Association of Guideline-Based Medical Therapy with Malignant Arrhythmias and Mortality among Heart Failure Patients Implanted with Cardioverter Defibrillator (ICD) or Cardiac Resynchronization-Defibrillator Device (CRTD).

AIM: Evaluate prevalence of heart failure (HF) medications and their association with ventricular arrhythmia (VA) and survival among patients implanted with primary prevention implantable cardiac defibrillator (ICD)/cardiac resynchronization therapy + defibrillator (CRTD) devices. METHODS: Association of treatment and dose (% guideline recommended target) of beta-adrenergic receptor antagonist (BB), angiotensin-antagonists (AngA), and mineralocorticoid-antagonists (MRA), after ICD/CRTD implant with VA and mortality was retrospectively analyzed. RESULTS: Study included 186 HF patients; 42.5% and 57.5% implanted with ICD and CRTD, respectively. During 3.8 (2.1;6.7) years; 52 (28%) had VA and 77 (41.4%) died. Treatment (% of patients) included: BB (83%), AngA (87%), and MRA (59%). Median doses were 25(12.5;50)% of target for all medications. BB treatment >25% target dose was associated with reduced VA incidence. In the multivariable model including age, gender, diabetes, heart rate, and medication doses, increased BB dose was associated with reduced VA (hazard ratio (HR) 0.443 95% CI 0.222-0.885; p = 0.021). In the multivariable model for overall mortality including age, gender, renal disease, VA, and medical treatment, VA was associated with increased mortality (HR 2.672; 95% CI 1.429-4.999; p = 0.002) and AngA treatment was associated with reduced mortality (HR 0.515; 95% CI 0.285-0.929; p = 0.028). CONCLUSIONS: In this cohort of real-life HF patients discharged after ICD/CRTD implant, prevalence of guideline-based HF medications was high, albeit with low doses. Higher BB dose was associated with reduced VA, while AngA was associated with improved survival.

Pulmonary Congestion Complicating Atrial Fibrillation Cardioversion.

Acute pulmonary congestion (APC) may occur within hours after electrical cardioversion of atrial fibrillation (AF). There is scarce data about its incidence, risk factors, and the outcome. In the present study, data of consecutive patients admitted for first electrical cardioversion for AF between 2007 and 2016 were retrospectively reviewed. APC within the 48 hours following cardioversion was defined as dyspnea and at least one of the following: drop in saturation to <90%, administration of intravenous diuretic or an emergent chest X-ray with new pulmonary congestion. All-cause mortality was determined from the national registry. Total of 1,696 patients had first cardioversion for AF, of whom 66 (3.9%) had APC. In a multivariate logistic regression model independent predictors of APC included (OR [CI], p): older age (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.02 to 1.08, p = 0.001), rapid ventricular response (OR 1.98, 95% CI 1.17 to 3.34, 0.010), previous heart failure (OR 3.53, 95% CI 2.09 to 5.97, p <0.001), Amiodarone loading (OR 2.38, 95% CI 1.18 to 4.79, p = 0.016) and diabetes mellitus (OR 1.77 95% CI 1.05 to 3.00, p = 0.033). There was no difference in cardioversion success rate (overall 94%). In-hospital mortality was 1.5% within the APC group and 0.5% without (p = 0.301). Patients with APC had higher rate of 6-month readmissions (28.8% vs 18.1% p <0.028). Within a median follow-up of 2.9 years, APC following cardioversion was an independent predictor of overall mortality (hazard ratio 1.73, 95% CI (1.17 to 2.56) p = 0.006). In conclusion, APC occurs in 3.9% of hospitalized patients following electrical AF cardioversion. Risk factors include increased age, diabetes mellitus, heart failure, Amiodarone loading and rapid ventricular response. APC following cardioversion is associated with increased rates of readmissions and mortality.