Cryoballoon Ablation as Initial Therapy for Atrial Fibrillation.

BACKGROUND: In patients with symptomatic paroxysmal atrial fibrillation that has not responded to medication, catheter ablation is more effective than antiarrhythmic drug therapy for maintaining sinus rhythm. However, the safety and efficacy of cryoballoon ablation as initial first-line therapy have not been established. METHODS: We performed a multicenter trial in which patients 18 to 80 years of age who had paroxysmal atrial fibrillation for which they had not previously received rhythm-control therapy were randomly assigned (1:1) to receive treatment with antiarrhythmic drugs (class I or III agents) or pulmonary vein isolation with a cryoballoon. Arrhythmia monitoring included 12-lead electrocardiography conducted at baseline and at 1, 3, 6, and 12 months; patient-activated telephone monitoring conducted weekly and when symptoms were present during months 3 through 12; and 24-hour ambulatory monitoring conducted at 6 and 12 months. The primary efficacy end point was treatment success (defined as freedom from initial failure of the procedure or atrial arrhythmia recurrence after a 90-day blanking period to allow recovery from the procedure or drug dose adjustment, evaluated in a Kaplan-Meier analysis). The primary safety end point was assessed in the ablation group only and was a composite of several procedure-related and cryoballoon system-related serious adverse events. RESULTS: Of the 203 participants who underwent randomization and received treatment, 104 underwent ablation, and 99 initially received drug therapy. In the ablation group, initial success of the procedure was achieved in 97% of patients. The Kaplan-Meier estimate of the percentage of patients with treatment success at 12 months was 74.6% (95% confidence interval [CI], 65.0 to 82.0) in the ablation group and 45.0% (95% CI, 34.6 to 54.7) in the drug-therapy group (P<0.001 by log-rank test). Two primary safety end-point events occurred in the ablation group (Kaplan-Meier estimate of the percentage of patients with an event within 12 months, 1.9%; 95% CI, 0.5 to 7.5). CONCLUSIONS: Cryoballoon ablation as initial therapy was superior to drug therapy for the prevention of atrial arrhythmia recurrence in patients with paroxysmal atrial fibrillation. Serious procedure-related adverse events were uncommon. (Supported by Medtronic; STOP AF First ClinicalTrials.gov number, NCT03118518.).

Same-day discharge after cryoballoon ablation of atrial fibrillation: A multicenter experience.

BACKGROUND: It is common practice to observe patients during an overnight stay (ONS) following a catheter ablation procedure for the treatment of atrial fibrillation (AF). OBJECTIVES: To investigate the safety and economic impact of a same-day discharge (SDD) protocol after cryoballoon ablation for treatment of AF in high-volume, geographically diverse US hospitals. METHODS: We retrospectively reviewed 2374 consecutive patients (1119 SDD and 1180 ONS) who underwent cryoballoon ablation for AF at three US centers. Baseline characteristics, acute procedure-related complications, and longer-term evaluations of safety were recorded during routine clinical follow-up. The mean cost of an ONS was used in a one-way sensitivity analysis to evaluate yearly cost savings as a function of the percentage of SDD cases per year. RESULTS: The SDD and ONS cohorts were predominately male (69% vs. 67%; p = .3), but SDD patients were younger (64 ± 11 vs. 66 ± 10; p < .0001) with lower body mass index (30 ± 6 vs. 31 ± 61; p < .0001) and CHA2 DS2 -VASc scores (1.4 ± 1.0 vs. 2.2 ± 1.4; p < .0002). There was no difference between SDD and ONS in the 30-day total complication rate (n = 15 [1.26%] versus n = 24 [2.03%]; p = .136, respectively). The most common complication was hematoma in both the SDD (n = 8; 0.67%) and ONS (n = 11; 0.93%) cohorts. Sensitivity analysis demonstrated that when 50% of every 100 patients treated were discharged the same day, hospital cost savings ranged from $45 825 to $83 813 per year across US hospitals. CONCLUSIONS: SDD following cryoballoon ablation for AF appears to be safe and is associated with cost savings across different US hospitals.

Atrioesophageal fistula complicating cryoballoon pulmonary vein isolation for paroxysmal atrial fibrillation.

Although atrioesophageal fistula (AEF) formation is a well known, albeit rare, catastrophic complication of atrial fibrillation radiofrequency ablation procedures, there are less data regarding this complication using the cryoballoon technique. We report on 3 cases of AEF as a complication of cryoballoon pulmonary vein isolation at 3 different institutions with 2 different generations of cryoballoons.

Cardiac perforation and lead dislodgement after implantation of a MR-conditional pacing lead: a single-center experience.

OBJECTIVE: The purpose of our study was to determine if the rate of lead-related complications was increased with the Medtronic CapSureFix MRI™ SureScan™ 5086 MRI pacing lead (5086; Medtronic Inc., Minneapolis, MN, USA) compared to the previous generation of Medtronic CapSureFix Novus™ 5076 pacing lead (5076). BACKGROUND: The 5086 lead is a newly introduced active-fixation pacemaker lead designed to be used conditionally in a magnetic resonance (MR) scanner. This lead has specific design changes compared to the previous generation of 5076 pacing leads. METHODS: This study was a retrospective case control study of 65 consecutive patients implanted with two 5086 leads compared to 92 consecutive control patients implanted with two 5076 leads over a 14-month period at a high-volume tertiary care hospital. RESULTS: Pericarditis, pericardial effusion, cardiac tamponade, or death within 30 days of implant were seen in eight patients from the 5086 cohort and two from the 5076 cohort (odds ratio 6.3, 95% confidence interval 1.3-30.8, P = 0.02). Lead dislodgement occurred in four of the 5086 patients and in none of the 5076 patients (P < 0.03). CONCLUSIONS: In a high-volume center, the incidence of pericarditis, cardiac perforation, tamponade, death, and lead dislodgement was significantly higher with the MR-conditional Medtronic 5086 lead when compared to the previous generation Medtronic 5076 lead.

Multidisciplinary Approach to Patent Foramen Ovale Closure for Cryptogenic Stroke: Brain-Heart Board Experience.

Background and Objectives: Patent foramen ovale (PFO) is present in approximately 25% of adult population. The prevalence of PFO is high in patients with cryptogenic stroke suggesting paradoxical embolism. PFO closure in carefully selected patients is an effective secondary preventive strategy in these patients. We report predictors of management recommendations by the multidisciplinary Board and their impact on outcomes. Methods: Brain-Heart Board comprises vascular and interventional neurology and cardiology subspecialties (structural, electrophysiology, and cardiac imaging). Adult patients referred to the Board for consideration of PFO closure between October 2017 to March 2021 were included in this retrospective cohort analysis. Demographics, comorbid conditions, risk of paradoxical embolism (RoPE) score, event frequencies (transient ischemic attack [TIA] or stroke, intracranial hemorrhage [ICH], post-PFO closure cardiac arrhythmias), and modified Rankin Scale (mRS) at 1 year were compared between the groups (PFO closure vs medical management). Multivariable logistic regression was used to identify factors associated with management recommendation and chi-square tests to test differences in outcomes for patients according to management. Results: Two hundred seventy patients (229 stroke; 41 TIA) were discussed by the Board for PFO closure. 119 (44.0%) patients were recommended for PFO closure of which 117 (98.3%) had evidence of ischemic infarct on imaging. In univariate analysis, age was similar (50 ± 11.9 vs 52 ± 12.8, p = 0.17), but RoPE score was higher in closure as compared with the medical management group (6 [IQR 5-7] vs 5 [IQR 4-7], p < 0.05). In multivariable analysis, TIA as the index event was an independent predictor of Board recommendation against PFO closure (OR 0.05, 95% CI 0.01-0.19, p < 0.05). Event frequency was low in both cohorts (5.9% vs 4.8%, p > 0.05) and comprised cardiac arrhythmias (6 cases of atrial fibrillation and 1 ICH in closure group; 1 TIA and 1 recurrent stroke in medical management group). Excellent functional outcome (mRS 0-1) was similar in both cohorts (66.3% vs 70.7%, p > 0.05) at 1 year. Discussion: Multidisciplinary Brain-Heart Board provides a clinical practice model of collaborative care to ensure proper patient selection for PFO closure. TIA as the index event is associated with recommendation of medical management by the multidisciplinary Brain-Heart Board.

Four-year follow-up of outcomes of the hybrid epicardial-endocardial ablation: A single-center experience.

BACKGROUND: The CONVERGE trial demonstrated that hybrid epicardial and endocardial ablation was more effective than catheter ablation for the treatment of persistent atrial fibrillation (AF) at 1 year. Long-term real-world outcome data are scarce. OBJECTIVE: We described a single-center experience by evaluating the long-term effectiveness and safety of hybrid epicardial-endocardial ablation. METHODS: This is a retrospective single-center study. Patients were followed up to 4 years. The primary end point was the rate of AF recurrence up to 4 years postablation. Secondary end points included reduction in antiarrhythmic therapy use, the effect of the ligament of Marshall removal, epicardial posterior wall, 3-dimensional mapping during epicardial ablation, and left atrial appendage exclusion as adjunct intraoperative interventions for AF recurrence. RESULTS: Of the 170 patients, 86.5% had persistent AF and 13.5% had long-standing persistent AF. AF-free survival was 87.6% at 1 year, 76.9% at 2 years, 70.4% at 3 years, and 59.3% at 4 years. Antiarrhythmic drug use was 87.6% at baseline and reduced to 21%, 20.6%, 18%, and 14.1% at year 1, 2, 3, and 4, respectively (P < .01 for all). Three-dimensional epicardial mapping showed a significant reduction in combined recurrence from 42% to 25% over 4 years of follow-up (P = .023). Ligament of Marshall and left atrial appendage exclusion showed numerical reduction in AF recurrence from 35% to 26% (P = .49) and from 44% to 30% (P = .07). CONCLUSION: The hybrid convergent procedure reduces AF recurrence and the need for antiarrhythmic drugs and, while maintaining a good safety profile, for the treatment of persistent and long-standing persistent AF.

Optimizing Care of Patients With Right Bundle Branch Block Undergoing Transcatheter Aortic Valve Replacement.

OBJECTIVES: To evaluate the use of temporary-permanent pacemaker (TPP) in patients with right bundle branch block (RBBB) undergoing transcatheter aortic valve replacement (TAVR). We also sought to identify key predictors of permanent pacemaker (PPM) within 30 days of TAVR in this population. BACKGROUND: RBBB is a well-recognized risk factor for PPM post TAVR. TPP provides stable transient pacing and reduces the need for critical care beds. METHODS: This is a retrospective chart review of 371 patients who underwent TAVR at our institution. All patients with pre-existing RBBB had TPP placed prior to TAVR (n = 37). The primary outcome was the need for critical care beds. Multivariate logistic regression analysis was performed to identify predictors of PPM within 30 days of TAVR. RESULTS: 67 patients required PPM within 30 days of TAVR, and 56 implanted before discharge. 51% (19 out of 37) of TPP group required PPM before discharge compared to 11% (37 out of 334) of No TPP (p < 0.001), yet TPP group spent significantly fewer hours in a critical care bed (19 vs 28 h, p = 0.01). Length of membranous septum (LMS) <8.49 mm was the strongest independent predictor of PPM within 30 days of TAVR (RAUC of 0.80, Sensitivity 0.7 and Specificity 0.8) and 98% of patients with LMS < 7 mm required PPM within 30 days. CONCLUSION: TPP-TAVR is a well-defined multidisciplinary protocol that reduces the need for critical care beds in patients with pre-existing RBBB referred for TAVR. Additionally, LMS is the strongest predictor of PPM implantation in this population. CONDENSED ABSTRACT (100 WORDS): This study evaluated the use of temporary-permanent pacemakers (TPP) in patients with right bundle branch block (RBBB) undergoing transcatheter aortic valve replacement (TAVR). TPP-TAVR provided stable pacing allowing for early mobilization and reduced the need for critical care beds. Multivariate logistic regression analysis identified length of membranous septum (LMS) <8.49 mm in patients with RBBB as the strongest independent predictor of PPM need within 30 days of TAVR. 98% of patients with RBBB and LMS < 7 mm required PPM at 30 days regardless of other characteristics including valve type and size.

Quality of life after the initial treatment of atrial fibrillation with cryoablation versus drug therapy.

BACKGROUND: The STOP AF First trial recently demonstrated that initial treatment with cryoballoon ablation (CBA) is safe and superior to antiarrhythmic drug (AAD) therapy for preventing atrial arrhythmia recurrence in patients with symptomatic atrial fibrillation (AF). OBJECTIVE: The purpose of this study was to evaluate the change in quality of life (QoL) and symptoms after first-line CBA vs AAD therapy. METHODS: Patients with symptomatic AF not previously receiving rhythm control therapy were randomized to AAD (class I or III) or CBA (Arctic Front Advance, Medtronic, Mounds View, MN). QoL was evaluated at baseline and at 6 and 12 months by using the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) and the European Quality of Life-5 Dimensions questionnaires. A review of AF-associated symptoms was conducted at baseline and at 1, 3, 6, and 12 months. RESULTS: In total, 203 subjects received either CBA (n = 104 [51.2%]) or AAD therapy (n = 99 [48.8%]). Improvements in the AFEQT summary and subscale scores were significantly larger with CBA than with AAD therapy at 6 and 12 months (P < .02 for all). Clinically meaningful improvement (>5 points) in the AFEQT summary score from baseline to 12 months was observed in 96.0% (100) of patients in the CBA arm vs 72.2% (71) of patients in the AAD arm (P < .001). No significant between-group differences were observed in the change in the European Quality of Life-5 Dimensions index or visual analog scale scores. Overall, 54.4% (57) of the CBA group vs 29.7% (29) of the AAD group reported no AF-specific symptom recurrence after a 90-day blanking period (P = .0005). CONCLUSION: First-line CBA vs AAD therapy is associated with larger improvements in AF-specific QoL and a higher rate of symptom resolution.

A cost comparison of atrial fibrillation monitoring strategies after embolic stroke of undetermined source.

Background: Detection of atrial fibrillation (AF) in patients with embolic stroke of undetermined source (ESUS) is challenging due to its paroxysmal nature. We sought to assess AF detection with an insertable cardiac monitor (ICM) and to perform cost analysis for various AF monitoring strategies post-ESUS We applied this cost analysis modeling to recently published Stroke AF and Per Diem trials. Methods: Retrospective chart review was performed in consecutive hospitalized patients with ESUS who had ICM placed prior to discharge. Utilizing rate of ICM-detected AF and Medicare average payments, we modeled 30-day per-patient diagnostic costs of Immediate ICM insertion prior to discharge versus using a wearable monitor followed by ICM in patients with ESUS, from Medicare and patient out-of-pocket perspectives. Similar modeling strategy and cost analysis was applied to the Stroke AF and Per Diem trials. Results: In 192 ESUS patients, AF detection increased with length of monitoring: 7.3 % at 14 days, 9.4 % at 30 days, and 17.2 % after a median ~ 6 months (189 days). Cost modeling predicted that immediate ICM leads to $3683-$4070 lower Medicare payments per-patient and $1425-$1503 lower patient out-of-pocket costs compared to Wearable-to-ICM strategies. Using similar modeling in the PER DIEM and STROKE AF trials, the additive costs of the 30-day ELR to ICM strategy ranged from $3786-$3946 from a payer perspective and $1472-$1503 from a patient out-of-pocket perspective. Conclusions: Use of ICM immediately after ESUS is cost-saving compared to Wearable-to-ICM strategies, due to the cost and low diagnostic yield of short-term wearable cardiac monitoring.

Combined epicardial and endocardial ablation for atrial fibrillation: Best practices and guide to hybrid convergent procedures.

The absence of strategies to consistently and effectively address nonparoxysmal atrial fibrillation by nonpharmacological interventions has represented a long-standing treatment gap. A combined epicardial/endocardial ablation strategy, the hybrid Convergent procedure, was developed in response to this clinical need. A subxiphoid incision is used to access the pericardial space facilitating an epicardial ablation directed at isolation of the posterior wall of the left atrium. This is followed by an endocardial ablation to complete isolation of the pulmonary veins and for additional ablation as needed. Experience gained with the hybrid Convergent procedure during the last decade has led to the development and adoption of strategies to optimize the technique and mitigate risks. Additionally, a surgical and electrophysiology "team" approach including comprehensive training is believed critical to successfully develop the hybrid Convergent program. A recently completed randomized clinical trial indicated that this ablation strategy is superior to an endocardial-only approach for patients with persistent atrial fibrillation. In this review, we propose and describe best practice guidelines for hybrid Convergent ablation on the basis of a combination of published data, author consensus, and expert opinion. A summary of clinical outcomes, emerging evidence, and future perspectives is also given.

Left Atrial Volume Index Predicts Arrhythmia-Free Survival in Patients with Persistent Atrial Fibrillation Undergoing Cryoballoon Ablation.

BACKGROUND: Pulmonary vein isolation (PVI) using cryoballoon ablation (PVI-C) is increasingly performed as a first-line strategy for the treatment of patients with persistent atrial fibrillation (PersAF); however, follow-up data and predictors of procedural success are lacking. OBJECTIVE: To study the efficacy of PVI-C in patients with PersAF, focusing on predictors of procedural success. METHODS: By retrospective review, 148 consecutive patients with PersAF who underwent PVI-C were analyzed. The impact of several variables on outcome was evaluated in univariate and multivariate analyses and Cox proportional hazards regression models. RESULTS: After a mean follow-up of 19.2±10.9 months, 75 (50.7%) patients remained arrhythmia-free without the need for antiarrhythmic drug therapy. Patients with a normal left atrial volume index (LAVI) achieved a 71.0% arrhythmia-free survival. LAVI was the most powerful predictor of procedural success. CONCLUSIONS: Arrhythmia-free survival after PVI-C in select patients with PersAF are promising. Moreover, LAVI is a valuable measurement to help guide ablation strategy and predict outcome when using cryoballoon ablation.

Safety of anticoagulation with uninterrupted warfarin vs. interrupted dabigatran in patients requiring an implantable cardiac device.

BACKGROUND: The optimal strategy of peri-procedural anticoagulation in patients undergoing permanent cardiac device implantation is controversial. Our objective was to compare the major bleeding and thromboembolic complications in patients managed with uninterrupted warfarin (UW) vs. interrupted dabigatran (ID) during permanent pacemaker (PPM) or implantable cardioverter defibrillators (ICD) implantation. METHODS: A retrospective cohort study of all eligible patients from July 2011 through January 2012 was performed. UW was defined as patients who had maintained a therapeutic international normalized ratio (INR) on the day of the procedure. ID was defined as stopping dabigatran ≥12 hours prior to the procedure and then resuming after implantation. Major bleeding events included hemothorax, hemopericardium, intracranial hemorrhage, gastrointestinal bleed, epistaxis, or pocket hematoma requiring surgical intervention. Thromboembolic complications included stroke, transient ischemic attack, deep venous thrombosis, pulmonary embolism, or arterial embolism. RESULTS: Of the 133 patients (73.4±11.0 years; 91 males) in the study, 86 received UW and 47 received ID. One (1.2%) patient in the UW group sustained hemopericardium perioperatively and died. In comparison, the ID patients had no complications. As compared to the ID group, the UW group had a higher median CHADS2 score (2 vs. 3, P=0.04) and incidence of Grade 1 pocket hematoma (0% vs. 7%, P=0.09). Neither group developed any thromboembolic complications. CONCLUSIONS: Major bleeding rates were similar among UW and ID groups. Perioperative ID appears to be a safe anticoagulation strategy for patients undergoing PPM or ICD implantation.

A comparison of treadmill scores to diagnose coronary artery disease.

BACKGROUND: Recently, several treadmill scores have been proposed as means for improving the diagnostic accuracy of the exercise treadmill test (ETT). Questions remain regarding the diagnostic accuracy of treadmill scores when applied to a different patient population than that from which they were derived; furthermore, many treadmill scores have not been compared with one another in the same population. HYPOTHESIS: The diagnostic accuracy of treadmill scores may not be the same. METHODS: A retrospective analysis of data collected prospectively was performed on consecutive patients referred for evaluation of chest pain. All patients underwent a standard ETT followed by coronary angiography. Using angiographic evidence of coronary artery disease (CAD) as a reference, the area under the curve (AUC) of receiver operator characteristic (ROC) plots of the ST response alone, the Duke Treadmill Score (DTS), the Morise score, the Detrano score, the VA score, and a Consensus score consisting of the Morise, Detrano, and VA scores together were calculated and compared. The predictive accuracies of the DTS and the Consensus score to stratify patients for the likelihood of CAD were calculated and compared. RESULTS: In all, 1,282 patients without a prior myocardial infarction had an ETT and coronary angiography. The AUC (+/- standard error) was 0.67+/-0.01 for the ST response, 0.73+/-0.01 for DTS, 0.76+/-0.01 for Detrano score, 0.77+/-0.01 for Morise score, 0.78+/-0.01 for VA score, and 0.78+/-0.01 for Consensus score. The AUC for each treadmill score was significantly higher (z-score > 1.96) than for the ST response alone. The AUC of DTS was significantly lower than all other treadmill scores (z-score > 1.96). The predictive accuracy (+/-95% confidence interval) of the DTS to risk stratify patients into high and low likelihood for CAD was 71 (65-77)%, versus 80 (74-86)% for the Consensus score (p < 0.0001). CONCLUSION: In this population, the DTS remains useful for diagnosing CAD and stratifying for the likelihood of CAD, although it is less accurate than other treadmill scores.

Attitudes of Implanting Physicians about Cardiac Rhythm Management Devices and Their Features.

Modern cardiac rhythm management systems have become increasingly complex. The decision on which specific system to implant in a given patient often rests with the implanting physician. We conducted a multiple-choice survey to assess the opinions and preferences of cardiologists and electrophysiologists who implant and follow cardiac rhythm management systems. Reliability and battery longevity were viewed as the most important characteristics in device selection. Patient characteristics which most affected device choice were pacing indication and life expectancy. Remote technology was used in 47% of pacemaker patients, 64% of ICD patients, and 65% of CRT-D patients, with wireless (radiofrequency) remote patient monitoring associated with higher patient compliance rates (74% versus 64%, resp.). Wireless remote patient management with alerts for atrial tachyarrhythmias was felt to be important by 76% of respondents. When choosing an MR-conditional device, physicians deemed patients with prior orthopedic problems, a history of cancer, or neurological disorders to be more likely to require a future MRI. Device longevity and reliability remain the most important factors which influence device selection. Wireless remote patient monitoring with alerts is considered increasingly important when choosing a specific cardiac rhythm management system to implant.

Radiofrequency Ablation of a Left Atrial Appendage Tachycardia on ECMO Support.

Extracorporeal membrane oxygenation (ECMO) has been utilized in the pediatric population for cardiogenic shock secondary to medically intractable arrhythmias. There is limited experience with cardiac radiofrequency ablation (RFA) on these patients while on ECMO. A 7-year-old girl presented with a tachycardia-mediated cardiomyopathy secondary to a left atrial appendage tachycardia. She suffered a cardiac arrest due to pulseless electrical activity and was placed on ECMO. Due to elevated left atrial pressures and the refractoriness of her arrhythmia to cardioversion and antiarrhythmic therapy, while on ECMO, blade atrial septostomy and radiofrequency ablation were performed. The patient tolerated the procedure well and was successfully decannulated. Her cardiac function normalized within four weeks of the ablation procedure. Twelve months after the procedure, she remains completely well, with no symptoms or tachycardia.

Syncope and recurrent ventricular tachycardia with a newly identified desmosomal gene mutation.

Ventricular arrhythmias in young people most commonly occur due to the presence of hypertrophic cardiomyopathy, long QT syndrome or Wolff-Parkinson-White syndrome. We present a case in which the patient had exercise induced syncopal spells and was found to have ventricular tachycardia (VT) during both exercise stress testing and an electrophysiology study. Further genetic studies showed a previously unseen desmosomal gene mutation confirming the presence of Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC).

Disparities in the use of primary prevention and defibrillator therapy among blacks and women.

OBJECTIVES: This study determines whether there are racial or gender disparities in the use of implantable cardioverter-defibrillator therapy for primary prevention of sudden cardiac death. BACKGROUND: Primary prevention of sudden death with implantable cardioverter-defibrillator therapy has been shown to improve survival for high-risk patients with coronary artery disease and left ventricular dysfunction. METHODS: The Center for Medicare and Medicaid Services Medicare database from the year 2002 was used to identify patients who were potential candidates for implantable cardioverter-defibrillator therapy on the basis of a combination of International Classification of Diseases, Ninth Revision, Clinical Modification codes that reflected the presence of an ischemic cardiomyopathy. This cohort was analyzed to determine which patients received implantable cardioverter-defibrillator therapy during the same year. The clinical characteristics of the potential implantable cardioverter-defibrillator candidates were compared with those who actually received an implantable cardioverter-defibrillator. RESULTS: A total 132565 Medicare patients hospitalized during 2002 were identified as having an ischemic cardiomyopathy; 10370 (8%) of these patients underwent implantable cardioverter-defibrillator implantation during the same year. The percentage of patients who underwent implantable cardioverter-defibrillator implantation was higher for men compared with women (10.2% vs 3.5%; P<.001) and whites compared with blacks (8.1 vs 5.4; P<.001). After multivariate analysis, age, gender, and race remained independent predictors of implantable cardioverter-defibrillator implantation. Women with an ischemic cardiomyopathy were 65% less likely to receive implantable cardioverter-defibrillator therapy compared with men (P<.001), and black patients were 31% less likely to receive implantable cardioverter-defibrillator therapy compared with patients of other races (P < .001). CONCLUSIONS: Use of implantable cardioverter-defibrillator therapy for primary prevention of sudden death among the elderly population identified as having an ischemic cardiomyopathy was significantly lower among women compared with men, and among blacks compared with whites. Further exploration of gender and racial barriers to appropriate implantable cardioverter-defibrillator use for primary prevention is needed.

The prognostic value of body mass index and standard exercise testing in male veterans with congestive heart failure.

OBJECTIVE: To evaluate the prognostic characteristics of body mass index (BMI) and standard exercise test variables in a consecutive series of patients with mild to moderate congestive heart failure (CHF) referred for standard exercise tests. BACKGROUND: Controversy exists regarding the prognostic importance of BMI, etiology, and exercise test variables in patients with CHF. METHODS: All patients referred for evaluation at two university-affiliated Veterans Affairs Medical Centers who underwent treadmill tests for clinical indications between 1987 and 2000 were determined to be dead or alive using the Social Security Death Index after a mean 6 years follow-up. Clinical and exercise test variables were collected prospectively according to standard definitions; testing and data management were performed in a standardized fashion using a computer-assisted protocol. Survival analysis was performed using all-cause mortality as the endpoint for follow-up. RESULTS: A total of 522 patients with a history and clinical findings of CHF underwent exercise testing. Forty-two percent died during the follow-up period, for an average annual mortality of 6.7%. Cox proportional hazards model chose peak metabolic equivalents (METs), BMI, age, and ischemic etiology in rank order as independently and significantly associated with time to death. A score based on these variables classified patients into low (2% annual mortality), medium (5.2%), and high-risk groups (7% annual mortality). CONCLUSION: Standard exercise testing and BMI can be used to estimate prognosis in outpatients with heart failure. A score incorporating METs, BMI, age, and etiology efficiently stratified these patients. BMI was chosen by the survival analysis, confirming its surprising inverse relationship to prognosis in CHF patients (i.e., heavier patients do better).