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Association between frequency of atrial and ventricular ectopic beats and biventricular pacing percentage and outcomes in patients with cardiac resynchronization therapy.

Publication ,  Journal Article
Ruwald, MH; Mittal, S; Ruwald, A-C; Aktas, MK; Daubert, JP; McNitt, S; Al-Ahmad, A; Jons, C; Kutyifa, V; Steinberg, JS; Wang, P; Moss, AJ; Zareba, W
Published in: J Am Coll Cardiol
September 9, 2014

BACKGROUND: A high percentage of biventricular pacing is required for optimal outcome in patients treated with cardiac resynchronization therapy (CRT), but the influence of ectopic beats on the success of biventricular pacing has not been well established. OBJECTIVES: This study sought to determine if increased ectopic beats reduce the chance of high biventricular pacing percentage and are associated with subsequent adverse outcomes. METHODS: From the MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy), 801 patients with an implanted CRT-defibrillator device with data available on biventricular pacing percentage and pre-implantation 24-h Holter recordings were included. Using logistic regression, we estimated the influence of ectopic beats on the percentage of biventricular pacing. Reverse remodeling was measured as reductions in atrial and left ventricular end-systolic volumes (LVESV) at 1 year. Cox models were used to assess the influence of ectopic beats on the outcomes of heart failure (HF) or death, ventricular tachyarrhythmias (VTAs), and death. RESULTS: In the pre-implantation Holter recording, ectopic beats accounted for a mean 3.2 ± 5.5% of all beats. The probability of subsequent low biventricular pacing percentage (<97%) was increased 3-fold (odds ratio: 3.37; 95% confidence interval: 1.74 to 6.50; p < 0.001) in patients with 0.1% to 1.5% ectopic beats and 13-fold (odds ratio: 13.42; 95% confidence interval: 7.02 to 25.66; p < 0.001) in patients with >1.5% ectopic beats compared with those with <0.1% ectopic beats. Patients with ≥0.1% ectopic beats had significantly less reverse remodeling (percent reduction in LVESV 31 ± 15%) than patients with <0.1% ectopic beats (percent reduction in LVESV 39 ± 14%; p < 0.001). The risk of HF/death and VTA was increased significantly in those with 0.1% to 1.5% ectopic beats (hazard ratio: 3.13 and 1.84, respectively) and for >1.5% ectopic beats (hazard ratio: 2.38 and 2.74, respectively). CONCLUSIONS: Relatively low frequencies of ectopic beats (≥0.1%) dramatically increase the probability of low biventricular pacing (<97%), with reduced CRT efficacy by less reverse remodeling and higher risk of HF/death and VTA. This supports pre-implantation Holter monitoring of patients selected for CRT for optimal outcome. (MADIT-CRT: Multicenter Automatic Defibrillator Implantation With Cardiac Resynchronization Therapy; NCT00180271).

Duke Scholars

Published In

J Am Coll Cardiol

DOI

EISSN

1558-3597

Publication Date

September 9, 2014

Volume

64

Issue

10

Start / End Page

971 / 981

Location

United States

Related Subject Headings

  • Ventricular Premature Complexes
  • Treatment Outcome
  • Tachycardia, Ventricular
  • Survival Rate
  • Sex Distribution
  • Severity of Illness Index
  • Risk Assessment
  • Proportional Hazards Models
  • Prognosis
  • Odds Ratio
 

Citation

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Ruwald, M. H., Mittal, S., Ruwald, A.-C., Aktas, M. K., Daubert, J. P., McNitt, S., … Zareba, W. (2014). Association between frequency of atrial and ventricular ectopic beats and biventricular pacing percentage and outcomes in patients with cardiac resynchronization therapy. J Am Coll Cardiol, 64(10), 971–981. https://doi.org/10.1016/j.jacc.2014.06.1177
Ruwald, Martin H., Suneet Mittal, Anne-Christine Ruwald, Mehmet K. Aktas, James P. Daubert, Scott McNitt, Amin Al-Ahmad, et al. “Association between frequency of atrial and ventricular ectopic beats and biventricular pacing percentage and outcomes in patients with cardiac resynchronization therapy.J Am Coll Cardiol 64, no. 10 (September 9, 2014): 971–81. https://doi.org/10.1016/j.jacc.2014.06.1177.
Ruwald MH, Mittal S, Ruwald A-C, Aktas MK, Daubert JP, McNitt S, et al. Association between frequency of atrial and ventricular ectopic beats and biventricular pacing percentage and outcomes in patients with cardiac resynchronization therapy. J Am Coll Cardiol. 2014 Sep 9;64(10):971–81.
Ruwald, Martin H., et al. “Association between frequency of atrial and ventricular ectopic beats and biventricular pacing percentage and outcomes in patients with cardiac resynchronization therapy.J Am Coll Cardiol, vol. 64, no. 10, Sept. 2014, pp. 971–81. Pubmed, doi:10.1016/j.jacc.2014.06.1177.
Ruwald MH, Mittal S, Ruwald A-C, Aktas MK, Daubert JP, McNitt S, Al-Ahmad A, Jons C, Kutyifa V, Steinberg JS, Wang P, Moss AJ, Zareba W. Association between frequency of atrial and ventricular ectopic beats and biventricular pacing percentage and outcomes in patients with cardiac resynchronization therapy. J Am Coll Cardiol. 2014 Sep 9;64(10):971–981.
Journal cover image

Published In

J Am Coll Cardiol

DOI

EISSN

1558-3597

Publication Date

September 9, 2014

Volume

64

Issue

10

Start / End Page

971 / 981

Location

United States

Related Subject Headings

  • Ventricular Premature Complexes
  • Treatment Outcome
  • Tachycardia, Ventricular
  • Survival Rate
  • Sex Distribution
  • Severity of Illness Index
  • Risk Assessment
  • Proportional Hazards Models
  • Prognosis
  • Odds Ratio