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Overcoming challenges in adopting guideline-based device therapy in patients with heart failure; a real-world experience

Session Poster Session 4

Speaker Anura Malaweera

Event : Heart Failure 2019

  • Topic : heart failure
  • Sub-topic : Chronic Heart Failure: Multidisciplinary Interventions
  • Session type : Poster Session

Authors : A Malaweera (Eastbourne,GB), V Kanthasamy (Eastbourne,GB), H Church (Eastbourne,GB), RA Veasey (Eastbourne,GB), AJ Marshall (Eastbourne,GB), J Hunt (Eastbourne,GB), NR Patel (Eastbourne,GB)

Authors:
A Malaweera1 , V Kanthasamy1 , H Church1 , RA Veasey1 , AJ Marshall1 , J Hunt1 , NR Patel1 , 1Eastbourne District General Hospital, Cardiology - Eastbourne - United Kingdom of Great Britain & Northern Ireland ,

On behalf: Cardiology Department, Eastbourne District General Hospital

Citation:

BACKGROUND: 
Once a disease that had a 5-year survival rate of only 25%, mortality in heart failure (HF) has reduced markedly. In the past two decades, several large clinical trials have shown an additional mortality benefit (up to 30-40%) with cardiac resynchronisation and/or defibrillator therapy (CRT-P or -D/ICDs) compared to medical therapy alone, in patients with severe left ventricular systolic dysfunction (LVSD). Current international clinical practice guidelines strongly recommend device therapy in the management of HF.

PURPOSE:
Although patients may fulfil the guideline-based criteria to warrant a device, in clinical practice, patient selection for device implantation is not straightforward. A systematic approach to identify these challenges has not been previously described. Therefore, we adopted a dedicated multidisciplinary team (MDT) strategy to address these issues.

METHODS:
The MDT consisted of 2 HF specialist nurses, 3 cardiology specialist consultants (devices/intervention, electrophysiology/devices and heart failure/imaging). Meetings were held each month to discuss all HF patients who were referred for a cardiac device from both outpatient and inpatient services at our district general hospital. The clinical history of each patient was discussed before device implantation or upgrade, and their imaging (e.g. cardiac MRI, echocardiograms) were also reviewed. Data were collected for 1-year (Sept 2017 – Aug 2018) and then a mixed-method (quantitative and qualitative) analysis was carried out.

RESULTS:
Of the 69 patients presented in the MDT, 77% were male and their average age was 71.3±11.3 years. 30% had atrial fibrillation (AF). 71% of patients were NYHA class II or III, with 93% having at least moderate LVSD with an ejection fraction of =45%. 70% had either LBBB or a QRS duration of =150ms. 33% had pacemakers (PMs) for a bradycardia indication and 94% of these patients had at least moderate LVSD. 

Qualitative analysis of the MDT outcomes revealed multiple barriers for device implantation or upgrade: 1. not being on optimal disease-modifying pharmacological therapy (11 patients) 2. discrepancies in the estimation of LV function after imaging review (9 patients) 3. recovery of LV function with medical therapy or no longer symptomatic (6 patients) 4. multiple medical comorbidities and frailty (5 patients)  5. patient choice (4 patients) 6. concomitant AV node ablation due to AF (1 patient). Only 32% of all patients referred were clinically appropriate for a new device or an upgrade from PM to CRT-P/D. 

CONCLUSIONS:
Our findings show that patients who are considered for cardiac device therapy should be assessed carefully. Inappropriate patient selection could potentially affect mortality, have an adverse psychosocial impact, and increase healthcare cost. We propose that a specialist device MDT, which reviews clinical cases prior to device implantation, will help to overcome these challenges.

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