Background: Based on current patient selection criteria, a significant proportion of recipients of cardiac resynchronization therapy(CRT) do not respond to treatment. The purpose of this analysis is to identify predic...Background: Based on current patient selection criteria, a significant proportion of recipients of cardiac resynchronization therapy(CRT) do not respond to treatment. The purpose of this analysis is to identify predictors and characterize the timing of response to CRT in patients with advanced heart failure. Methods: Patients randomized to receive CRT in the MIRACLE and MIRACLE-ICD trials, designed to assess the benefit of CRT compared with standard medical therapy in patients with advanced heart failure, left ventricular ejection fraction< 0.35, and QRS ≥130 milliseconds, were included for this analysis. Patients with an improvement of ≥1 New York Heart Association(NYHA)class from baseline to the 6-month follow-up were considered responders and those who had no change or worse NYHA class or died were classified as nonresponders. Responders were subdivided into early(within 1-3 months) and late(6 months). Results: One hundred forty-three(64%) of 224 and 190(61%) of 313 patients in the MIRACLE and MIRACLEICD trials, respectively, responded to therapy, with 81(57%) of 143 and 100(53%) of 190 responding early. Several but differing factors predicted CRT response and timing in the two trials with a high sensitivity(89%-90%) but, owing to a low specificity(31%-49%), a modest predictive accuracy(66%-75%). Conclusions: Based on improvement of ≥1 NYHA class, less than two thirds of patients enrolled in the MIRACLE or MIRACLE-ICD trials responded to CRT, with just more than half responding within the first month. Several factors predicted CRT response and timing, but given their modest predictive accuracy, comparable for both studies, additional methods for selecting candidates most likely to benefit from CRT are needed.展开更多
Background: The association between higher New York Heart Association(NYHA) class and outcomes in patients with heart failure and preserved systolic function is not well known. Methods: We performed a retrospective fo...Background: The association between higher New York Heart Association(NYHA) class and outcomes in patients with heart failure and preserved systolic function is not well known. Methods: We performed a retrospective follow- up study of 988 patients with heart failure with ejection fraction >45% who participated in the DIG trial. Using Cox proportional hazard models, we estimated risks of all- cause mortality, heart failure mortality, all- cause hospitalization, and hospitalization due to worsening heart failure during a median follow- up of 38.5 months. Results: Patients had a median age of 68 years; 41.2% were women and 13.9% , nonwhites. Overall, 23.4% of patients died, and 19.9% were hospitalized because of worsening heart failure. Proportion of patients with NYHA classes I, II, III, and IV were 19.9% , 58.0% , 20.9% , and 1.2% , respectively, and 14.7% , 21.1% , 35.9% , and 58.3% , respectively, died of all causes(P< .001 for trend). Respective rates for heart failure related hospitalizations were 14.2% , 17.1% , 32.5% , and 33.3% (P< .001 for trend). Compared with NYHA class I patients, adjusted hazard ratios(HRs) for all- cause mortality for class II, III, and IV patients were 1.54(95% CI 1.02- 2.32, P=.042), 2.56(95% CI 1.64- 24.01, P< .001), and 8.46(95% CI 3.57- 20.03, P< .001), respectively. Respective adjusted HRs(95% CI) for hospitalization due to heart failure for class II, III, and IV patients were 1.16(0.76- 1.77)(P=.502), 2.27(1.45- 3.56)(P< .001), and 3.71(1.25- 11.02)(P=.018). New York Heart Association classes II through IV were also associated with higher risk of all- cause hospitalization. Conclusion: Higher NYHA classes were associated with poorer outcomes in patients with heart failure and preserved systolic function.展开更多
文摘Background: Based on current patient selection criteria, a significant proportion of recipients of cardiac resynchronization therapy(CRT) do not respond to treatment. The purpose of this analysis is to identify predictors and characterize the timing of response to CRT in patients with advanced heart failure. Methods: Patients randomized to receive CRT in the MIRACLE and MIRACLE-ICD trials, designed to assess the benefit of CRT compared with standard medical therapy in patients with advanced heart failure, left ventricular ejection fraction< 0.35, and QRS ≥130 milliseconds, were included for this analysis. Patients with an improvement of ≥1 New York Heart Association(NYHA)class from baseline to the 6-month follow-up were considered responders and those who had no change or worse NYHA class or died were classified as nonresponders. Responders were subdivided into early(within 1-3 months) and late(6 months). Results: One hundred forty-three(64%) of 224 and 190(61%) of 313 patients in the MIRACLE and MIRACLEICD trials, respectively, responded to therapy, with 81(57%) of 143 and 100(53%) of 190 responding early. Several but differing factors predicted CRT response and timing in the two trials with a high sensitivity(89%-90%) but, owing to a low specificity(31%-49%), a modest predictive accuracy(66%-75%). Conclusions: Based on improvement of ≥1 NYHA class, less than two thirds of patients enrolled in the MIRACLE or MIRACLE-ICD trials responded to CRT, with just more than half responding within the first month. Several factors predicted CRT response and timing, but given their modest predictive accuracy, comparable for both studies, additional methods for selecting candidates most likely to benefit from CRT are needed.
文摘Background: The association between higher New York Heart Association(NYHA) class and outcomes in patients with heart failure and preserved systolic function is not well known. Methods: We performed a retrospective follow- up study of 988 patients with heart failure with ejection fraction >45% who participated in the DIG trial. Using Cox proportional hazard models, we estimated risks of all- cause mortality, heart failure mortality, all- cause hospitalization, and hospitalization due to worsening heart failure during a median follow- up of 38.5 months. Results: Patients had a median age of 68 years; 41.2% were women and 13.9% , nonwhites. Overall, 23.4% of patients died, and 19.9% were hospitalized because of worsening heart failure. Proportion of patients with NYHA classes I, II, III, and IV were 19.9% , 58.0% , 20.9% , and 1.2% , respectively, and 14.7% , 21.1% , 35.9% , and 58.3% , respectively, died of all causes(P< .001 for trend). Respective rates for heart failure related hospitalizations were 14.2% , 17.1% , 32.5% , and 33.3% (P< .001 for trend). Compared with NYHA class I patients, adjusted hazard ratios(HRs) for all- cause mortality for class II, III, and IV patients were 1.54(95% CI 1.02- 2.32, P=.042), 2.56(95% CI 1.64- 24.01, P< .001), and 8.46(95% CI 3.57- 20.03, P< .001), respectively. Respective adjusted HRs(95% CI) for hospitalization due to heart failure for class II, III, and IV patients were 1.16(0.76- 1.77)(P=.502), 2.27(1.45- 3.56)(P< .001), and 3.71(1.25- 11.02)(P=.018). New York Heart Association classes II through IV were also associated with higher risk of all- cause hospitalization. Conclusion: Higher NYHA classes were associated with poorer outcomes in patients with heart failure and preserved systolic function.
