A restrictive inflow pattern does not predict implantable cardioverter-defibrillator therapy in primary prevention
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Published on: February 28, 2012
Jennifer L Dorosz1, Keith D Aaronson, Eric D Good
1University of Michigan, Ann Arbor, Michigan, USA.
Insights
Echocardiography showing severe diastolic dysfunction, specifically a restrictive mitral inflow pattern, did not predict appropriate implantable cardioverter-defibrillator (ICD) therapy in primary prevention patients. This finding suggests current echocardiographic methods are insufficient for selecting high-risk individuals for ICDs.
Area of Science:
- Cardiology
- Medical Imaging
- Electrophysiology
Background:
- Current implantable cardioverter-defibrillator (ICD) guidelines are broad, increasing healthcare costs.
- Identifying specific patient subsets who benefit from ICDs is crucial for cost-effective care.
- Severe diastolic dysfunction predicts adverse events in secondary ICD prevention but its role in primary prevention is unstudied.
Purpose of the Study:
- To test if a restrictive mitral inflow pattern on echocardiography predicts appropriate ICD therapy risk.
- To evaluate echocardiographic parameters for improved patient selection for primary prevention ICDs.
Main Methods:
- Retrospective study of 145 primary prevention ICD patients with pre-implantation echocardiograms.
- Defined restrictive pattern as E/A ratio > 2 or deceleration time < 150 ms.
- Analyzed time to first appropriate ICD therapy over average 680-day follow-up.
Main Results:
- A restrictive pattern was present in 40.7% of patients.
- Appropriate ICD therapy occurred in 11.5% with restrictive pattern vs. 18.4% with nonrestrictive pattern (P=NS).
- Cox regression showed restrictive pattern did not predict time to first ICD therapy.
Conclusions:
- Echocardiographic findings of severe diastolic dysfunction do not help target ICD use in primary prevention patients.
- Restrictive mitral inflow pattern is not a reliable predictor of appropriate ICD therapy in this population.
- Further research is needed to identify better biomarkers for primary prevention ICD selection.
Background:
Current guidelines for the use of implantable cardioverter-defibrillators (ICDs) are broad and significantly increase the cost of caring for patients with heart failure. In an effort to identify the specific subset of patients who benefit from this therapy, the predictive value of numerous echocardiographic parameters have been studied. Severe diastolic dysfunction has been shown to predict adverse events in a group of patients who received an ICD for secondary prevention, but has not been tested in those who receive ICDs for primary prevention.
Hypothesis:
We tested the hypothesis that a restrictive mitral inflow pattern on echocardiography will predict the risk of appropriate therapy in this patient population.
Methods:
This retrospective study identified 145 consecutive patients who met primary prevention criteria for ICD implantation and had an echo performed no more than 1 year prior to receiving the ICD. A restrictive pattern was defined as a mitral inflow E/A > 2 or a deceleration time < 150 ms.
Results:
A restrictive pattern was present in 69 patients (40.7% of the group). Appropriate ICD therapy occurred in 8 (11.5%) subjects with a restrictive pattern and 14 (18.4%) with a nonrestrictive pattern over 680 days of average follow-up (P = not significant). Cox regression analysis showed the presence of a restrictive pattern was not helpful in predicting time to first ICD therapy.
Conclusions:
In a population of patients who received ICDs for primary prevention, echocardiographic findings of severe diastolic dysfunction were not helpful in targeting the use of ICDs to those at highest risk.
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