title: Atrial fibrillation in cardiac resynchronization therapy with a defibrillator: a risk factor for mortality, appropriate and inappropriate shocks.
abstract: BACKGROUND
  Knowledge about predictive factors for mortality and (in)appropriate shocks in cardiac resynchronization therapy with a defibrillator (CRT-D) should be available and updated to predict clinical outcome.
  
  
  METHODS
  We retrospectively analyzed 543 consecutive patients assigned to CRT-D in 2 tertiary medical centers. The aim of this study was to assess risk factors for all-cause mortality, appropriate and inappropriate shocks.
  
  
  RESULTS
  Mean follow-up time was 3.2 (±1.8) years. A total of 110 (20%) patients died, 71 (13%) received ≥1 appropriate shocks, and 33 (6.1%) received ≥1 inappropriate shocks. No patients received a His bundle ablation and biventricular pacing percentage was not analyzed. Multivariable Cox regression analysis showed that a history of atrial fibrillation (AF) (HR 1.74 CI 1.06-2.86), higher creatinine (HR 1.12; CI 1.08-1.16), and a poorer left ventricular ejection fraction (LVEF) (HR 0.97; CI 0.94-1.01) independently predict all-cause mortality. In the entire cohort, history of AF and secondary prevention were independent predictors of appropriate shocks and variables associated with inappropriate shocks were history of AF and QRS ≥150 milliseconds. In primary prevention patients, history of AF also predicted appropriate shocks as did ischemic cardiomyopathy and poorer LVEF. History of AF, QRS ≥150 milliseconds, and lower creatinine were associated with inappropriate shocks in this subgroup. Appropriate shocks increased mortality risk, but inappropriate shocks did not.
  
  
  CONCLUSIONS
  In symptomatic CHF patients treated with CRT-D, history of AF is an independent risk factor not only for mortality, but also for appropriate and inappropriate shocks. Further efforts in AF management may optimize the care in CRT-D patients.
authors.affiliation: Department of Cardiology, Medical Centre Alkmaar (MCA), Alkmaar, The Netherlands.
authors.forename: Nick
authors.initials: N
authors.lastname: van Boven
authors.forename: Dominic
authors.initials: D
authors.lastname: Theuns
authors.forename: Kjell
authors.initials: K
authors.lastname: Bogaard
authors.forename: Jaap
authors.initials: J
authors.lastname: Ruiter
authors.forename: Geert
authors.initials: G
authors.lastname: Kimman
authors.forename: Lily
authors.initials: L
authors.lastname: Berman
authors.forename: Tjeerd
authors.initials: T
authors.lastname: VAN DER Ploeg
authors.forename: Isabella
authors.initials: I
authors.lastname: Kardys
authors.forename: Victor
authors.initials: V
authors.lastname: Umans
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000401:mortality* / Q000503:physiopathology; D058406:Cardiac Resynchronization Therapy / Q000009:adverse effects / Q000401:mortality*; D058409:Cardiac Resynchronization Therapy Devices; D002423:Cause of Death; D016009:Chi-Square Distribution; D017147:Defibrillators, Implantable; D004554:Electric Countershock / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality*; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009426:Netherlands; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D011475:Prosthesis Failure; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013318:Stroke Volume; D062606:Tertiary Care Centers; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left
keywords: atrial fibrillation; cardiac resynchronization therapy; heart failure; implantable cardioverter defibrillator; mortality