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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
42
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
43
OptiVol fluid index
Daily impedance
Diagnostic Trends:OptiVol®
Monitoring Atrial Fibrillation
Is Atrial Fibrillation Present?
46
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?
47
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
50
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?
51
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?
53
Patient Management
53
• 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?
55
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?
58
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%
60
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