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Beyond 3 Months: Unraveling the prolonged Impact of optimized medical therapy on LVEF and ICD implantation in HFrEF Patients
Session:
Sessão de Posters 39 - Insuficiência cardíaca: abordagem a longo prazo
Speaker:
Daniel Inácio Cazeiro
Congress:
CPC 2024
Topic:
D. Heart Failure
Theme:
10. Chronic Heart Failure
Subtheme:
10.6 Chronic Heart Failure - Clinical
Session Type:
Cartazes
FP Number:
---
Authors:
Daniel Inácio Cazeiro; Catarina Gregório; Diogo Ferreira; Catarina Simões de Oliveira; Ana Beatriz Garcia; Fátima Salazar; Nuno Lousada; Rafael Santos; Doroteia Silva; Fausto J. Pinto; Dulce Brito; João Agostinho
Abstract
<p><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000"><strong>Introduction: </strong></span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">Guidelines advise implanting a cardiac defibrillator (ICD) in symptomatic heart failure </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">patients with reduced ejection fraction (HFrEF) and left ventricle ejection fraction (LVEF) </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">≤35% after 3 months of optimized medical therapy (OMT). However, this recommendation </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">predates the standard use of sacubitril-valsartan and SGLT-2 inhibitors. Concomitantly, some </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">literature suggests that the HFrEF therapy impact in cardiac remodeling goes beyond 3 </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">months. This study aims to assess LVEF improvement in HFrEF patients from 3 months to 1 year after achieving OMT and how it could potentially impact ICD implantation.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000"><strong>Methods: </strong></span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">Single-center, observational retrospective study of HFrEF patients without cardiac </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">resynchronization device (CRT), followed at an outpatient clinic of a tertiary hospital. </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">The population was stratified in two groups based on LVEF after 3 months of OMT: ≤35% </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">vs. >35%. T-test compared mean LVEF at baseline, 3 months, and one-year and Kaplan-</span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">Meier survival analysis was used to identify prognostic impact.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000"><strong>Results: </strong></span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">From a total of 154 patients included, 24.4% were female, 46.7% were ischemic and 41.7% </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">had dilated cardiomyopathy, with a mean age of 64.3±14.2 years. Thirty-four patients had a </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">CRT implanted. In the remaining 120 patients, 67.5% experienced LVEF improvement to >35% at 3-month after OMT, demonstrating a significant enhancement from a baseline mean LVEF of 31.1% to 44.7% (p<0.001). However, this improvement suffers a plateau, with no further significant change observed at 1 year after OMT (p=NS). </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">Conversely, the remaining 32.5% of patients maintained a LVEF ≤35% at 3 months after </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">OMT (mean baseline LVEF of 27.3%). There was no statistically significant improvement in </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">this subgroup at the 3-month mark (mean LVEF of 29.4%). Importantly, this lack of </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">improvement persisted at 1 year, with the mean LVEF reaching 32.2% (p=NS). Only four </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">patients from this subgroup achieved a LVEF greater than 35% at 1 year after OMT, 3 of </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">whom had dilated cardiomyopathy, showcasing a mean LVEF at 3 months close to the 35% </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">threshold (34.1%). </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">Patients with LVEF ≤35% at 3 months had a statistically significant greater risk of the </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">composite outcome of all-cause death and HF-hospitalization at two-year follow-up (HR: 3.6, </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">95% CI: 1.2-12.1, p=0.025).</span></span></span></p> <p><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000"><strong>Conclusion: </strong></span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">In challenging the conventional 3-month timeframe for assessing LVEF in HFrEF patients </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">and deciding whether ICD implantation may be indicated, it was found that LVEF showed </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">significant improvement up to 3 months after OMT, but this improvement plateaus afterwards </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">up until 1 year. Consequently, decisions concerning device implantation should align with the </span></span></span><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">current guideline recommendation of the 3-month after OMT reassessment.</span></span></span></p>
Slides
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