Portal de Periódicos da CAPES

Comparison of Detection of Arrhythmias in Patients With Chronic Heart Failure Secondary to Non-Ischemic Versus Ischemic Cardiomyopathy by 1 Versus 7-Day Holter Monitoring

2010; Elsevier BV; Volume: 106; Issue: 5 Linguagem: Inglês

10.1016/j.amjcard.2010.04.027

1879-1913

Francisco J. Pastor‐Pérez, Sergio Manzano‐Fernández, Rebeca Goya–Esteban, Domingo A. Pascual‐Figal, Óscar Barquero‐Pérez, José Luis Rojo‐Álvarez, Maria Dolores Martinez Martinez-Espejo, Mariano Valdés Chávarri, Arcadi Garcı́a-Alberola,

Cardiac electrophysiology and arrhythmias

The purpose of this study was to compare the diagnostic sensitivity of 1-day Holter monitoring versus 7-day Holter monitoring (7DH) to detect atrial and ventricular arrhythmias in a population of stable patients with chronic heart failure and left ventricular dysfunction. Sixty-three consecutive stable patients with chronic heart failure with left ventricular ejection fractions ≤50% were included. Blood samples were obtained, the Minnesota Living With Heart Failure Questionnaire was administered, and echocardiography, 6-minute walk tests, and 7DH were performed at enrollment. The mean ejection fraction was 35.8 ± 9.8%, and the mean age was 55.5 ± 13.9 years. Seven-day Holter monitoring did not significantly increase the detection of nonsustained atrial tachycardia or atrial fibrillation. In contrast, the incidence of nonsustained ventricular tachycardia increased in nonischemic patients from 35.1% on day 1 to 54.1% on day 7 (p = 0.01). In ischemic patients, the sensitivity increased from 11.5% to 46.2% (p = 0.004). Two patients without nonsustained ventricular tachycardia on day 1 had episodes of 13 and 16 beats on days 3 and 6 of monitoring. In patients with left ventricular ejection fractions >35% and N-terminal–pro-brain natriuretic peptide levels 35% and N-terminal–pro-brain natriuretic peptide levels <1,000 pg/ml, no episodes of nonsustained ventricular tachycardia were detected on day 1 in nonischemic and ischemic patients, but 7DH detected 3 new patients in each group. In conclusion, 7DH clearly improves the detection and allows a better characterization of ventricular arrhythmic episodes but seems to be less useful for supraventricular events. The purpose of this study was to compare the diagnostic sensitivity of 1-day Holter monitoring (1DH) versus 7-day Holter monitoring (7DH) to detect atrial and ventricular arrhythmias in a population of stable patients with chronic heart failure (CHF) and systolic dysfunction in ischemic versus nonischemic cardiomyopathy. The study was carried out following the principles of the Declaration of Helsinki. It was approved by the local ethics committee, and written informed consent was obtained from each patient. Patients were recruited during scheduled outpatient visits to cardiology heart failure outpatient clinic at our center. From September 2007 to February 2008, 63 consecutive patients with established diagnoses of stable CHF1Dickstein K. Cohen-Solal A. Filippatos G. Funck-Brentano C. Hellemans I. Kristensen S.D. McGregor K. Sechtem U. Silber S. Tendera M. Widimsky P. Zamorano J.L. Tendera M. Auricchio A. Bax J. Bohm M. Corra U. della B.P. Elliott P.M. Follath F. Gheorghiade M. Hasin Y. Hernborg A. Jaarsma T. Komajda M. Kornowski R. Piepoli M. Prendergast B. Tavazzi L. Vachiery J.L. Verheugt F.W. Zamorano J.L. Zannad F. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM).Eur J Heart Fail. 2008; 10: 933-989Crossref PubMed Scopus (1662) Google Scholar met eligibility criteria and gave written informed consent to participate. All patients had ejection fractions (EFs) ≤50% and were clinically stable, without need for hospital admission or intravenous vasoactive agents. Exclusion criteria included age <18 years and serious co-morbid conditions with associated life expectancy <1 year. Hospitalization for myocardial infarction, unstable angina, or heart failure within the past 3 months and any cardiac revascularization procedure 140 mm Hg or diastolic blood pressure >90 mm Hg or the use of antihypertensive drugs), hypercholesterolemia (low-density lipoprotein cholesterol >160 mg/dl, lipid-lowering medication use, or dietary control) and diabetes mellitus (all patients with fasting plasma glucose >126 mg/dl or receiving antidiabetic therapy). All subjects underwent 12-lead electrocardiography, chest x-rays, and 6-minute walk tests according to standardized procedures.2ATS statement: guidelines for the six-minute walk test.Am J Respir Crit Care Med. 2002; 166: 111-117Crossref PubMed Scopus (8440) Google Scholar The Minnesota Living With Heart Failure Questionnaire3Rector T.S. Cohn J.N. Pimobendan Multicenter Research GroupAssessment of patient outcome with the Minnesota Living With Heart Failure Questionnaire: reliability and validity during a randomized, double-blind, placebo-controlled trial of pimobendan.Am Heart J. 1992; 124: 1017-1025Abstract Full Text PDF PubMed Scopus (798) Google Scholar was administered and 7DH performed at enrollment. Echocardiography was also performed (Sonos 7500; Philips Medical Systems, Andover, Massachusetts), and standardized projections and measurements were made for chamber quantification. The left ventricular EF was calculated using Simpson's biplane method.4Lang R.M. Bierig M. Devereux R.B. Flachskampf F.A. Foster E. Pellikka P.A. Picard M.H. Roman M.J. Seward J. Shanewise J.S. Solomon S.D. Spencer K.T. Sutton M.S. Stewart W.J. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology.J Am Soc Echocardiogr. 2005; 18: 1440-1463Abstract Full Text Full Text PDF PubMed Scopus (9645) Google Scholar All patients received standard management as recommended by contemporary guidelines.1Dickstein K. Cohen-Solal A. Filippatos G. Funck-Brentano C. Hellemans I. Kristensen S.D. McGregor K. Sechtem U. Silber S. Tendera M. Widimsky P. Zamorano J.L. Tendera M. Auricchio A. Bax J. Bohm M. Corra U. della B.P. Elliott P.M. Follath F. Gheorghiade M. Hasin Y. Hernborg A. Jaarsma T. Komajda M. Kornowski R. Piepoli M. Prendergast B. Tavazzi L. Vachiery J.L. Verheugt F.W. Zamorano J.L. Zannad F. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM).Eur J Heart Fail. 2008; 10: 933-989Crossref PubMed Scopus (1662) Google Scholar Ambulatory 7-day, 3-channel electrocardiographic recordings with x-y-z orthogonal leads were obtained using a commercially available device (Lifecard CF; Del Mar Reynolds, Issaquah, Washington). The raw electrocardiographic data, stored in a proprietary format, were exported to the International Society for Holter and Noninvasive Electrocardiology standard5Badilini F. The ISHNE Holter standard output file format.Ann Noninvas Electrocardiol. 1998; 3: 263-266Crossref Scopus (34) Google Scholar using custom-made software in accordance with the specifications provided by the manufacturer.6Pathfinder 710 family data formats customer definition. Issue 5. Reynolds Medical, Edinburgh, United KingdomMay 2001Google Scholar To improve the accuracy of the QRS template classification and preliminary Holter analysis, data were split into 7 pieces and processed using standard Holter analysis software (ELA Medical, Sorin Group, Paris, France). A visual check of the QRS complex classification and every arrhythmic event was performed by a trained cardiologist, and manual corrections were made as needed. Nonsustained atrial tachycardia (NSAT) was defined as ≥3 consecutive premature normal beats at >120 beats/min and nonsustained ventricular tachycardia (NSVT) as ≥3 consecutive ventricular premature beats at >120 beats/min. Continuous variables were tested for a normal distribution using the Kolmogorov-Smirnov test. Normally distributed data are presented as mean ± SD and non-normally distributed data as medians with interquartile ranges. Categorical variables are expressed as percentages. Student's t test (impaired data) or the Mann-Whitney U test if appropriate was used to compare continuous variables, and the chi-square test was used for categorical variables. McNemar's test was used to compare the percentage of events (supraventricular or ventricular) between day 1 and the end of the monitoring period (days 1 to 7). We also examined the presence of NSVT, comparing day 1 to days 1 to 7 according to the EF and N-terminal–pro-brain natriuretic peptide (NT-proBNP) levels. We used a cut-off point of 35% for the left ventricular EF and 1,000 pg/ml for NT-proBNP because these values have been associated with increased morbidity and mortality in stable patients with CHF.7Masson S. Latini R. Amino-terminal pro-B-type natriuretic peptides and prognosis in chronic heart failure.Am J Cardiol. 2008; 101: 56-60Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Data were processed using SPSS version 13 (SPSS, Inc., Chicago, Illinois). A p value 10 premature ventricular beats/hour increased with the time of monitoring from 50.8% on day 1 to 73.0% on days 1 to 7 (p <0.001). Ischemic and nonischemic patients showed significant increases in sensitivity (from 42.3% to 73.1%, p 12 beats. The sensitivity to detect NSVT improved during the monitoring period, from 25.4% on day 1 to 50.8% on days 1 to 7 (p 35% and NT-proBNP 355/19 (26%)8/19 (42%)0.250/13 (0%)5/13 (38%)0.06NT-proBNP (pg/ml) 35% and NT-proBNP 35% and NT-proBNP <1,000 pg/ml, no episodes of NSVT were detected on day 1, but up to 30% presented with arrhythmias at the end of the monitoring period. The available data indicate that the use of implantable cardioverter-defibrillators provides a significant reduction in mortality in high-risk patients with EFs <30% to 35% with ischemic and nonischemic cardiomyopathy, as part of primary prevention strategy.24Bardy G.H. Lee K.L. Mark D.B. Poole J.E. Packer D.L. Boineau R. Domanski M. Troutman C. Anderson J. Johnson G. McNulty S.E. Clapp-Channing N. Davidson-Ray L.D. Fraulo E.S. Fishbein D.P. Luceri R.M. Ip J.H. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure.N Engl J Med. 2005; 352: 225-237Crossref PubMed Scopus (5497) Google Scholar, 25Moss A.J. Zareba W. Hall W.J. Klein H. Wilber D.J. Cannom D.S. Daubert J.P. Higgins S.L. Brown M.W. Andrews M.L. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction.N Engl J Med. 2002; 346: 877-883Crossref PubMed Scopus (5812) Google Scholar However the decisions in some patients could be difficult, and other parameters should be considered. The presence of NSVT was required in other primary prevention studies in addition to the presence of a depressed EF.26Buxton A.E. Lee K.L. Fisher J.D. Josephson M.E. Prystowsky E.N. Hafley G. Multicenter Unsustained Tachycardia Trial InvestigatorsA randomized study of the prevention of sudden death in patients with coronary artery disease.N Engl J Med. 1999; 341: 1882-1890Crossref PubMed Scopus (2244) Google Scholar, 27Moss A.J. Hall W.J. Cannom D.S. Daubert J.P. Higgins S.L. Klein H. Levine J.H. Saksena S. Waldo A.L. Wilber D. Brown M.W. Heo M. Multicenter Automatic Defibrillator Implantation Trial InvestigatorsImproved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia.N Engl J Med. 1996; 335: 1933-1940Crossref PubMed Scopus (3632) Google Scholar This risk marker could potentially alter management in difficult situations. The limitations of this study include the possibility of misclassification of supraventricular QRS with aberrant conduction as ventricular beats. This is a limitation inherent to all electrocardiographic recordings, but we tried to minimize its impact through the manual and careful checking of the automatic classification performed by the analysis software. A second limitation is that the number of patients was relatively small, which precludes obtaining more information across other potentially interesting subgroups (i.e., functional status). Previous risk stratification studies relied on limited 24- to 48-hour Holter monitoring, and we have demonstrated that the sensitivity to detect NSVT considerably increases with 7DH. Whether this finding will translate into a better tool for risk stratification purposes remains to be established.