Improving haemodynamic optimization of cardiac resynchronization therapy for heart failure.

Objective: Optimization of cardiac resynchronization therapy using non-invasive haemodynamic parameters produces reliable optima when performed at high atrial paced heart rates. Here we investigate whether this is a result of increased heart rate or atrial pacing itself. Approach: Forty-three patients with cardiac resynchronization therapy underwent haemodynamic optimization of atrioventricular (AV) delay using non-invasive beat-to-beat systolic blood pressure in three states: rest (atrial-sensing, 66 +/- 11 bpm), slow atrial pacing (73 +/- 12 bpm), and fast atrial pacing (94 +/- 10 bpm). A 20-patient subset underwent a fourth optimization, during exercise (80 +/- 11 bpm). Main results: Intraclass correlation coefficient (ICC, quantifying information content mean +/- SE) was 0.20 +/- 0.02 for resting sensed optimization, 0.45 +/- 0.03 for slow atrial pacing (p < 0.0001 versus rest-sensed), and 0.52 +/- 0.03 for fast atrial pacing (p = 0.12 versus slow-paced). 78% of the increase in ICC, from sinus rhythm to fast atrial pacing, is achieved by simply atrially pacing just above sinus rate. Atrial pacing increased signal (blood pressure difference between best and worst AV delay) from 6.5 +/- 0.6 mmHg at rest to 13.3 +/- 1.1 mmHg during slow atrial pacing (p < 0.0001) and 17.2 +/- 1.3 mmHg during fast atrial pacing (p = 0.003 versus slow atrial pacing). Atrial pacing reduced noise (average SD of systolic blood pressure measurements) from 4.9 +/- 0.4 mmHg at rest to 4.1 +/- 0.3 mmHg during slow atrial pacing (p = 0.28). At faster atrial pacing the noise was 4.6 +/- 0.3 mmHg (p = 0.69 versus slow-paced, p = 0.90 versus rest-sensed). In the exercise subgroup ICC was 0.14 +/- 0.02 (p = 0.97 versus rest-sensed). Significance: Atrial pacing, rather than the increase in heart rate, contributes to similar to 80% of the observed information content improvement from sinus rhythm to fast atrial pacing. This is predominantly through increase in measured signal.