Patient expectations from implantable defibrillators to prevent death in heart failure.

BACKGROUND: Indications for implantable cardioverter-defibrillators (ICDs) in heart failure (HF) are expanding and may include more than 1 million patients. This study examined patient expectations from ICDs for primary prevention of sudden death in HF. METHODS AND RESULTS: Study participants (n = 105) had an EF <35% and symptomatic HF, without history of ventricular tachycardia/fibrillation or syncope. Subjects completed a written survey about perceived ICD benefits, survival expectations, and circumstances under which they might deactivate defibrillation. Mean age was 58, LVEF 21%, 40% were New York Heart Association Class III-IV, and 65% already had a primary prevention ICD. Most patients anticipated more than10 years survival despite symptomatic HF. Nearly 54% expected an ICD to save >or=50 lives per 100 during 5 years. ICD recipients expressed more confidence that the device would save their own lives compared with those without an ICD (P < .001). Despite understanding the ease of deactivation, 70% of ICD recipients indicated they would keep the ICD on even if dying of cancer, 55% even if having daily shocks, and none would inactivate defibrillation even if suffering constant dyspnea at rest. CONCLUSIONS: HF patients anticipate long survival, overestimate survival benefits conferred by ICDs, and express reluctance to deactivate their devices even for end-stage disease.

Handheld echocardiography offers rapid assessment of clinical volume status.

BACKGROUND: Assessment of volume status is vital for successful management of patients in heart failure (HF) programs. Bedside determination of elevated left-sided filling pressure (LFP) can be challenging and frequently inaccurate; therefore, incorporating technology such as handheld echocardiography, to aid in estimation of LFP, may improve patient care. In this study, we evaluated the feasibility and accuracy of handheld echocardiography by a nonexpert for potential use in the point of care evaluation of compensation. METHODS: Subjects were recruited from the HF clinic or inpatient service at a single center. Each subject underwent a focused handheld transthoracic echocardiogram by a medical resident trained for 10 hours. Subjects were assigned to 1 of 4 filling patterns (1 = normal, 2 = abnormal relaxation, 3 = pseudonormal, 4 = restrictive) based on measurements by pulsed wave and tissue Doppler. A 3-step echocardiography test for congestion in HF (TEC-HF) was devised for estimation of LFP. The gold standard for determining elevated LFP was clinical evaluation by a HF specialist, who classified subjects as being euvolemic or hypervolemic. RESULTS: A total of 100 consecutive subjects (72% male) were recruited, with average age of 60 years and left ventricular ejection fraction of 27%. All subjects had evaluable echocardiographic data. Based on TEC-HF, filling patterns 3 and 4 predicted hypervolemia and patterns 1 and 2 predicted euvolemia, with sensitivity and specificity of 86% and 92%, respectively, and positive and negative predictive values of 86% and 92%, respectively. CONCLUSIONS: Applying TEC-HF with handheld echocardiography accurately reflects clinical LFP as assessed by HF specialists. This procedure was easily taught to nonexpert medical staff who obtained adequate images in all patients. Handheld echocardiography could be a useful tool for assessing volume status in nonspecialized community settings.