term effect of changes in medical treatment in these patients. Several factors have been examined to improve the response rate in the ”non-responder” group, however this is still a challenge.Paper I. investigated the feasibility and incremental value of using an integrated bullseye model for presenting data from cardiac computed tomography, magnetic resonance imaging and echocardiography for evaluation of segmental mechanical delay for guiding optimal left ventricular lead placement in CRT. 39 patients were included in a prospective design, and it was found that the new method is conventient for identification of the appropiate site of LV lead placementPaper II. examined the value of speckle-tracking radial strain to predict the presence of scar in the left ventricle. The strain values in the respective segment were compared to magnetic resonance imaging in 34 prospectively included patients, in a total of 404 left ventricular segments. It was found that the prespecified 9.8% cut off value has low predictive value for identification of transmural scar, and therefore in patients with ischemic heart disease, magnetic resonance imaging should be considered as preoperative evaluation in order to avoid placing the left ventricular pacing electrode in scar tissue.Paper III examined the the correlation of echocardiographic and clinical response to baseline demographics in relation to change in NT-proBNP levels at 6 months post-implant. 211 CRT patients were included retrospectively and NT-proBNP, echocardiographical factors, NYHA class were compared, and 4 groups were identified; (nonresponder, echo reponder, clinical responder and double responder). A reduction of NT-proBNP of more than 25% was able to separate the nonresponders from the other groups, and the most pronounced reduction was in the double responder group. At the same time, lack of NT-proBNP reduction was associated with worse prognosis.Paper IV investigated the association of medical therapy changes on morbidity and mortality in CRT treated patients, with focus on diuretic therapy. 211 patients were included, and it was concluded that furosemide therapy more than 40mg daily was associated with higher risk for mortality and morbidity, but was not associated with an improvement of heart failure symptoms, or greater likelihood of positive remodelling from CRT.In this thesis it was found, that magnetic resonance imaging in combination with cardiac computed thomography and echocardiography is feasible to present the latest left ventricular segment with suitable vein acess on a bullseye plot. At the same time, using a cut-off radial strain value 9.8% alone has low sensitivity, but by using it in combination with data from neighbouring segments it was able to evaluate the presence of scar. Biochemical marker NT-proBNP reduction in CRT patients of less than 25% was associated with non-response to CRT. The reduction of this heart failure marker has a stronger colleration with clinical symptoms than with reverse remodelling on echocardiograpy. The long term effect of furosemide therapy in mortality and morbidity in CRT patients carries negative prognostic value. Optimization of medical therapy after CRT implantation may be important.
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| 6. |
- BAKOS, ZOLTAN, et al.
(författare)
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Positive Response to Cardiac Resynchronization Therapy : The Role of NT-proBNP
- 2016
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Ingår i: International journal of cardiovascular research. - : OMICS Publishing Group. - 2324-8602. ; 5:2
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Tidskriftsartikel (refereegranskat)abstract
- Abstract Background: Cardiac resynchronization therapy (CRT) is effective, but only 60-70% of patients benefit from the therapy. Despite numerous implantations, identification of predictive factors for response is still a challenge. We sought to assess the correlation of echocardiographic and clinical response to baseline demographics in relation to change in NT-proBNP levels at 6 months. Methods: 211 patients on optimal medical therapy were included retrospectively (72 ± 10 yrs., 66% LBBB, 48% DCMP, 80% male) and investigated at baseline and 6 months later. Improvement of ≥ 1 NYHA class was used as a marker for clinical response, and >15% reduction of left ventricular end-systolic volume was used to de ne reverse remodeling. NT-proBNP levels were measured at baseline and at 6 months and were compared to echocardiographic and clinical response status.Results: Four groups were identi ed: 1) non-responder, 2) echo responder, 3) clinical responder, and 4) double responder (echo and clinical). Responders were younger (70 vs. 74 years, p=0.04), had better NYHA class (2.1 vs. 2.5, p=0.01) and had lower NT- proBNP compared to non-responders at baseline. NT-proBNP slightly increased or remained unchanged in non-responders, whereas reduction in NT-proBNP was of similar magnitude for clinical or echo responders, and was most pronounced for double responders. A reduction of NT-proBNP ≥25% separated non- responders from responders (p=0.01). No signi cant differences in NT-proBNP levels and no signi cant changes in NT-proBNP were found across the responder subgroups.Conclusion: Six-month reduction in NT-proBNP is most pronounced for “double responders, ” but was comparable in patients with either clinical or echo response. Lack of NT-proBNP reduction can help identify the non-responders for further intervention.Keywords Cardiac resynchronization therapy; Electrocardiography; Echocardiography
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| 7. |
- Borgquist, Rasmus, et al.
(författare)
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Cardiac Resynchronization Therapy Guided by Echocardiography, MRI, and CT Imaging : A Randomized Controlled Study
- 2020
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Ingår i: JACC: Clinical Electrophysiology. - : Elsevier BV. - 2405-500X. ; 6:10, s. 1300-1309
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: This study evaluated if selecting the left ventricular (LV) target segment by echocardiography-derived late mechanical activation, with access to multimodality imaging for scar and venous anatomy, could help to increase responder rates to cardiac resynchronization therapy (CRT). Background: LV lead placement is important for clinical outcome, but the optimal strategy for LV lead placement in CRT is still debated. Methods: This study conducted a prospective, blinded randomized controlled trial on 102 patients with indication for CRT (27% women, 46% with ischemic cardiomyopathy, 63% in New York Heart Association functional class III, 74% with left bundle branch block, and with mean ejection fraction of 23%). Optimal LV lead location was defined as the latest mechanically activated available segment (free of transmural scar), determined by radial strain echocardiography, cardiac computed tomography, and cardiac magnetic resonance (n = 70). The primary endpoint was reduction of LV end-systolic volume by ≥15% at 6 months post-implantation. Results: Patients were followed for 47 ± 21 months. Based on imaging, optimal or adjacent lead placement was feasible in 96% of all cases and was obtained in 83% of the intervention group versus 80% of the control group. Fifty-six percent of the patients were LV end-systolic volume responders compared with the control group (55%) (p = 0.96), and 71% improved ≥1 New York Heart Association functional class (74% vs. 67%; p = 0.43). Death or heart failure hospitalization within 2 years occurred in 6% (2% of the intervention group vs. 10% of the control group; p = 0.07). Conclusions: Radial strain-guided LV lead placement, in combination with multimodality imaging, did not result in increased clinical or echocardiographic response, nor in a significant reduction of death or heart failure hospitalization. (Combining Myocardial Strain and Cardiac CT to Optimize Left Ventricular Lead Placement in CRT Treatment [CRT Clinic]; NCT01426321)
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| 8. |
- Borgquist, Rasmus, et al.
(författare)
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Targeting the latest site of left ventricular mechanical activation is associated with improved long-term outcomes for recipients of cardiac resynchronization therapy
- 2022
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Ingår i: Heart Rhythm O2. - : Elsevier BV. - 2666-5018. ; 3:4, s. 377-384
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Tidskriftsartikel (refereegranskat)abstract
- Background: Previous studies have suggested that targeting the site of latest mechanical activation of the left ventricle (LV) results in improved cardiac resynchronization therapy (CRT) outcomes. It is not known whether these benefits are sustained over medium-term follow-up. Objective: To assess the clinical outcome of imaging-guided LV lead position. Methods: We sought to assess the medium-term clinical outcome by performing a patient-level meta-analysis of 2 previously published randomized controlled trials (the “STARTER” trial and the “CRT Clinic” trial). These 2 trials compared imaging-guided LV lead placement in the latest activated scar-free segment (intervention group) to standard of care (control). Mortality and heart failure hospitalization outcomes over extended follow-up were gathered from the medical records and merged. Results were stratified for native electrocardiogram (ECG) morphology. Results: A total of 289 patients were followed for a median of 6.3 years. Seven years post implant, 47 (28%) in the intervention group had died, vs 47 (38%) in the control group (P = .13); 49 (30%) vs 53 (42%) had been hospitalized for heart failure (P = .035); and 47% vs 59% (P = .057) had reached the combined endpoint. In Kaplan-Meier analysis, patients in the intervention group had better survival free of heart failure hospitalization (P = .045) and lower risk of heart failure hospitalization (P = .019). Conclusion: Targeting the latest mechanically activated segment in CRT results in better medium-term clinical outcome, mainly driven by a reduced risk of hospitalization for heart failure. The effect was seen regardless of native ECG morphology.
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| 9. |
- Kekecs, Zoltan, et al.
(författare)
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Raising the value of research studies in psychological science by increasing the credibility of research reports : the transparent Psi project
- 2023
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Ingår i: Royal Society Open Science. - : The Royal Society. - 2054-5703. ; 10:2
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Tidskriftsartikel (refereegranskat)abstract
- The low reproducibility rate in social sciences has produced hesitation among researchers in accepting published findings at their face value. Despite the advent of initiatives to increase transparency in research reporting, the field is still lacking tools to verify the credibility of research reports. In the present paper, we describe methodologies that let researchers craft highly credible research and allow their peers to verify this credibility. We demonstrate the application of these methods in a multi-laboratory replication of Bem's Experiment 1 (Bem 2011 J. Pers. Soc. Psychol. 100, 407-425. (doi:10.1037/a0021524)) on extrasensory perception (ESP), which was co-designed by a consensus panel including both proponents and opponents of Bem's original hypothesis. In the study we applied direct data deposition in combination with born-open data and real-time research reports to extend transparency to protocol delivery and data collection. We also used piloting, checklists, laboratory logs and video-documented trial sessions to ascertain as-intended protocol delivery, and external research auditors to monitor research integrity. We found 49.89% successful guesses, while Bem reported 53.07% success rate, with the chance level being 50%. Thus, Bem's findings were not replicated in our study. In the paper, we discuss the implementation, feasibility and perceived usefulness of the credibility-enhancing methodologies used throughout the project.
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| 10. |
- Markstad, Hanna, et al.
(författare)
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Preoperative CT of cardiac veins for planning left ventricular lead placement in cardiac resynchronization therapy
- 2019
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Ingår i: Acta Radiologica. - : SAGE Publications. - 0284-1851 .- 1600-0455. ; 60:7, s. 859-865
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Tidskriftsartikel (refereegranskat)abstract
- Background: Successful cardiac resynchronization therapy (CRT) requires appropriate left ventricular (LV) lead placement on a suitable segment of the free LV wall. Current guidelines suggest targeted lead placement, but the individual anatomy of the cardiac veins is often a limiting factor. Purpose: To map cardiac veins with multidetector computed tomography (MDCT) and plot the veins in cardiac segments to facilitate successful CRT implantation. Material and Methods: Ninety-nine patients were included (mean age = 68 ± 9 years; 26% women; 46% ischemic cardiomyopathy). Contrast-enhanced, ECG-gated, dose-modulated MDCT was used to depict the coronary veins. CT data were reformatted into short-axis view. Veins with diameter ≥1.5 mm and traversing the free LV wall were manually transferred into a 17-segment bulls-eye plot model. Results: In 98 patients, a CT scan with acceptable image quality was obtained. Median radiation dose as dose-length protocol was 231 mGy/cm (interquartile range = 276 mGy/cm). Mean contrast dose, expressed as total iodine load, was 38 ± 8 g. A median of three suitable veins (range = 1–7) covered a mean of 4.4 ± 1.5 relevant LV segments. There was no difference between patients with dilated or ischemic cardiomyopathy in number of veins (2.5 vs. 2.7, P = 0.45) or in number of cardiac segments traversed by suitable veins (4.4 vs. 4.5, P = 0.74). Conclusion: In CRT patients, MDCT can be used for preoperative mapping of the cardiac veins to assess availability of suitable veins in potential target segments for pacemaker-lead placement. Using the 17-segment plot of the left ventricle may improve the clinical usefulness of the data.
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