Ascertaining cause of mortality among middle-aged and older persons using computer-coded and expert review verbal autopsies in the China Health and Retirement Longitudinal Study.

BACKGROUND: Verbal autopsy is designed to ascertain causes of death that are not registered or certified. Verbal autopsy has been validated in multiple settings but has not been as widely evaluated for older populations as for younger age groups. OBJECTIVE: This study aims to provide empirical evidence of the value of verbal autopsy interviews in the context of population-based surveys of older adults by comparing the cause-of-death assignments derived from two methods of interpreting verbal autopsy data. METHODS: Data used in this study come from the China Health and Retirement Longitudinal Study, a nationally representative longitudinal survey of older Chinese. We compared 407 causes of death determined using InterVA, which is a computer-coded method, and causes of death as assigned by experts; then evaluated factors that affect the results of the two approaches. RESULTS: Among the 407 deaths, neoplasms, cardiac disease, and stroke are the leading causes of death according to both approaches. The consistency of the two approaches is about 45% at the individual level. The primary reason for the mismatch is that no cause of death could be assigned for more than 25% of the sample based on expert review. A higher likelihood of mismatch is associated with advanced age and a long period between death and verbal autopsy interview. CONCLUSION: Both approaches identify the same leading causes of death at the aggregate level, but consistency is relatively low at the individual level. InterVA works well when causes of death are characterized by distinctive signs and symptoms. Grouping the various causes of death with shared etiology or common risk factors may help improve the quality of the ascertainment of causes of death. Open-ended narratives are helpful because they provide information about the circumstances surrounding the death that are not available in the structured verbal autopsy interviews.

Impact of the introduction of a standardised ICD programming protocol: real-world data from a single centre.

PURPOSE: Randomised trials have shown that empiric ICD programming, using long detection times and high detection zones, reduces device therapy in ICD recipients. However, there is less data on its effectiveness in a "real-world" setting, especially secondary prevention patients. Our aim was to evaluate the introduction of a standardised programming protocol in a real-world setting of unselected ICD recipients. METHODS: We analysed 270 consecutive ICD recipients implanted in a single centre-135 implanted prior to protocol implementation (physician-led group) and 135 after (standardised group). The protocol included long arrhythmia detection times (30/40 or equivalent) and high rate detection zones (primary prevention lower treatment zone 200 bpm). Programming in the physician-led group was at the discretion of the implanter. The primary endpoint was time-to-any therapy (ATP or shocks). Secondary endpoints were time-to-inappropriate therapy and time-to-appropriate therapy. The safety endpoints were syncopal episodes, hospital admissions and death. RESULTS: At 12 months follow-up, 47 patients had received any ICD therapy (physician-led group, n = 31 vs. standardised group, n = 16). There was a 47 % risk reduction in any device therapy (p = 0.04) and an 86 % risk reduction in inappropriate therapy (p = 0.009) in the standardised compared to the physician-led group. There was a non-significant 30 % risk reduction in appropriate therapy (p = 0.32). Results were consistent across primary and secondary prevention patients. There were no significant differences in the rates of syncope, hospitalisation, and death. CONCLUSIONS: In unselected patients in a real-world setting, introduction of a standardised programming protocol, using long detection times and high detection zones, significantly reduces the burden of ICD therapy without an increase in adverse outcomes.

Atrioventricular and ventricular-to-ventricular programming in patients with cardiac resynchronization therapy: results from ALTITUDE.

PURPOSE: Cardiac resynchronization therapy (CRT) improves outcomes in patients with heart failure, yet response rates are variable. We sought to determine whether physician-specified CRT programming was associated with improved outcomes. METHODS: Using data from the ALTITUDE remote follow-up cohort, we examined sensed atrioventricular (AV) and ventricular-to-ventricular (VV) programming and their associated outcomes in patients with de novo CRT from 2009-2010. Outcomes included arrhythmia burden, left ventricular (LV) pacing, and all-cause mortality at 4 years. RESULTS: We identified 5709 patients with de novo CRT devices; at the time of implant, 34% (n = 1959) had entirely nominal settings programmed, 40% (n = 2294) had only AV timing adjusted, 11% (n = 604) had only VV timing adjusted, and 15% (n = 852) had both AV and VV adjusted from nominal programming. Suboptimal LV pacing (<95%) during follow-up was similar across groups; however, the proportion with atrial fibrillation (AF) burden >5% was lowest in the AV-only adjusted group (17.9%) and highest in the nominal (27.7%) and VV-only adjusted (28.3%) groups. Adjusted all-cause mortality was significantly higher among patients with non-nominal AV delay >120 vs. <120 ms (adjusted heart rate (HR) 1.28, p = 0.008) but similar when using the 180-ms cutoff (adjusted HR 1.13 for >180 vs. ≤180 ms, p = 0.4). CONCLUSIONS: Nominal settings for de novo CRT implants are frequently altered, most commonly the AV delay. There is wide variability in reprogramming. Patients with nominal or AV-only adjustments appear to have favorable pacing and arrhythmia outcomes. Sensed AV delays less than 120 ms are associated with improved survival.