Heart Rhythm Congress 2016 Chronotropic incompetence in heart failure patients
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1 Heart Rhythm Congress 2016 Chronotropic incompetence in heart failure patients Carel C. de Cock
2 Case report : an Amsterdam taxi driver with recurrent syncope MF Koster
3 History 1994: recurrent syncope with sudden complete LOC MF Koster
4 MF Koster
5 DDD/rate drop response MF Koster Eur Heart J 2013;34:
6 1995 remains having pre-syncopal attacks 2003: recurrent near syncope with restriction to drive 2003: device ERI change to Philos DR (accelerometer) 2003: restriction to drive MF Koster
7 2004: device change to Cylos DR (CLS) 2005: no syncope resuming work as a taxi driver MF Koster
8 2004: acute anterior myocardial infarction: CABG (St. Elsewhere) one months later: syncope (CLS function off??!!???) : NYHA II-III poor LV function (LVEF = 0.28) ICD MF Koster
9 MF Koster
10 Closed Loop Stimulation & ICD? MF Koster
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14 chamber ICD (left side) and PG (right side) VF zone 230 bpm, monitor zone 160 bpm ICD off during threshold measurements No professional taxi driver Still non-professional driving MF Koster
15 2009 NHYA III optimal medical therapy QRS duration ± 200 msec MF Koster
16 MF Koster
17 Upgrade to CRT-D. CLS-pacemaker remains in situ. Suboptimal LV position. RV output mandatory for CLS function. Lower rate CRT-D 30 bpm. Triggered mode. MF Koster
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19 2015 implantation Iperia DR. Explantation pulse generator NYHA I-II still recreational driving MF Koster
20 Chronotropic incompetence (CI) Is the inability of the heart to increse its rate commensurate with increased activity or demand Brubaker et al Circulation 2011;123:
21 Maximal aerobic exercise (VO2 peak increase) - 2,2 fold by inrease inheart rate - 1,5 fold by increase inartrerio-venous oxygen difference - 0,3 fold by increase in stroke volume Total approximal 4 fold increase in VO2 peak Brubaker et al Circulation 2011;123:
22 Prevalence of CI in heart failure patients CI in 25% - 70% of patients (depending on definition and patients characteristics e.g. age, disease severity and medication) Brubaker et al Circulation 2011;123:
23 Brubaker et al JACC Heart Failure 2013;3:267-69
24 Definition(s) of CI Prediction of maximal HR; 220 bpm age However: studies in middle aged men with high incidence of CAD high incidence of ß blokker use Brubaker et al Circulation 2011;123:
25 Definition(s) of CI Prediction of maximal HR; 220 bpm age Consequentely: high intersubject variability standard deviation of ± 11 bpm high standard deviation in CAD (± 40 bpm) Brubaker et al Circulation 2011;123:
26 Definition(s) of CI Tanaka et al studied older aged men ánd women no CAD no medication Tanaka J Am Coll Cardiol 2001;37:153-6
27 Retrospective analysis Prospective analysis Tanaka J Am Coll Cardiol 2001;37:153-6
28 HRMAX IS 208 0,7 X AGE (SOLID LINE) Tanaka J Am Coll Cardiol 2001;37:153-6
29 Definition(s) of CI Brawner et al studied patients with CAD with or without ß blokker therapy age limit 80 years Brawner et al Am Heart J 2004;148:910-14
30 Brawner et al Am Heart J 2004;148:910-14
31 n = 5437 Gulati et al Circulation 2010;122:130-7
32 Borlaug et al Circulation 2006;114:
33 1538 patients referred for pacemaker implantation CI: heart rate reserve < 80% of metabolic reserve Randomized to two types of RR systems (accelerometer XL and XL ánd minute ventilation) Coman et al Pacing Clin Electrophysiol 2008;11:
34 Coman et al Pacing Clin Electrophysiol 2008;11:
35 Coman et al Pacing Clin Electrophysiol 2008;11:
36 Coman et al Pacing Clin Electrophysiol 2008;11:
37 Coman et al Pacing Clin Electrophysiol 2008;11:
38 20 patients with heart failure referred for CRT All had CI (< 85% APHR ánd < 80% HRR) Randomized to DDD or DDDR Tse et al J Am Coll Cardiol 2005;46:
39 DDDR DDD Tse et al J Am Coll Cardiol 2005;46:
40 DDDR DDD Tse et al J Am Coll Cardiol 2005;46:
41 Conclusion: 1. CI is present in at least 1/3 of patients with heart failure 2. CI is associated with impaired exercise tolerance, quality of life and prognosis
42 Conclusion: 3. RR pacing should be considered for the bad guys with respect to CI 4. RR pacing in these patients improves dynamic exercise and quality of life 5. All sensors are not the same
43 QUESTION 1 In a normal individual Vo2max can increase during exercise 1. Two fold 2. Four fold 3. Six fold 4. Twelve fold 5. Three fold
44 QUESTION 2 Compared to patients with heart failure and reduced ejection fraction the prevalence of CI in patients with hert failure and preserved ejection fraction is: 1. About the same 2. More prevalent 3. Less prevalent 4. Has not been studied so far 5. Is dependent on the functional (NYHA) class
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51 Tse et al J Am Coll Cardiol 2005;46:
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