Agnes Muskens-Heemskerk’s research while affiliated with Erasmus MC and other places

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Publications (5)


Prognostic Role of High-Sensitivity C-Reactive Protein and B-Type Natriuretic Peptide in Implantable Cardioverter-Defibrillator Patients
  • Article

December 2011

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21 Reads

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12 Citations

Pacing and Clinical Electrophysiology

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Tim Smith

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Tamas Szili-Torok

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High-sensitivity C-reactive protein (hs-CRP) and B-type natriuretic peptide (BNP) are useful biomarkers for cardiovascular risk stratification. Little data are available regarding the prognostic value of hs-CRP and BNP serum levels and future ventricular arrhythmic events triggering implantable cardioverter defibrillator (ICD) therapy. A total of 100 patients eligible for ICD implantation were enrolled in a prospective cohort study. Serum levels of hs-CRP and BNP were obtained the day before ICD implantation and at scheduled follow-up visits. For risk analysis, the study cohort was dichotomized based on serum level of hs-CRP using a cut-off value of 3 mg/L. The endpoint was appropriate ICD therapy triggered by ventricular arrhythmias during a follow-up of 24 months. Appropriate ICD therapy was delivered in 20% of patients. Median baseline serum level of hs-CRP was significantly higher in patients with appropriate ICD therapy than in those without appropriate ICD therapy (5.33 mg/L vs 2.19 mg/L; P = 0.002). The same was true for median serum levels of hs-CRP and BNP during follow-up (5.43 mg/L vs 2.61 mg/L, P = 0.001 and 261.0 pg/mL vs 80.1 pg/mL, P = 0.01, respectively). Multivariate analysis demonstrated that baseline hs-CRP level > 3 mg/L was independently associated with appropriate ICD therapy (odds ratio 4.0, 95% 1.1-14.2; P = 0.03). Elevated preimplantation hs-CRP serum level is independently associated with increased risk for appropriate ICD therapy. Monitoring for elevated BNP levels during follow-up adds to the assessment of risk for future arrhythmias.


Survivors of ventricular fibrillation have persistent cardiovascular risk factors late in follow-up

December 2011

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21 Reads

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1 Citation

European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology

Objective: Implantable cardioverter-defibrillators (ICDs) prevent arrhythmic death, but do not modify disease progression. The prevalence of persistent cardiovascular risk factors in patients receiving an ICD and their adherence to optimal pharmacological therapy at late follow-up is unknown. The aim of this study was to assess the prevalence of cardiovascular and specific sudden cardiac arrest (SCA) risk factors, and the pharmacological treatment in ICD recipients who survived SCA caused by ventricular fibrillation (VF). Design: Cross-sectional study. A total of 100 consecutive ICD patients who survived SCA due to documented VF, not due to a transient or reversible cause or an arrhythmogenic disease, were interviewed and examined at the routine outpatient clinic. Results: The mean age of the patients was 60 ± 11 years, and they were analysed at a median interval of 1092 days after SCA. The majority of patients had coronary artery disease. The New York Heart Association class at the time of implantation was ≥ II in 62%. A single chamber device was used in 49% and a resynchronization device in 12%. At the routine control, the most prevalent risk factors were overweight or obesity (63%), hypertension (41%), and smoking (16%). Pharmacological therapy was suboptimal in 18-32% of the patients. Eight per cent of the patients had known diabetes and 29% had elevated HbA1c levels. While only 7% had pre-existing overt heart failure, 43% had N-terminal pro-brain natriuretic peptide levels ≥ 100 pmol/l. High sensitivity C-reactive protein was ≥ 3 mg/l in 52% of the patients. Family history was positive for sudden cardiac death (SCD) in 46% of the patients. Conclusions: Despite regular medical consultation, a large proportion of the patients had persistent cardiovascular risk factors and were often suboptimally treated. Unexpectedly, latent heart failure and unrecognized diabetes are observed in a large proportion of the patients, as well as elevated inflammatory markers. Genetic analysis may be rewarding, as 46% of the patients had a family history of SCD. Full medical attention, optimizing drug therapy, and counselling of these patients is necessary.


Table 1 Baseline characteristics
Table 2 Follow-up data from hospital records
Table 3 Hospitalisation (≥1) and unscheduled outpatient consultations per patient as obtained from the questionnaires
Kaplan-Meier analysis, comparing mortality in both centres
Kaplan-Meier analysis, comparing the rate of first appropriate ICD interventions (shocks and antitachycardia pacing) in both centres

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Health care utilisation after defibrillator implantation for primary prevention according to the guidelines in 2 Dutch academic medical centres
  • Article
  • Full-text available

July 2011

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41 Reads

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6 Citations

Netherlands heart journal: monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation

The benefit of implantable defibrillators (ICDs) for primary prevention remains debated. We analysed the implications of prophylactic ICD implantation according to the guidelines in 2 tertiary hospitals, and made a healthcare utilisation inventory. The cohort consisted of all consecutive patients with coronary artery disease (CAD) or dilated cardiomyopathy (DCM) receiving a primary prophylactic ICD in a contemporary setting (2004-2008). Follow-up was obtained from hospital databases, and mortality checked at the civil registry. Additional data came from questionnaires sent to general practitioners. There were no demographic differences between the 2 centres; one had proportionally more CAD patients and more resynchronisation therapy (CRT-D). The 587 patients were followed over a median of 28 months, and 50 (8.5%) patients died. Appropriate ICD intervention occurred in 123 patients (21%). There was a small difference in intervention-free survival between the 2 centres. The questionnaires revealed 338 hospital admissions in 52% of the responders. Device-related admissions happened on 68 occasions, in 49/276 responders. The most frequently reported ICD-related admission was due to shocks (20/49 patients); for other cardiac problems it was mainly heart failure (52/99). Additional outpatient visits occurred in 19%. Over a median follow-up of 2 years, one fifth of prophylactic ICD patients receive appropriate interventions. A substantial group undergoes readmission and additional visits. The high number of admissions points to a very ill population. Overall mortality was 8.5%. The 2 centres employed a similar procedure with respect to patient selection. One centre used more CRT-D, and observed more appropriate ICD interventions.

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Clinical experience with a novel subcutaneous implantable defibrillator system in a single center

March 2011

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319 Reads

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109 Citations

Clinical Research in Cardiology

Implantable cardioverter-defibrillators (ICDs) reduce mortality in both primary and secondary prevention, but are associated with substantial short- and long-term morbidity. A totally subcutaneous ICD (S-ICD) system has been developed. We report the initial clinical experience of the first 31 patients implanted at our hospital. All patients had an ICD indication according to the ACC/AHA/ESC guidelines. The first 11 patients were part of the reported CE trial. The implantation was performed without fluoroscopy. The device was implanted subcutaneously in the anterior axillary line, with a parasternal lead tunneled from the xiphoid to the manubrial-sternal junction. Ventricular fibrillation (VF) was induced to assess detection accuracy and defibrillation efficacy using 65 J shocks. Post-implant, 52 sustained episodes of VF were induced. Sensitivity was 100% and induced conversion efficacy was 100% (with standard polarity in 29 patients). Mean time to therapy was 13.9 ± 2.5 s (range 11-21.6 s). Late procedure-related complications were observed in 2 of the first 11 implantations (lead migration). During follow-up, spontaneous ventricular arrhythmias occurred in four patients, with accurate detection of all episodes. Inappropriate therapy was observed in five patients. Recurrences were prevented with reprogramming. The S-ICD system can be implanted without the use of fluoroscopy by using anatomical landmarks only. Episodes of VF were accurately detected using subcutaneous signals, and all induced and clinical episodes were successfully converted. The S-ICD system is a viable alternative to conventional ICD systems for selected patients.


Citations (5)


... In secondary prevention of SUD, in patients with sustained ventricular tachycardia/fibrillation or survivors of sudden cardiac death drug treatment alone is ineffective and can be used as an adjunct to ICD to decrease episodes of ventricular tachycardia/fibrillation and non-sustained ventricular tachycardia to reduce ICD discharge, to slow the rate of ventricular tachycardia and to increase haemodynamic stability. 96,99 Patients with advanced heart failure and low LVEF in which symptoms progress despite optimal pharmacotherapy and ICD device implantation may benefit in future from devices engineered to restore sympathovagal balance to the heart by electrical neuromodulation. Several options have been investigated in animal models, involving baroreflex activation therapy (BAT) and vagal stimulation. ...

Reference:

Sudden death: Neurogenic causes, prediction and prevention
Survivors of ventricular fibrillation have persistent cardiovascular risk factors late in follow-up
  • Citing Article
  • December 2011

European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology

... In addition, a positive association between higher serum hs-CRP level and the occurrence of ventricular arrhythmias was found in a prospective cohort study on implantable cardioverter defibrillator recipients (11). Additionally, higher CRP levels increasing the risk of ventricular arrhythmia has been previously described in the literature (12)(13)(14); however, the mechanisms underlying this association remain unclear. In a population-based sample, Vianello et al (15) found a negative association between CRP level and serum calcium concentration, suggesting that calcium homeostasis imbalance induced by CRP may contribute to arrhythmia. ...

Prognostic Role of High-Sensitivity C-Reactive Protein and B-Type Natriuretic Peptide in Implantable Cardioverter-Defibrillator Patients
  • Citing Article
  • December 2011

Pacing and Clinical Electrophysiology

... [8][9][10] This can be explained by longer follow up, underreporting of complications and implantation in more difficult patients who, in contrast to clinical trials, are not excluded from the potential benefit of a device. 10,14 However, in the United States a decreasing number of complications is seen in registry data. 8 One of the most feared complications is infection, and many of the cited complications will increase the risk for infection, especially in patients undergoing generator change and placement of additional leads. ...

Health care utilisation after defibrillator implantation for primary prevention according to the guidelines in 2 Dutch academic medical centres

Netherlands heart journal: monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation

... The advantage of S-ICDs concerns the components, which are completely outside of the chest. This substantial difference minimizes the risk of lead fractures or systemic infections, some of the most feared complications of TV-ICDs [3], as well as making any extraction procedure much simpler and less dangerous [4]. Consequently, the outlook for S-ICDs is stronger in two scenarios: when used in younger patients, who are usually affected by genetic heart diseases and are at high risk of sudden cardiac death (SCD) such as hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), and genetic arrhythmia syndromes [5][6][7]; and in instances in which the transvenous route is inaccessible. ...

Clinical experience with a novel subcutaneous implantable defibrillator system in a single center

Clinical Research in Cardiology

... Of the 37 included studies, 11 trials dealt with patients with newly implanted pacemaker [22][23][24][25][26][27][28][29][30][31][32], 11 trials analyzed patients with new ICDs [33][34][35][36][37][38][39][40][41][42][43] and 15 trials examined patients with new LVADs [44][45][46][47][48][49][50][51][52][53][54][55][56][57][58]. In total, 7 of the 39 trials had control groups not receiving the respective devices while all other trials were cohort studies with longitudinal data acquisition of patients before and after implantation. ...

Type-D personality but not ICD indication is associated with impaired health-related quality of life 3 months post implantation
  • Citing Article
  • August 2007

Europace