Evaluation of comprehensive geriatric assessment in older patients undergoing pacemaker implantation.

BACKGROUND: This study evaluated the use of comprehensive geriatric assessment (CGA) in older patients undergoing pacemaker implantation. METHODS: In this prospective cohort, CGA was performed in 197 patients ≥75 years at pacemaker implantation and yearly thereafter. CGA embraced the following domains: cognition, mobility, nutrition, activities of daily living (ADLs), and falls (with or without loss of consciousness). Based on comorbidities, the Charlson comorbidity index (CCI) was calculated. For predictive analysis, logistic regression was used. RESULTS: During a mean follow-up duration of 2.4 years, the incidence rates of syncope decreased from 0.46 to 0.04 events per year (p < 0.001), and that of falls without loss of consciousness from 0.27 to 0.15 (p < 0.001) before vs. after implantation. Sixty-three patients (32.0%) died. Impaired mobility (OR 2.60, 95%CI 1.22-5.54, p = 0.013), malnutrition (OR 3.26, 95%CI 1.52-7.01, p = 0.002), and a higher CCI (OR per point increase 1.25, 95%CI 1.04-1.50, p = 0.019) at baseline were significant predictors of mortality. Among 169 patients who survived for more than 1 year and thus underwent follow-up CGA, CGA domains did not deteriorate during follow-up, except for ADLs. This decline in ADLs during follow-up was the strongest predictor of later nursing home admission (OR 9.29, 95%CI 1.82-47.49, p = 0.007). Higher baseline age (OR per year increase 1.10, 95%CI 1.02-1.20, p = 0.018) and a higher baseline CCI (OR per point increase 1.32, 95%CI 1.05-1.65, p = 0.017) were associated with a decline in ADLs during follow-up. CONCLUSIONS: CGA is useful to detect functional deficits, which are associated with mortality or nursing home admission after pacemaker implantation. The present study seems to support the use of CGA in older patients undergoing pacemaker implantation as functional deficits and falls are amenable to geriatric interventions.

Improvement of cardiac function with device-based diaphragmatic stimulation in chronic heart failure patients: the randomized, open-label, crossover Epiphrenic II Pilot Trial.

AIMS: Device-based pacing-induced diaphragmatic stimulation (PIDS) may have therapeutic potential for chronic heart failure (HF) patients. We studied the effects of PIDS on cardiac function and functional outcomes. METHODS AND RESULTS: In 24 chronic HF patients with CRT, an additional electrode was attached to the left diaphragm. Randomized into two groups, patients received the following PIDS modes for 3 weeks in a different sequence: (i) PIDS off (control group); (ii) PIDS 0 ms mode (PIDS simultaneously with ventricular CRT pulse); or (iii) PIDS optimized mode (PIDS with optimized delay to ventricular CRT pulse). For PIDS optimization, acoustic cardiography was used. Effects of each PIDS mode on dyspnoea, power during exercise testing, and LVEF were assessed. Dyspnoea improved with the PIDS 0 ms mode (P = 0.057) and the PIDS optimized mode (P = 0.034) as compared with the control group. Maximal power increased from median 100.5 W in the control group to 104.0 W in the PIDS 0 ms mode (P = 0.092) and 109.5 W in the PIDS optimized mode (P = 0.022). Median LVEF was 33.5% in the control group, 33.0% in the PIDS 0 ms mode, and 37.0% in the PIDS optimized mode (P = 0.763 and P = 0.009 as compared with the control group, respectively). PIDS was asymptomatic in all patients. CONCLUSION: PIDS improves dyspnoea, working capacity, and LVEF in chronic HF patients over a 3 week period in addition to CRT. This pilot study demonstrates proof of principle of an innovative technology which should be confirmed in a larger sample. TRIAL REGISTRATION: NCT00769678.

Sequential use of bare-metal stents and drug-coated balloons to treat coronary artery stenosis.

INTRODUCTION: Drug-coated balloons (DCBs) are increasingly used in percutaneous coronary intervention (PCI). The sequential use of DCB and bare-metal stent (BMS) represents a novel approach and results of pilot studies have been encouraging. The aim of this study was to assess long-term outcomes of patients who received treatment with DCB and BMS and additionally study whether the order (BMS or DCB first) affected outcomes. METHODS: This is a single-center, non-randomized, prospective study of patients who underwent PCI between July 2009 and July 2011. Two groups were defined: DCB followed by BMS (DCB→BMS) or BMS followed by DCB (BMS→DCB). Our primary outcome was target lesion revascularization (TLR) at 7 months. RESULTS: A total of 128 patients (173 lesions) with a mean age of 67 years were included. The BMS→DCB group consisted of 53 patients (78 lesions) and the DCB→BMS group consisted of 75 patients (95 lesions). The mean follow-up was 7.4 months. The TLR rate was 4/76 (5%) in the BMS→DCB group and 3/90 (3%) in the DCB→BMS group (P=.83). CONCLUSION: Our study demonstrates good results of sequential BMS and DCB use in an all-comers population. If confirmed by larger studies, this could be a valuable approach in patients with contraindications to drug-eluting stent implantation.

Good efficacy of drug-eluting balloons in a mixed population of patients with coronary artery disease.

INTRODUCTION: Drug-coated balloons (DCB) are being increasingly used in interventional cardiology and are established for the treatment of in-stent restenosis (ISR). It is unclear how effective they are in patients with de novo lesions. METHODS: A prospective registry of patients treated with the In.Pact DCB at our institution was conducted. Patients with ISR and those with planned surgery or contraindication to long-term use of double-antiplatelet therapy were included. OUTCOME MEASURES: 12-month rates of clinically driven target-lesion revascularization (TLR). The efficacy of DCB was compared between patients with ISR and de novo lesions and in those with reference vessel diameter (RVD) < and > 2.75 mm. RESULTS: A total of 139 patients (222 lesions) were followed up for 12 months. The mean age was 69 ± 10 years. Ninety-five patients (68%) had stable angina and 44 patients (32%) had acute coronary syndrome. Clinically driven TLR was performed in 6/126 lesions (4.8%) in the de novo group and in 5/92 lesions (5.4 %) in the ISR group (P=1.0). In the de novo group, TLR rate was 1/45 (2.2%) in patients with vessel diameter >2.75 mm and 5/81 (6.2%) in those with diameter <2.75 (P=.42). In the ISR group, TLR was 3/71 (4.2%) in patients with vessel diameter >2.75 mm and 2/21 (9.5%) in those with diameter <2.75 mm (P=.32). CONCLUSIONS: DCB are a valuable treatment option for patients with ISR offering good rates of TLR. Additionally, DCB can be an alternative to drug-eluting stents, if the use of long-term double antiplatelet medications is not desired.