Long-Term Outcomes of CRT-PM Versus CRT-D Recipients

Objective: To compare the rates of all-cause mortality in recipients of cardiac resynchronization therapy devices without (CRT-PM) versus with defibrillator (CRT-D).
Methods: Between February 1999 and July 2004, 233 patients (mean age = 69 ± 8 years, 180 men) underwent implantation of CRT-PM or CRT-D devices. New York Heart Association (NYHA) heart failure functional class II was present in 11%, class III in 69%, and class IV in 20% of patients; mean left ventricle ejection fraction (LVEF) was 26.5 ± 6.5 %, 48% presented with idiopathic dilated cardiomyopathy and 49% with ischemic heart disease. Cox multiple variable regression analysis was performed in search of predictors of death.
Results: The clinical characteristics of the 117 CRT-PM and 116 CRT-D recipients were similar, except for LVEF (28.2 ± 6.2% vs 25.0 ± 6.5%, respectively; P < 0.001), and ischemic versus nonischemic etiology of heart failure (41% vs 56%, respectively P = 0.02). Over a mean follow-up of 58 ± 15 months, no significance difference in overall mortality rate was observed between the two study groups. Male sex, NYHA functional class IV, and atrial fibrillation at implant were significant predictors of death.
Conclusions: There was no difference in long-term survival rate among patients with CRT-D versus CRT-PM, although CRT-D more effectively lowered the sudden death rate. Male sex, NYHA functional class IV, and atrial fibrillation predicted the worst prognosis.     

Impact of the Main Implantable Cardioverter-Defibrillator Trials for Primary and Secondary Prevention in Italy: A Survey of the National Activity During the Years 2001–2004

Background: Several trials demonstrated the lifesaving role of implantable cardioverter-defibrillator (ICD) in high-risk groups of patients. Aim of this review was to report the clinical characteristics of patients enrolled in the ICD Registry of the Italian Association of Arrhythmology (AIAC) in the years 2001–2004.
Methods: The Registry collects prospectively 85% of national ICD implantation activity on the basis of European ICD form (EURID).
Results: The number of implanted ICDs in Italy was 2,418 in the year 2001, 3,992 in the year 2002, 5,595 in the year 2003, and 7,190 in the year 2004. The number of ICDs per million of inhabitants was 42.1 in the year 2001 (+11.8% respect to 2000), 70.0 in the year 2002 (+65.1% respect to 2001), 98.3 in the year 2003 (+40.4% respect to 2002), and 125.0 in the year 2004 (+27.2% respect to 2003). The median age was 67 years in the years 2001–2002, 68 years in the years 2003–2004. The main indications during the study were syncope (24.2–14.9%) and cardiac arrest (28.5–17.3%), followed by palpitations and dizzy spells (15.5–17.2%, and 9.4–6.9% of patients, respectively). The use of prophylactic ICD had a fourfold increase in the examined period (5.8% in 2001, 22.9% in 2004). Ventricular tachycardia was the main arrhythmic indication in 44.4–54.6% of cases, ventricular fibrillation in 11.8–18.0%, both in 3.5–6.5%. In the years 2002, 2003, and 2004 single chamber ICDs were implanted in 45.5%, 38.8%, and 33.7% of patients, dual chamber ICDs in 35.1%, 32.3%, and 30.5%, biventricular ICDs in 19.4%, 28.9%, and 34.7%, respectively.
Conclusion: The ICD implantation rate in Italy increased significantly in the period 2001–2004, similarly to the trend in other western countries. The Registry showed an important increase of prophylactic and dual or triple chamber ICDs use.     

Left Ventricular Mechanical Assist Devices and Cardiac Device Interactions: An Observational Case Series

Background: Nonpulsatile left ventricular assist devices (LVADs) are increasingly used for treatment of refractory heart failure. A majority of such patients have implanted cardiac devices, namely implantable cardioverter-defibrillators (ICDs) or cardiac resynchronization therapy-pacemaker (CRT-P) or cardiac resynchronization therapy-defibrillator (CRT-D) devices. However, potential interactions between LVADs and cardiac devices in this category of patients remain unknown.
Methods: We reviewed case records and device logs of 15 patients with ICDs or CRT-P or CRT-D devices who subsequently had implantation of a VentrAssist LVAD (Ventracor Ltd., Chatswood, Australia) as destination therapy or bridge to heart transplantation. Pacemaker and ICD lead parameters before and after LVAD implant were compared. In addition, ventricular tachyarrhythmia event logs and potential electromagnetic interference reports were evaluated.
Results: Right ventricular (RV) sensing decreased in the first 6 months post-LVAD. Mean R-wave amplitude preimplant was 10.9 ± 5.25 mV compared with 7.2 ± 3.4 mV during follow-up (P = 0.02). RV impedance also decreased from 642 ± 240 ohms at baseline to 580 ± 212 ohms at follow-up (P = 0.007). There was a significant increase in RV stimulation threshold following implantation of the LVAD from 0.8 ± 0.6 V at baseline to 1.4 ± 1.0 V in the first 6 months postimplant (P = 0.01). A marked increase in ventricular tachyarrhythmia burden was observed in three patients. One patient displayed electromagnetic interference between the LVAD and defibrillator, resulting in inappropriate defibrillation therapy.
Conclusions: LVADs have a definite impact on cardiac devices in respect with alteration of lead parameters, ventricular tachyarrhythmias, and electromagnetic interference.     

Outcome after device implantation in chronic heart failure is dependent on concomitant medical treatment

Background  Device implantation in chronic heart failure (CHF) for cardiac resynchronization therapy (CRT) with or without implantable cardioverter/defibrillator (ICD) is an established treatment option for symptomatic patients under medical baseline therapy. Although recommended, the need for optimization of medical therapy was never proven. As in 'the real world', medical therapy is not always up-titrated to the desirable dosages; this provides the opportunity to evaluate the impact of optimizing medical therapy in patients who had received a device therapy with proven effectiveness.
Materials and methods  This observational cohort study retrospectively assessed the 'real life'-effect of CRT compared with that of CRT/ICD therapy and the impact of concomitant pharmacotherapy on outcome. Outcome of patients with guideline recommended renin–angiotensin system inhibitor and ß-blocker dosages was compared with that of patients who failed to reach the desired dosages. Mean follow-up for the 205 CHF (95 CRT and 110 CRT/ICD) patients was 16·8 ± 12·4 months.
Results  In the total study cohort, 83 (41%) reached the combined primary endpoint of all-cause death or cardiac hospitalization [CRT group: 25 (26%), CRT/ICD group: 58 (52·7%), P  < 0·001]. Multiple cox regression analysis revealed non-optimized medical therapy at follow-up [HR = 2·080 (1·166–3·710), P  = 0·013] and CRT/ICD vs. CRT [HR = 2·504 (1·550–4·045), P  < 0·001] as significant predictors of the primary endpoint.
Conclusion  Our data stress the importance of professional monitoring and titration of pharmacotherapy not only in medically treated CHF patients but also in patients under device therapy by a heart failure unit or a specialized cardiologist.     

Gender Differences in Patients Referred for Atrial Fibrillation Management to a Tertiary Center

Background: Atrial fibrillation (AF) ablation is less frequently performed in women than in men. Although the prevalence of AF is slightly higher in men, this does not fully account for the lower number of AF ablations performed in women. This study sought to examine the effect of gender on referral for AF and subsequent AF management.
Methods: Consecutive patients referred to our tertiary arrhythmia outpatient clinic for AF management were retrospectively analyzed.
Results: Of 264 patients referred, only 27% were women. Women were older than men (63 ± 9 vs 58 ± 11 years, P = 0.002), more often had paroxysmal AF (78% vs 63% in men, P = 0.022), and women more frequently complained about palpitations (71% vs 49%, P = 0.002). In addition, they had more often experienced amiodarone side effects than men (56% vs 36%, P = 0.046). In this referred population, there was no difference in the proportion of women and men undergoing AF ablation immediately following the initial evaluation (21% vs 25%, P = ns), at any time during the follow-up (38% vs 44%, P = ns), and there was no difference in the proportion of patients undergoing atrioventricular node ablation in both sexes (6% of women vs 3% of men, P = ns).
Conclusions: There is an important difference in the proportion of men and women referred for management of AF in a specialized outpatient arrhythmia clinic, with women being referred three times less often than men. However, there is no gender-related difference in the subsequent treatment decisions. These findings emphasize the importance of focusing on management of symptomatic AF in women.     

Does a Gender Difference in Response to Cardiac Resynchronization Therapy Exist?

BACKGROUND: Cardiac resynchronization therapy (CRT) has a beneficial effect on clinical symptoms, exercise capacity, and systolic left ventricular (LV) performance in patients with heart failure. The aim of the current study was to evaluate whether a gender difference exists in response to CRT. METHODS: Consecutive patients with end-stage heart failure (New York Heart Association, NYHA, class III-IV), LV ejection fraction (LVEF) < or =35%, QRS duration >120 ms, and left bundle branch block configuration underwent CRT. At baseline and 6 months post-CRT, clinical and echocardiographic parameters were evaluated; follow-up was obtained up to 5 years. The effects of CRT were compared between women and men. RESULTS: The study population comprised 137 men and 36 women (mean age 66 +/- 11 years). No differences in baseline characteristics were observed except that nonischemic cardiomyopathy was more frequent in women than men (67% vs 38%, P < 0.05). In all patients, clinical and echocardiographic parameters improved significantly at 6-month follow-up. The magnitude of improvement in different parameters was similar between women and men, e.g., the improvement in NYHA Class was 0.9 +/- 0.6 in women and 1.0 +/- 0.7 in men (NS) and the increase in LVEF was 8 +/- 8% in women as compared to 7 +/- 9% in men (NS). The percentage of individual responders was not different between women and men (76% vs 80%, NS) and 2-year survival was comparable for women and men (84% vs 80%, NS). CONCLUSION: No gender differences were observed in response to CRT and long-term survival after CRT.     

Racial disparity in hospice use in the United States in 2002

We used complete Centers for Disease Control death certificate records and the Centers for Medicare and Medicaid Services 100% Standard Analytic File for hospice claims for 2002 to examine differences in hospice utilization between African-American and white decedents living in the United States. White decedents were more likely to use hospice in the year before their death than African-American decedents (29% vs 22%). Cause-specific hospice utilization rates among women were consistently higher than among men within a given race. African-American decedents were consistently less likely to use hospice than white decedents for almost all conditions. Hospice utilization was lower among African-American than among white decedents in 31 of 40 states. The higher the overall hospice utilization in a state, the less the positive difference between white and African-American usage rates; that is, the more accepted hospice is, as measured by 'market share', the lower the racial disparity in its use.     

Cardiac resynchronization therapy: gender related differences in left ventricular reverse remodeling

AIM: Gender related differences in epidemiology, treatment, and prognosis of heart failure (HF) have been reported. We examined the sex influence in patients treated with cardiac resynchronization therapy (CRT). METHODS AND RESULTS: Out of 334 consecutive HF patients (19.7% women) who underwent CRT, 195 patients reached clinical and echocardiographic evaluation at six and 12 months and were selected for analysis. A reduction in left ventricular (LV) end-diastolic volume/m(2) (EDVi) and end systolic volume/m(2) (ESVi) was evident in the overall population at six months (P < 0.001) and from six to 12 months (P < 0.001). Compared to men, women showed significantly greater changes in LV volumes at mid (P < 0.05) and long-term (P < 0.001) follow-up and a significantly higher LV ejection fraction (EF) (40.8 +/- 12.3 vs 34.1 +/- 10.1, P < 0.01) at one year. Multiple regression analysis, including several demographic and clinical parameters, revealed that female gender is independently associated with greater reduction in LV ESVi. At the 12-month follow-up, the proportion of responders (defined in terms of ESV reduction by at least 10%) was higher in women than in men (76.1% vs 59.3%, P < 0.05). CONCLUSIONS: CRT induced a gender specific LV remodeling response.     

Elevated serum creatinine at baseline predicts poor outcome in patients receiving cardiac resynchronization therapy

Background: Renal insufficiency is recognized as a predictor of mortality and poor outcome in heart failure patients. We sought to study the impact of baseline serum creatinine on subsequent outcome in cardiac resynchronization therapy ( CRT) recipients.
Methods: We retrospectively reviewed hospital records of all CRT recipients at Pittsburgh Veterans Affairs (VA) Healthcare System (2003–2005) and University of Pittsburgh Medical Center (2004) . We recorded clinical characteristics at the time of implantation including demographics, New York Heart Association (NYHA) functional class, ejection fraction, QRS duration, cardiomyopathy etiology, medical history, medication use, and serum creatinine. Mortality alone and mortality combined with heart failure hospitalization were the study endpoints.
Results: Out of the 330 patients studied, a total of 66 (20.0%) patients died over a mean follow-up duration of 19.7 ± 9.0 months (range 1–44). The cohort was studied by three creatinine tertiles (0.6–1.0, 1.1–1.3, 1.4–3.0 mg/dL). Both study endpoints were observed more frequently in patients in the highest creatinine tertile compared to others (28.7% vs 14.0%, P = 0.008 for death and 41.6% vs 21.5%, P = 0.001 for the combined endpoint). High creatinine remained an independent predictor of mortality (hazard ratio [HR] 1.89, 95% confidence interval [CI] 1.06–3.39, P = 0.032) and the combined endpoint (HR 1.94, 95% CI 1.20–3.13, P = 0.007) in multivariate adjusted models. Studied as a continuous variable, increase in creatinine level by 0.1 mg/dL was associated with an 11% increase in mortality risk and a 7% increase in the combined endpoint.
Conclusion: In an unselected cohort of CRT recipients, the baseline creatinine was found to predict worse survival and poor outcome over a modest follow-up duration.     

The impact of age and gender on cardiac resynchronization therapy outcome

BACKGROUND: Cardiac resynchronization therapy (CRT) outcome varies significantly among patients. We aimed to determine the impact of age, gender, and heart failure etiology on the long-term outcome of patients receiving CRT. METHODS: A total of 117 patients with drug-refractory heart failure, New York Heart Association (NYHA) Class III or IV, and a wide QRS complex, who received CRT, were followed for one year. Long-term outcome was measured as a combined end point of hospitalization for heart failure and/or all cause mortality. Efficacy of CRT was compared between men and women, between older and younger patients, and between patients with ischemic and nonischemic heart disease. Time to the primary end point was estimated by the Kaplan-Meier method and comparisons were made using the Breslow-Wilcoxon test. RESULTS: Baseline clinical characteristics were comparable between gender, age, and heart failure etiology subgroups. There was no significant difference in the combined end point between older versus younger (age >70, (n = 71), versus age < 70, (n = 46), P = 0.52); both genders (men, n = 91 vs women, n = 26, P = 0.46) and etiology of the cardiomyopathy (ischemic (n = 79) vs nonischemic (n = 38), P = 0.12). Substratification of the genders by the etiology of the cardiomyopathy, showed that women with ischemic cardiomyopathy (IW, n = 10) had a trend to a worse outcome compared to the other groups i.e., nonischemic women (NIW, n = 16), ischemic men (IM, n = 69), and nonischemic men (NIM, n = 22), P = 0.04. After adjusting for potential covariates, a Cox regression analysis showed no significant difference between the groups (P = 0.61). CONCLUSIONS: CRT outcome appears independent of age, gender, and heart failure etiology in this single institution study.     

Relevance of Echocardiographic Evaluation of Right Ventricular Function in Patients Undergoing Cardiac Resynchronization Therapy

Aims: Right ventricular (RV) dysfunction is a marker of poor prognosis in heart failure (HF) patients. It is still unclear whether RV function might influence response to cardiac resynchronization therapy (CRT).
Methods: Forty-four consecutive patients with HF, large QRS, and either intraventricular or interventricular dyssynchrony underwent echocardiographic evaluation before, 1 month after, and 6 months after CRT. Response to CRT was considered in case of significant LV reverse remodeling, defined as the occurrence of LV end-systolic volume (LVESV) reduction ≥15% at 6 months.
Results: All echocardiographic indexes of baseline RV function and dimensions were significantly more impaired in nonresponders versus responders to CRT: tricuspid annular plane systolic excursion (TAPSE 15 ± 4 mm vs 20 ± 5 mm, P = 0.001), RV systolic pulmonary artery pressure (RVSP 39 ± 14 mmHg vs 27 ± 8 mmHg, P = 0.02), RV end-diastolic area (RVEDA 23 ± 6 cm² vs 16 ± 3 cm² P < 0.001), RV end-systolic area (RVESA 16 ± 6 cm² vs 8 ± 2 cm², P = 0.001), and RV fractional area change (30 ± 12% vs 48 ± 8%, P < 0.001). All the indexes of RV function significantly correlated with the percentage of LVESV reduction after CRT. Severe RV dysfunction was defined as TAPSE ≤14 mm and the population was stratified into two groups based on baseline TAPSE ≤ or > 14 mm. As compared to those with high TAPSE (n = 30), patients with low TAPSE (n = 14) were less likely to show LV reverse remodeling after CRT (76% vs 14%, P < 0.001).
Conclusions: Our study suggests that RV function significantly affects response to CRT. Poor LV reverse remodeling occurs after CRT in patients with HF having severe RV dysfunction at baseline.     

Cardiac Resynchronization Therapy in Patients with Right Ventricular Pacing-Induced Cardiomyopathy

Background: It is not known whether patients with normal baseline left ventricular (LV) function who develop right ventricular (RV) pacing-induced cardiomyopathy as a result of dual-chamber pacing can benefit from cardiac resynchronization therapy (CRT). We retrospectively assessed the effect of a CRT upgrade on RV pacing-induced cardiomyopathy.
Methods and Results: We reviewed the charts of patients who received a CRT device for RV pacing-induced cardiomyopathy. We assessed the effects of CRT on LV function, recovery, and other response parameters. From September 2005 through February 2009, 21 patients (13 men; aged 63 ± 9 years) underwent a treatment upgrade to a CRT system. Before the dual-chamber pacemaker was implanted, the LV ejection fraction (LVEF) was 53 ± 2.3%. After pacing, the LVEF was 31.2 ± 3.8%, the LV end-diastolic dimension (LVEDD) was 5.8 ± 0.5 cm, and B-type natriuretic peptide (BNP) levels were 426 ± 149 pg/mL. The duration of pacing before documentation of pacing-induced cardiomyopathy was 3.8 ± 1.5 months. All the patients had been on a stable medical regimen for at least 2 months. After the upgrade to CRT, the follow-up time was 4.9 ± 0.9 months. Sixteen patients (76%) reported a significant improvement in their symptoms. After the CRT upgrade, the LVEF increased to 37.4 ± 9.0% (P < 0.01 vs pre-CRT). The LVEDD decreased to 5.0 ± 1.0 cm (P = 0.03 vs pre-CRT), and BNP levels decreased to 139 ± 92 pg/mL (P = 0.08 vs pre-CRT).
Conclusion: A CRT upgrade is an effective treatment for RV pacing-induced cardiomyopathy and should be implemented as soon as the diagnosis is established. Unfortunately, about 24% of our patients did not respond to the upgrade. (PACE 2010; 37–40)     

Female gender is associated with a better outcome after cardiac resynchronization therapy

Background: Some studies have suggested that women respond differently to cardiac resynchronization therapy (CRT). We sought to determine whether female gender influences long‐term clinical outcome, symptomatic response as well as echocardiographic response after CRT. Methods and Results: A total of 550 patients (age 70.4 ± 10.7 yrs [mean ± standard deviation]) were followed up for a maximum of 9.1 years (median: 36.2 months) after CRT‐pacing (CRT‐P) or CRT‐defibrillation (CRT‐D) device implantation. Outcome measure included mortality as well as unplanned hospitalizations for heart failure or major adverse cardiovascular events (MACE). Female gender predicted survival from cardiovascular death (hazard ratio [HR]: 0.52, P = 0.0051), death from any cause (HR: 0.52, P = 0.0022), the composite endpoints of cardiovascular death /heart failure hospitalizations (HR: 0.56, P = 0.0036) and death from any cause/hospitalizations for MACE (HR: 0.67, P = 0.0214). Female gender predicted death from pump failure (HR: 0.55, P = 0.0330) but not sudden cardiac death. Amongst the 322 patients with follow‐up echocardiography, left ventricular (LV) reverse remodelling (≥15% reduction in LV end‐systolic volume) was more pronounced in women (62% vs 44%, P = 0.0051). In multivariable Cox proportional hazards analyses, the association between female gender and cardiovascular survival was independent of age, LV ejection fraction, atrial rhythm, QRS duration, CRT device type, New York Heart Association (NYHA) class, and LV reverse remodelling (adjusted HR: 0.48, P = 0.0086). At one year, the symptomatic response rate (improvement by ≥1 NYHA classes or ≥25% increase in walking distance) was 78% for both women and men. Conclusions: Female gender is independently associated with a lower mortality and morbidity after CRT. (PACE 2011; 82–88)     

Gender differences in functional status and pain in a Medicare population undergoing elective total hip arthroplasty

BACKGROUND: The major indication for total hip arthroplasty (THA) is pain and disability in the hip. Evidence from state and local studies suggests that women may be more disabled than men at the time of THA. Whether worse disability at the time to THA affects outcomes is unknown. OBJECTIVE: To examine differences in functional status and pain in men and women at the time of THA and at 1 year in a nationally representative Medicare population. METHODS: Cohort of patients undergoing THA. Data were collected at the time of THA, 4 to 6 months after surgery, and 1 year after surgery. SETTING: All Medicare recipients older than age 65 in 12 selected states were eligible. PATIENTS: One thousand six hundred forty patients who underwent THA were identified and 1120 (432 men and 688 women) were enrolled. MAIN OUTCOME MEASURES: Pain and functional status. RESULTS: At the time of THA, women were more likely than men to report severe pain with walking (67% vs. 58%; P <0.01), and needing assistance with walking (56% vs. 45%; P <0.01), housework (49% vs. 30%; P <0.01), and grocery shopping (51% vs. 31%; P <0.01). Men could also walk greater distances. These differences persisted after adjustment for comorbidities and age. One year following THA, women were more likely to report needing assistance with walking (30% vs. 21%; P <0.01), housework (29% vs. 23%; P <01), and grocery shopping (27% vs. 19%; P <0.01) and could walk shorter distances. These differences were partially accounted for by differences in comorbidities and baseline status. CONCLUSION: Compared with men, women in Medicare are more disabled at the time of THA and do not do as well at 1 year. Whether this difference arises from patients' preferences or bias in the health care system is unknown.     

Long-Term Survival in Patients Treated with Cardiac Resynchronization Therapy: A 3-Year Follow-Up Study from the InSync/InSync ICD Italian Registry

Background: Studies reporting the long-term survival of patients treated with cardiac resynchronization therapy (CRT) outside the realm of randomized controlled trials are still lacking. The aim of this study was to quantify the survival of patients treated with CRT in clinical practice and to investigate the long-term effects of CRT on clinical status and echocardiographic parameters.
Methods: The study population consisted of 317 consecutive patients with implanted CRT devices from eight Italian University/Teaching Hospitals. The patients were enrolled in a national observational registry and had a minimum follow-up of 2 years. A visit was performed in surviving patients and mortality data were obtained by hospital file review or direct telephone contact.
Results: During the study period, 83 (26%) patients died. The rate of all-cause mortality was significantly higher in ischemic than nonischemic patients (14% vs 8%, P = 0.002). Multivariate analysis showed that ischemic etiology (HR 1.72, CI 1.06–2.79; P = 0.028) and New York Heart Association (NYHA) class IV (HR 2.87, CI 1.24–6.64; P = 0.014) were the strongest predictors of all-cause mortality. The effects of CRT persisted at long-term follow-up (for at least 2 years) in terms of NYHA class improvement, increase of left ventricular ejection fraction, decrease of QRS duration (all P = 0.0001), and reduction of left ventricular end-diastolic and end-systolic diameters (P = 0.024 and P = 0.011, respectively).
Conclusions: During long-term (3 years) follow-up after CRT, total mortality rate was 10%/year. The outcome of ischemic patients was worse mainly due to a higher rate of death from progressive heart failure. Ischemic etiology along with NYHA class IV was identified as predictors of death. Benefits of CRT in terms of clinical function and echocardiographic parameters persisted at the time of long-term follow-up.     

Gender Disparity in Analgesic Treatment of Emergency Department Patients with Acute Abdominal Pain

Objectives:  Oligoanalgesia for acute abdominal pain historically has been attributed to the provider's fear of masking serious underlying pathology. The authors assessed whether a gender disparity exists in the administration of analgesia for acute abdominal pain.
Methods:  This was a prospective cohort study of consecutive nonpregnant adults with acute nontraumatic abdominal pain of less than 72 hours' duration who presented to an urban emergency department (ED) from April 5, 2004, to January 4, 2005. The main outcome measures were analgesia administration and time to analgesic treatment. Standard comparative statistics were used.
Results:  Of the 981 patients enrolled (mean age ± standard deviation [SD] 41 ± 17 years; 65% female), 62% received any analgesic treatment. Men and women had similar mean pain scores, but women were less likely to receive any analgesia (60% vs. 67%, difference 7%, 95% confidence interval [CI] = 1.1% to 13.6%) and less likely to receive opiates (45% vs. 56%, difference 11%, 95% CI = 4.1% to 17.1%). These differences persisted when gender-specific diagnoses were excluded (47% vs. 56%, difference 9%, 95% CI = 2.5% to 16.2%). After controlling for age, race, triage class, and pain score, women were still 13% to 25% less likely than men to receive opioid analgesia. There was no gender difference in the receipt of nonopioid analgesia. Women waited longer to receive their analgesia (median time 65 minutes vs. 49 minutes, difference 16 minutes, 95% CI = 3.5 to 33 minutes).
Conclusions:  Gender bias is a possible explanation for oligoanalgesia in women who present to the ED with acute abdominal pain. Standardized protocols for analgesic administration may ameliorate this discrepancy.     

Depression among Emergency Medicine Residents over an Academic Year

Objectives: To describe the frequency of depression among emergency medicine (EM) residents by month, gender, rotation type, postgraduate year (PGY), and number of hours worked.
Methods: This was a prospective, nonblinded, cohort study of consenting EM residents in a four-year, 51-resident EM residency program from July 2003 to June 2004. Participants received an anonymous monthly survey via Web site that consisted of the Center for Epidemiologic Studies Depression Scale (CESD) and the resident's gender, PGY, number of hours worked in the previous week (≤40, 41–60, 61–80 and >80), and rotation type (EM, intensive care unit, non-EM clinical, or other). Residents were excluded from analysis if they did not complete at least one survey during each season. For each resident, the peak score for each three-month period was recorded and analyzed with a mixed-model analysis of variance to account for a repeated-measures effect.
Results: Fifty of 51 (98.0%) residents consented for participation. Nineteen (38%) were excluded because of incomplete data. The prevalence of depression was 12.1% (95% confidence interval [95% CI] = 7.5% to 19.0%; 15 of 124 scores). The women had numerically, but not statistically, significantly lower mean ± standard deviation CESD scores than the men (6.4 ± 6.8 vs. 8.7 ± 8.6, p = 1.0). There was no significant difference in mean CESD score by month, PGY, rotation type, or number of hours worked.
Conclusions: Season, number of hours worked, rotation type, PGY, and gender all failed to predict depression among EM residents in this single-center trial. The prevalence of depression was comparable to that of the general population.     

性别因素对心力衰竭住院患者病因和预后的影响

目的调查不同性别对心力衰竭住院患者病因和预后的影响。方法 1993年1月至2007年12月初次住院有效诊断充血性心力衰竭患者6949例(男4344例,女2605例),按照性别不同分成2组,比较各组间的病因及30 d在院病死率。结果心力衰竭住院患者中,男性病因以冠心病(49.6%)、高血压(39.3%)和心肌病(8.0%)为主。而女性以瓣膜性心脏病(37.5%),肺心病(10.6%)和甲亢(1.0%)为主。在18～29岁人群组,女性的死亡率几乎为男性的3倍(4.8%vs 1.7%);在≥80岁以上人群组,女性死亡率显著高于男性(16.1%vs 11.4%)。随着年龄增长,男性和女性死亡率均增加。结论性别不同,心力衰竭住院患者的病因和在院死亡率不同。     

Cardiac resynchronization therapy: a review of proarrhythmic and antiarrhythmic mechanisms

Available evidence supports the hypothesis that cardiac resynchronization therapy (CRT) results in favorable structural as well as electrical remodeling. Electrical remodeling seems to be related, to a large extent, to structural remodeling, usually referred to as reverse remodeling of left ventricular (LV) dysfunction. This can lead to amelioration of the arrhythmogenic substrate associated with depressed LV systolic function and heart failure. However, a direct electrophysiological effect due to favorable remodeling of repolarization with reduction of the dispersion of repolarization cannot be ruled out. On the other hand, in a small subgroup of patients, CRT could increase the dispersion of repolarization and induce malignant ventricular tachyarrhythmias. Clinical trials have consistently shown improved outcome with CRT-defibrillators (CRT-D) and more trials have demonstrated the benefits of the defibrillator in the population with depressed LV function. However, some physicians argue that implanting the less expensive and less complicated CRT-pacemaker (CRT-P) may be appropriate in certain groups of patients. Before this position is accepted, it is imperative that criteria for the selection of this group of patients with presumably low risk for sudden arrhythmic death as well as the proarrhythmic effect of CRT be clearly defined.     

Time course of effects of cardiac resynchronization therapy in chronic heart failure: benefits in patients with preserved exercise capacity

Objectives: To assess in patients with chronic heart failure the effect of cardiac resynchronization therapy (CRT) over 12 months' follow-up the time course of the changes in functional and neurohormonal indices and to identify responders to CRT.
Methods: Eighty-nine patients (74.1 ± 1 years, left ventricular ejection fraction [LVEF] < 35%), QRS complex duration >150 ms, in stable New York Heart Association (NYHA) class III or IV on optimal medical treatment were prospectively randomized either in a control (n = 45) or CRT (n = 44) group and underwent clinical evaluation, cardiopulmonary exercise testing (CPET), 2D-Echo, heart rate variability (HRV), carotid baroreflex (BRS), and BNP assessments before and at 6- and 12-month follow-up.
Results: In the CRT group, improvement of cardiac indices and BNP concentration were evident at medium term (over 6 months) follow-up, and these changes persisted on a longer term (12 months) (all P < 0.05). Instead CPET indices and NYHA class improved after 12 months associated with restoration of HRV and BRS (all P < 0.05). We identified 26 responders to CRT according to changes in LVEF and diameters. Responders presented less depressed hemodynamic (LVEF 25 ± 1.0 vs 22 ± 0.1%), functional (peak VO₂ 10.2 ± 0.2 vs 6.9 ± 0.3 ml/kg/min), and neurohormonal indices (HRV 203.6 ± 15.7 vs 147.6 ± 10.ms, BRS 4.9 ± 0.2 vs 3.6 ± 0.3 ms/mmHg) (all P < 0.05). In the multivariate analysis, peak VO₂ was the strongest predictor of responders.
Conclusions: Improvement in functional status is associated with restoration of neurohormonal reflex control at medium term. Less depressed functional status (peak VO₂) was the strongest predictor of responders to CRT.