CPAP is an important therapy in OSA patients undergoing PVI that improves arrhythmia free survival. PVI offers limited value to OSA patients not treated with CPAP.

To evaluate the clinical usefulness of measuring transthoracic electrical impedance in patients with pulmonary edema, we studied 27 normal subjects and 33 patients. In normal subjects, impedance increased when body position changed from supine to standing (p less than 0.01) and when lung volume increased from residual volume to total lung capacity (p less than 0.01). Impedance values vari7 omega) when measured hourly without removing the electrodes. In only five of 11 patients with clinically severe pulmonary edema and five of eight with radiologically severe pulmonary edema were impedance values outside the normal range. Changes in impedance values correlated with changes in clinical and radiographic indexes of pulmonary edema. We conclude that (1) single measurements of impedance are useless in diagnosing pulmonary edema, and (2) impedance changes as predicted as pulmonary edema increases and decreases, and these changes are readily detected by simpler methods of evaluation.

Objectives The purpose of the study was to define the extent and nature of cardiac resynchronization therapy (CRT) device usage outside consensus guidelines using national data. Background Recent literature has shown that the application of CRT in clinical practice frequently does not adhere to evidence-based consensus guidelines. Factors underlying these practices have not been fully explored. Methods From the National Cardiovascular Data Registry’s Implantable Cardiac-Defibrillator Registry, we defined a cohort of 45,392 cardiac resynchronization therapy-defibrillator (CRT-D) implants between January 2006 and June 2008 with a primary prevention indication. We defined “off-label” implants as those in which the ejection fraction was >35%, the New York Heart Association functional class was below III, or the QRS interval duration was <120 ms in the absence of a documented need for ventricular pacing. The relationships between patient, implanting physician, and hospital characteristics with off-label use were explored with multivariable hierarchical logistic regression models. Results Overall, 23.7% of devices were placed without meeting all 3 implant criteria, most often due to New York Heart Association functional class below III (13.1% of implants) or QRS interval duration <120 ms (12.0%). Atrial fibrillation/flutter, previous percutaneous coronary intervention, and the performance of an electrophysiology study before implant were independently associated with increased odds of off-label use, whereas diabetes mellitus, increasing age, and female sex were associated with decreased odds. Physician training and insurance payer were weakly associated with the likelihood of off-label use. Conclusions Nearly 1 in 4 patients receiving CRT devices in the study time frame did not meet guideline-based indications. Given the evolving evidence base supporting the use of CRT, these practices require careful scrutiny.

Cardiac resynchronization therapy (CRT) reduces morbidity and mortality among selected patients with left ventricular systolic dysfunction and severe heart failure symptoms despite guideline directed medical therapy (GDMT). Contemporaneous guidelines provided clear recommendations regarding selection of patients for CRT, including that all patients should first receive GDMT with beta-blockers and renin-angiotensin axis antagonists. Prevalence of GDMT among real-world patients receiving CRT defibrillators (CRT-D) has not been well studied. We identified 45,392 patients in the National Cardiovascular Data Registry Implantable Cardioverter-Defibrillator Registry who underwent first CRT-D implantation for primary prevention of sudden death between January 2006 and June 2008. We calculated the proportion of patients with contemporaneous Class I guideline indications for CRT-D, the proportion receiving GDMT for heart failure, and the proportions receiving GDMT who had Class I guideline indications for CRT-D. Among patients without contraindications, 87% were prescribed beta-blockers, 78% an angiotensin converting enzyme inhibitors (ACE-I) or an angiotensin II receptor inhibitors (ARB), and 70% both a beta-blocker and an ACE-I or ARB at discharge. Finally, 50% of patients met Class I guideline indications and were prescribed GDMT at discharge; 9% neither met Class I indications nor were prescribed GDMT at discharge. The major limitation of this study is the lack of dosage information in the ICD Registry and lack of prescribing information at times other than discharge. In conclusion, many patients receiving CRT-D are not receiving GDMT at discharge. Ensuring that all patients receiving CRT-D are also receiving GDMT appears to be a quality improvement target.

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Hypoplastic coronary artery disease is a rare congenital anomaly that may present with ischaemic heart disease, heart failure or sudden cardiac death (SCD). We describe a case of cardiac arrest in a healthy young man. Work-up revealed a hypoplastic left anterior descending artery. The patient underwent cardioverter-defibrillator implantation for secondary prevention.

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