Routine Follow-Up of CRT Patients (ECG, Device Stored Information & Regular F/U SOP)

Routine Follow-Up of CRT Patients (ECG, Device Stored Information & Regular F/U SOP)

1. Routine Follow-Up of CRT Patients (ECG, Device Stored Information & Regular F/U SOP) 林口長庚醫院 張伯丞

2. Frequency of Device Follow Up 2012 Heart Rhythm Guideline

3. Using the PBL-STOP Method

4. “P” – Presenting Rhythm, Rate and Percent Pacing

5. “B” – Battery Status

6. Indicators of Battery Life

7. “L” – Lead Status

8. “S” – Sensing

9. “T” – Thresholds

10. “O” – Observations

11. 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.

12. ®

13. Monitoring Fluid Status

14. 42 Impedance Pulmonary Congestion: As fluid accumulates in the thoracic space, intrathoracic impedance decreases Fluid New Trend to Assess Lung Fluid Status

15. 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

16. Diagnostic Trends: OptiVol ®

17. Monitoring Atrial Fibrillation

18. 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

19. Practice: AT/AF Is AF present in this patient? Considerations Is 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

20. Monitoring Heart Rate Variability

21. 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 system 1 Lower levels of HRV have been associated with increased all-cause mortality risk 2 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.

22. 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

23. Monitoring Day and Night Heart Rates

24. 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.

25. Monitoring Patient Activity

26. 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

27. Monitoring % CRT Pacing

28. 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

29. Summary

30. 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

31. “P” – Programming and Print (or PDF)

32. CRT EKG

33. CRT EKG

34. CRT EKG

35. EKG CRT

36. CXR

37. Dyssynchrony: SPWMD

38. Post CRT: SPWMD

39. 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 !! ขอบคุณสำหรับความสนใจของคุณ !! Tibi gratias ago pro attentio !! 당신의주의를 당신을 감사하십시오 !! Спасибо за внимание !! תודה על תשומת הלב שלך !!