Permanent pacemaker use among patients with heart failure and preserved ejection fraction: Findings from the Acute Decompensated Heart Failure National Registry (ADHERE) National Registry.

BACKGROUND: Heart failure with preserved ejection fraction may be associated with chronotropic incompetence, but little is known about the incidence and prevalence of permanent pacemaker use in this population or factors associated with its use. METHODS: We analyzed patients with heart failure with preserved ejection fraction (ie, left ventricular ejection fraction greater than 40%) from the ADHERE registry (2001-2006) linked with Medicare claims. We described the use of both prevalent and incident permanent pacemakers in heart failure with preserved ejection fraction and determined factors associated with pacemaker use with logistic regression models. RESULTS: Among 13,881 patients with heart failure with preserved ejection fraction, 3136 (22.6%) had a permanent pacemaker, and of these patients, 636 had a permanent pacemaker implanted during hospitalization. Permanent pacemaker use was more common among older patients (81 vs 79 years; P < .001), men (38% vs 34%; P < .001), patients with atrial fibrillation (58% vs 36%; P < .001), and patients with wider QRS duration (140 ms vs 94 ms; P < .001). Rates of digoxin, aldosterone antagonist, and loop diuretic use were slightly higher in patients with a permanent pacemaker compared with patients with no permanent pacemaker. Factors associated with both prevalent and incident pacemaker use included age, fast or slow heart rate, atrial fibrillation, and lower body mass index. CONCLUSIONS: Use of permanent pacemakers is relatively common among patients with heart failure with preserved ejection fraction.

The Metabolic Syndrome and Risk of Sudden Cardiac Death: The Atherosclerosis Risk in Communities Study.

BACKGROUND: Prior studies have demonstrated a link between the metabolic syndrome and increased risk of cardiovascular mortality. Whether the metabolic syndrome is associated with sudden cardiac death is uncertain. METHODS AND RESULTS: We characterized the relationship between sudden cardiac death and metabolic syndrome status among participants of the ARIC (Atherosclerosis Risk in Communities) Study (1987-2012) free of prevalent coronary heart disease or heart failure. Among 13 168 participants, 357 (2.7%) sudden cardiac deaths occurred during a median follow-up of 23.6 years. Participants with the metabolic syndrome (n=4444) had a higher cumulative incidence of sudden cardiac death than those without it (n=8724) (4.1% versus 2.3%, P<0.001). After adjustment for participant demographics and clinical factors other than components of the metabolic syndrome, the metabolic syndrome was independently associated with sudden cardiac death (hazard ratio, 1.70, 95% confidence interval, 1.37-2.12, P<0.001). This relationship was not modified by sex (interaction P=0.10) or race (interaction P=0.62) and was mediated by the metabolic syndrome criteria components. The risk of sudden cardiac death varied according to the number of metabolic syndrome components (hazard ratio 1.31 per additional component of the metabolic syndrome, 95% confidence interval, 1.19-1.44, P<0.001). Of the 5 components, elevated blood pressure, impaired fasting glucose, and low high-density lipoprotein were independently associated with sudden cardiac death. CONCLUSIONS: We observed that the metabolic syndrome was associated with a significantly increased risk of sudden cardiac death irrespective of sex or race. The risk of sudden cardiac death was proportional to the number of metabolic syndrome components.

Use of Heart Failure Medical Therapies Among Patients With Left Ventricular Assist Devices: Insights From INTERMACS.

BACKGROUND: Use of left ventricular assist devices (LVADs) for treatment of advanced heart failure has expanded significantly over the past decade. However, concomitant use of heart failure medical therapies after implant is poorly characterized. METHODS AND RESULTS: We examined the use of heart failure medications before and after LVAD implant in adult patients enrolled in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) between 2008 and 2013 (N = 9359). Using logistic regression, we examined relationships between patient characteristics and medication use at 3 months after implant. Baseline rates of heart failure therapies before implant were 38% for angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), 55% for ß-blockers, 40% for mineralocorticoid receptor antagonists (MRAs), 87% for loop diuretics, 54% for amiodarone, 11% for phosphodiesterase inhibitors, 22% for warfarin, and 54% for antiplatelet agents. By 3 months after implant, the rates were 50% for ACE inhibitors or ARBs, 68% for ß-blockers, 33% for MRAs, 68% for loop diuretics, 42% for amiodarone, 21% for phosphodiesterase inhibitors, 92% for warfarin, and 84% for antiplatelet agents. In general, age, preimplant INTERMACS profile, and prior medication use were associated with medication use at 3 months. CONCLUSIONS: Overall use of neurohormonal antagonists was low after LVAD implant, whereas use of loop diuretics and amiodarone remained high. Heart failure medication use is highly variable, but appears to generally increase after LVAD implantation. Low neurohormonal antagonist use may reflect practice uncertainty in the clinical utility of these medications post-LVAD.