View
32
Download
0
Category
Preview:
DESCRIPTION
Mechanical Dyssynchrony Defined by Phase Analysis from GSPECT:. Does It Predict Mortality?. Paul L. Hess, MD; Linda K. Shaw, MS; Robert Clare, MS; Mary L. Shepherd, CNMT; Michael MacKenzie, MS; Robert Pagnanelli, BSRT, CNMT, NCT; Mona Fiuzat, PharmD; Jonathan P. Piccini, MD, MHS; - PowerPoint PPT Presentation
Citation preview
All Rights Reserved, Duke Medicine 2008
Mechanical Dyssynchrony Defined by Phase Analysis from GSPECT:
Does It Predict Mortality?
Paul L. Hess, MD; Linda K. Shaw, MS; Robert Clare, MS; Mary L. Shepherd, CNMT; Michael MacKenzie, MS; Robert Pagnanelli, BSRT, CNMT, NCT;
Mona Fiuzat, PharmD; Jonathan P. Piccini, MD, MHS; Sana M. Al-Khatib, MD, MHS; Christopher M. O’Connor, MD;
and Salvador Borges-Neto, MD
All Rights Reserved, Duke Medicine 2008
Cardiac Resynchronization Therapy (CRT)
• Selection criteria– Reduced ejection fraction (< 35%)– New York Heart Association Class I-IV– QRS duration > 120 ms
• One third of recipients do not benefit.
All Rights Reserved, Duke Medicine 2008
Phase Analysis by GSPECT MPI
• Standard deviation
• Bandwidth
Dyssynchrony measures
Chen J et al. Assessment of Left Ventricular Mechanical Dyssynchrony by Phase Analysis of ECG-gated SPECT Myocardial Perfusion Imaging. J Nucl Cardiol 2008; 15: 127-36.
All Rights Reserved, Duke Medicine 2008
Prevalence of Dyssynchrony by GSPECT MPI
Samad Z et al. Prevalence and Predictors of Mechanical Dyssynchrony as Defined by Phase Analysis in Patients with Left Ventricular Dysfunction Undergoing Gated SPECT Myocardial Perfusion Imaging. J Nucl Cardiol 2011; 18: 24-30.
39%
71%
31%
56%52%
All Rights Reserved, Duke Medicine 2008
Objective
To determine whether mechanical dyssynchrony detected by phase analysis of GSPECT MPI can identify patients with coronary disease at increased risk of all-cause mortality and/or cardiovascular mortality.
All Rights Reserved, Duke Medicine 2008
Data Source
Duke Databank for Cardiovascular Disease
Study Population (n=1,434)
Stress testing
Angiographically significant coronary disease
GSPECT MPI between July 2003 and August 2009
Exercise treadmill testing was preferred
All Rights Reserved, Duke Medicine 2008
Emory Toolbox Software (Atlanta, GA) programs were used to assess mechanical dyssynchrony
Dyssynchrony Measurement
Statistical Analysis
Cox proportional hazards modeling
Kaplan-Meier survival analysis
• Unadjusted• Adjusted for standard clinical covariates• Adjusted for above and LV function
All Rights Reserved, Duke Medicine 2008
Age, median (IQR) 64 (55, 72)
Male sex 69.6
Race
White 73.8
Black 22.2
Other 4.0
Congestive heart failure 24.3
Diabetes mellitus 36.2
Hypertension 76.1
Hyperlipidemia 69.7
COPD 6.6
Renal disease 5.4
Baseline Characteristics (n=1,434)*
*Data are presented as % unless otherwise specified.
All Rights Reserved, Duke Medicine 2008
Outcomes Associated with Bandwidth*
*Per 10° increment
†Adjusted for age, sex, race, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, peripheral vascular disease, cerebrovascular disease, prior myocardial infarction, congestive heart failure, renal insufficiency, and tobacco use
‡Adjusted for above and left ventricular ejection fraction
All-cause Mortality P Cardiovascular Mortality P
Unadjusted 1.06 (1.05, 1.08) <0.001 1.08 (1.06-1.10) <0.001
Clinical Model† 1.06 (1.04, 1.07) <0.001 1.07 (1.05-1.09) <0.001
Clinical Model + EF‡ 1.02 (1.00-1.04) 0.120 1.02 (1.00-1.05) 0.093
All Rights Reserved, Duke Medicine 2008
Outcomes Associated with Phase SD*
*Per 10° increment
†Adjusted for age, sex, race, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, peripheral vascular disease, cerebrovascular disease, prior myocardial infarction, congestive heart failure, renal insufficiency, and tobacco use
‡Adjusted for above and left ventricular ejection fraction
All-cause Mortality P Cardiovascular Mortality P
Unadjusted 1.21 (1.16, 1.27) <0.001 1.30 (1.23-1.38) <0.001
Clinical Model† 1.19 (1.14, 1.25) <0.001 1.23 (1.16-1.31) <0.001
Clinical Model + EF‡ 1.06 (0.99-1.13) 0.101 1.06 (0.98-1.16) 0.158
All Rights Reserved, Duke Medicine 2008
Outcomes Associated with Bandwidth By LVEF*
Outcome† Left Ventricular Function HR (95% CI) Interaction P
All-cause mortality EF > 35% 1.06 (1.04-1.07) 0.002
EF < 35% 0.97 (0.93-1.02)
Cardiovascular Mortality EF > 35% 1.07 (1.05-1.09) 0.002
EF < 35% 0.99 (0.93-1.05)
*Per 10° increment
†Adjusted for age, sex, race, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, peripheral vascular disease, cerebrovascular disease, prior myocardial infarction, congestive heart failure, renal insufficiency, tobacco use, and left ventricular ejection fraction.
All Rights Reserved, Duke Medicine 2008
All-Cause Death Over Time Stratified byLeft Ventricular Function and Bandwidth
Pro
po
rtio
n d
ead
Years
P=0.604
P<0.001
EF < 35%, BW > 100
EF < 35%, BW < 100
EF > 35%, BW > 100
EF > 35%, BW < 100
All Rights Reserved, Duke Medicine 2008
Cardiovascular Death Over Time Stratified byLeft Ventricular Function and Bandwidth
Pro
po
rtio
n d
ead
Years
EF < 35%, BW > 100
EF < 35%, BW < 100
EF > 35%, BW > 100
EF > 35%, BW < 100 P=0.783
P<0.001
All Rights Reserved, Duke Medicine 2008
Implication
Patients with LVEF > 35% who do not meet current criteria for CRT may nonetheless benefit from device placement.
Principal Finding
Mechanical dyssynchrony detected by GSPECT MPI is an early marker of all-cause and cardiovascular mortality among patients with LVEF >35%.
All Rights Reserved, Duke Medicine 2008
Limitations
Limited number of patients with reduced EF
Retrospective, observational study design
Sampling bias
Diagnostic bias
Presence of LBBB unknown
All Rights Reserved, Duke Medicine 2008
Conclusions
Mechanical dyssynchrony detected by phase analysis of GSPECT MPI can identify patients with coronary disease at increased risk of all-cause mortality and/or cardiovascular mortality after adjustment for standard clinical covariates exclusive of left ventricular ejection fraction.
Phase bandwidth is associated with adverse outcomes among patients with LVEF > 35%.
Recommended