Cardiac resynchronization therapy indications: Difference between revisions
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==Indications== | ==Indications== | ||
==2021 ESC Guideline for management of [[ | ==2021 ESC Guideline for management of [[]]== | ||
<span style="font-size:85%">'''Abbreviations:''' | <span style="font-size:85%">'''Abbreviations:''' | ||
'''AF:''' [[Atrial fibrillation]]; | '''AF:''' [[Atrial fibrillation]]; | ||
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|}<ref name="pmid34447992">{{cite journal |vauthors=McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A |title=2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure |journal=Eur Heart J |volume=42 |issue=36 |pages=3599–3726 |date=September 2021 |pmid=34447992 |doi=10.1093/eurheartj/ehab368 |url=}}</ref> | |}<ref name="pmid34447992">{{cite journal |vauthors=McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A |title=2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure |journal=Eur Heart J |volume=42 |issue=36 |pages=3599–3726 |date=September 2021 |pmid=34447992 |doi=10.1093/eurheartj/ehab368 |url=}}</ref> | ||
===[[Cardiac resynchronization therapy]]=== | |||
*[[CRT]] reduces [[morbidity]] and [[mortality]]. | |||
*[[CRT]] improves [[cardiac]] function, and enhances [[quality of life]]. | |||
*Several characteristics predictors of improvement in [[morbidity]] and [[mortality]] including the extent of reverse remodelling as the most important mechanisms of action of [[CRT]]. | |||
* [[Patients]] with [[HFrEF]] and [[ischemic]] etiology have less improvement in [[LV ]] function due to [[myocardial]] scar tissue, which is less likely to undergo favorable remodelling. | |||
*[[Women]] may be more likely to respond to [[CRT]] than [[men]], possibly due to smaller body and [[heart]] size. | |||
* [[QRS]] duration predicts [[CRT]] response. | |||
* [[QRS]] morphology is related to a beneficial response to [[CRT]]. | |||
* [[Patients]] with [[left bundle branch block]] ([[LBBB]]) morphology are more likely to respond favorably to [[CRT]], whereas there is less certainty about [[patients]] with non-[[LBBB]] [[morphology]]. | |||
* [[Patients]] with [[LBBB]] morphology often have wider [[QRS]] durations, and there is a current debate about whether [[QRS]] durations or [[QRS]] morphology is the | |||
the main [[predictor]] of a beneficial response to [[CRT]]. | |||
* there is little evidence to suggest that [[QRS]] morphology or etiology of disease influence the effect of [[CRT]] on [[morbidity]] or [[mortality]]. | |||
* Implantation of [[CRT]] is not recommended if [[QRS]] duration is <130 ms. | |||
*If a [[patient]] is scheduled to receive an [[ICD]] and is in [[sinus rhythm]], with a [[LBBB]], [[CRT-D ]] should be considered if the [[QRS]] is between 130 and 149 ms and is recommended if QRS is >_150 ms. | |||
* When [[LVEF]] is reduced, [[RV]] pacing may exacerbate [[cardiac dyssynchrony]]. | |||
* This can be prevented by [[CRT]], which might improve [[patient]] [[outcomes]]. | |||
* [[CRT]] rather than [[RV]] pacing is recommended for [[patients]] with [[HFrEF]] regardless of [[NYHA]] class who have an indication for [[ventricular]] pacing in order to reduce [[morbidity]], although no clear effect on [[mortality]] was observed. | |||
* Patients with HFrEF who | |||
have received a conventional pacemaker or an ICD and subsequently | |||
develop worsening HF with a high proportion of RV pacing, despite | |||
OMT, should be considered for ‘upgrading’ to CRT. | |||
Only two small trials have compared pharmacological therapy | |||
alone vs. CRT in patients with AF, with conflicting results. Several | |||
studies have indicated that CRT is superior to RV pacing in patients | |||
undergoing atrio-ventricular (AV) node ablation. 217,218,231 | |||
However, AF is not an indication to carry out AV node ablation in | |||
patients with CRT except in a few cases when ventricular rate | |||
remains persistently high despite attempts at pharmacological rate | |||
control. A subgroup analysis of patients with AF from the RAFT | |||
study found no benefit from CRT-D compared with ICD, although | |||
less than half of patients had >90% biventricular capture. 219 In view | |||
of the paucity of evidence for the efficacy of CRT in patients with | |||
AF, it may be an option in selected patients—particularly those | |||
with a QRS >_150 ms—ensuring a proportion of biventricular pac- | |||
ing as high as possible. | |||
Observational studies report that when biventricular capture is | |||
<98%, the prognosis of patients with CRT declines.218,232 Whether | |||
this association reflects a loss of resynchronization (which might be | |||
remedied by device programming), poor placement of the LV lead | |||
==References== | ==References== | ||
Revision as of 07:27, 25 February 2022
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Cardiac resynchronization therapy Microchapters |
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Treatment |
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Cardiac resynchronization therapy indications On the Web |
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American Roentgen Ray Society Images of Cardiac resynchronization therapy indications |
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Directions to Hospitals Administering Cardiac resynchronization therapy |
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Risk calculators and risk factors for Cardiac resynchronization therapy indications |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Bhaskar Purushottam, M.D. [2], Hardik Patel, M.D.
Overview
Cardiac resynchronization therapy (CRT) with or without an implantable cardiac defibrillator (ICD) is indicated in patients who have an LVEF less than or equal to 35%, left bundle branch block (LBBB) with a QRS duration greater than or equal to 0.15 seconds, and normal sinus rhythm, for the treatment of NYHA functional Class III or ambulatory Class IV heart failure symptoms in patients whose medical therapy has been optimized.
Indications
2021 ESC Guideline for management of [[]]
Abbreviations:
AF: Atrial fibrillation;
A-V: Atrio-ventricular;
CRT: Cardiac resynchronization therapy ;
HFrEF: Heart failure with reduced ejection fraction;
ICD: Implantable cardioverter-defibrillato;
LBBB:Left bundle branch block;
LVEF: Left ventricular ejection fraction;
NYHA:New York Heart Association;
RV: = Right ventricular
| Recommendations for cardiac resynchronization therapy implantation in patients with heart failure |
| (Class I, Level of Evidence A): |
|
❑ CRT is recommended for symptomatic patients with HF in sinus rhythm with a QRS duration >_150 ms and LBBB QRS morphology and with LVEF <_35%
despite optimal medical therapy in order to improve symptoms and reduce morbidity and mortality |
| (Class IIa, Level of Evidence B): |
|
❑ CRT should be considered for symptomatic patients with HF in sinus rhythm with a QRS duration >_150 ms and non-LBBB QRS morphology and
with LVEF <_35% despite OMT in order to improve symptoms and reduce morbidity and mortality |
| (Class IIb, Level of Evidence B) : |
|
❑ CRT may be considered for symptomatic patients with HF in sinus rhythm with a QRS duration of 130-149 ms and non-LBBB QRS morphology and with LVEF <_35% despite optimal medical therapy in order to improve symptoms and reduce morbidity and mortality |
| (Class III, Level of Evidence A) : |
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❑CRT is not recommended in patients with a QRS duration <130 ms who do not have an indication for pacing due to high degree AV block |
| The above table adopted from 2021 ESC Guideline |
|---|
Cardiac resynchronization therapy
- CRT reduces morbidity and mortality.
- CRT improves cardiac function, and enhances quality of life.
- Several characteristics predictors of improvement in morbidity and mortality including the extent of reverse remodelling as the most important mechanisms of action of CRT.
- Patients with HFrEF and ischemic etiology have less improvement in LV function due to myocardial scar tissue, which is less likely to undergo favorable remodelling.
- Women may be more likely to respond to CRT than men, possibly due to smaller body and heart size.
- QRS duration predicts CRT response.
- QRS morphology is related to a beneficial response to CRT.
- Patients with left bundle branch block (LBBB) morphology are more likely to respond favorably to CRT, whereas there is less certainty about patients with non-LBBB morphology.
- Patients with LBBB morphology often have wider QRS durations, and there is a current debate about whether QRS durations or QRS morphology is the
the main predictor of a beneficial response to CRT.
- there is little evidence to suggest that QRS morphology or etiology of disease influence the effect of CRT on morbidity or mortality.
- Implantation of CRT is not recommended if QRS duration is <130 ms.
- If a patient is scheduled to receive an ICD and is in sinus rhythm, with a LBBB, CRT-D should be considered if the QRS is between 130 and 149 ms and is recommended if QRS is >_150 ms.
- When LVEF is reduced, RV pacing may exacerbate cardiac dyssynchrony.
- This can be prevented by CRT, which might improve patient outcomes.
- CRT rather than RV pacing is recommended for patients with HFrEF regardless of NYHA class who have an indication for ventricular pacing in order to reduce morbidity, although no clear effect on mortality was observed.
- Patients with HFrEF who
have received a conventional pacemaker or an ICD and subsequently develop worsening HF with a high proportion of RV pacing, despite OMT, should be considered for ‘upgrading’ to CRT. Only two small trials have compared pharmacological therapy alone vs. CRT in patients with AF, with conflicting results. Several studies have indicated that CRT is superior to RV pacing in patients undergoing atrio-ventricular (AV) node ablation. 217,218,231 However, AF is not an indication to carry out AV node ablation in patients with CRT except in a few cases when ventricular rate remains persistently high despite attempts at pharmacological rate control. A subgroup analysis of patients with AF from the RAFT study found no benefit from CRT-D compared with ICD, although less than half of patients had >90% biventricular capture. 219 In view of the paucity of evidence for the efficacy of CRT in patients with AF, it may be an option in selected patients—particularly those with a QRS >_150 ms—ensuring a proportion of biventricular pac- ing as high as possible. Observational studies report that when biventricular capture is <98%, the prognosis of patients with CRT declines.218,232 Whether this association reflects a loss of resynchronization (which might be remedied by device programming), poor placement of the LV lead
References
- ↑ McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland J, Coats A, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam C, Lyon AR, McMurray J, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano G, Ruschitzka F, Kathrine Skibelund A (September 2021). "2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure". Eur Heart J. 42 (36): 3599–3726. doi:10.1093/eurheartj/ehab368. PMID 34447992 Check
|pmid=value (help). Vancouver style error: initials (help)