Routine Follow-Up of CRT Patients (ECG, Device Stored

Information & Regular F/U SOP)

林口長庚醫院 張伯丞

Frequency of Device Follow Up

2012 Heart Rhythm Guideline

Using the PBL-STOP Method

“P” – Presenting Rhythm,Rate and

Percent Pacing

“B” – Battery Status

Indicators of Battery Life

“L” – Lead Status

“S” – Sensing

“T” – Thresholds

“O” – Observations

Cardiac Compass® provides 14 months of trended data recorded by the device, such as:

• Frequency of arrhythmias

• Level of activity• OptiVol® fluid index

Compare trends to patient reported symptoms.

®

Monitoring Fluid Status

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Impedance

Pulmonary Congestion:

As fluid accumulates in the thoracic space, intrathoracic impedance decreases

Fluid

New Trend to Assess Lung Fluid Status

Assess Lung Fluid Status with Heart Failure Management Report

OptiVol fluid index tracks the accumulation of the difference between the Daily impedance and Reference impedance

Physician-set threshold for indicating fluid build-up of clinical significance

Reference impedance slowly adapts to daily impedance

Daily impedance is the average of multiple measurements taken each day

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OptiVol fluid index

Daily impedance

Diagnostic Trends:OptiVol®

Monitoring Atrial Fibrillation

Is Atrial Fibrillation Present?

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Chronic, stable AT/AF episodes?– Verify medication adherence (especially beta-blockers, antiarrhythmics)– May need AV nodal ablation if unable to tolerate or control AF

New onset of AT/AF or increased frequency?

– Evaluate patient ASAP, obtain 12 lead EKG to confirm rhythm– Assess for evidence of decompensation; Discuss medication adherence or changes – Obtain labs to evaluate for electrolyte abnormalities, thyroid disorders– Coordinate communication between providers managing heart failure and managing device

Practice: AT/AF

Is AF present in this patient?

ConsiderationsIs this a new finding?

Does the onset of worsening symptoms correlate with this occurrence of AF?

What next steps do I need to consider?

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Monitoring Heart Rate Variability

What Is My Patient’s Level of Heart Rate Variability (HRV)?

HRV is a physiologic marker of autonomic dysfunction in heart failure patients as characterized by sympathetic overdrive paired with attenuation of the parasympathetic nervous system1

Lower levels of HRV have been associated with increased all-cause mortality risk2

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1 Goldsmith R, Bigger T, Bloomfield D, et al. Long-term Carvedilol therapy increases parasympathetic nervous system activity in chronic congestive heart failure. Am J Cardiol. 1997;80:1101-1104.

2 Adamson P, Smith A, Abraham W, et al. Continuous autonomic assessment in patient with symptomatic heart failure. Circulation 2004;110:2389-2394.

What is My Patient’s Level of Heart Rate Variability?

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Patient Management• If HRV remains stable, no intervention required• If HRV has declined recently, evaluate patient ASAP• Correlate with symptoms, clinical examination, and other trend

data to identify possible causes, e.g. decompensation, arrhythmias• BNP level may be useful in diagnosing decompensation

Monitoring Day and Night Heart Rates

Is the Resting Heart Rate Increasing?

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Patient Management

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• With worsening of heart failure, HR increases during the day and night.1

This is indicative of increased sympathetic nervous system activity

– Patients with increased average heart rates need to be seen more frequently until the heart rates return to baseline/normal Assess for signs/symptoms of decompensation

– Verify adherence to low sodium diet and medication regimen– BNP levels may be useful in diagnosing decompensation

• Correlate with heart rate variability and activity for more insight into overall status

1. Casolo GC, et. al. European Heart Journal 1995;16(3):360-7.

Monitoring Patient Activity

How Active Is My Patient?

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Patient Management• Goal: 30 minutes 5x/week

• Patient physically active -> Encourage continued or increased activity

• Activity levels decreased -> Correlate with symptoms, clinical exam, and other trend data to identify possible cause, e.g. decompensation, arrhythmias

• Patient remains inactive and is clinically stable -> encourage increased activity

• Refer to cardiac rehab if appropriate

• Share activity report with patient as a teaching tool • Engage family assistance in emphasizing importance of increased activity

Monitoring % CRT Pacing

How Much Pacing is My Patient Receiving?

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Patient Management• If ventricular pacing is not > 90% for CRT patients, schedule office visit

ASAP to evaluate possible cause, e.g. atrial fibrillation, device issue, device not optimized

– Device interrogation, reprogramming, Echo with AV optimization, possible diagnostic testing: 12 lead EKG, Chest x-ray?

• Coordinate communication between providers managing heart failure and

the device implanter

Ideal case: ~100% V-paced Low A-paced

Summary

Does the Trend Information Fit with Signs of Worsening Heart Failure?

Resting Night Heart Rate

Heart Rate Variability

Patient Activity

OptiVol Fluid Index Crosses Physician-Set Threshold

V Pacing < 90%

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Daily Impedance

Atrial Fibrillation

“P” – Programming and Print (or PDF)

CRT EKG

CRT EKG

CRT EKG

EKG CRT

CXR

Dyssynchrony: SPWMD

Post CRT: SPWMD

Thank you for your attention!!感謝聆聽 !!Gracias por su atención!!Grazie per l'attenzione!!

Merci pour votre attention!!ご清聴ありがとうございました !!

Vielen Dank für Ihre Aufmerksamkeit!!Σας ευχαριστώ για την προσοχή σας!!ขอบคณุสำหรบัควมสนใจของคณุ!!

Tibi gratias ago pro attentio!!당신의주의를 당신을 감사하십시오 !!

Спасибо за внимание!!!!תודה על תשומת הלב שלך