Cardiac resynchronization therapy indications: Difference between revisions
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==='''[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]'''=== | ==='''[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]'''=== | ||
'''1)''' CRT is indicated for patients who have LVEF less than or equal to 35%, sinus rhythm, LBBB with a QRS duration greater than or equal to 150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT. (Level of Evidence: A for NYHA class III/IV (16–19); Level of Evidence: B for NYHA class II) | '''1)''' CRT is indicated for patients who have LVEF less than or equal to 35%, sinus rhythm, LBBB with a QRS duration greater than or equal to 150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]] for NYHA class III/IV (16–19); Level of Evidence: B for NYHA class II) | ||
==='''[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]'''=== | ==='''[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]'''=== | ||
'''1)''' | '''1)''' CRT can be useful for patients who have LVEF less than or equal to 35%, sinus rhythm, LBBB with a QRS duration 120 to 149 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) | ||
'''2)''' | '''2)''' CRT can be useful for patients who have LVEF less than or equal to 35%, sinus rhythm, a non-LBBB pattern with a QRS duration greater than or equal to 150 ms, and NYHA class III/ambulatory class IV symptoms on GDMT. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) | ||
'''3)''' CRT can be useful in patients with atrial fibrillation and LVEF less than or equal to 35% on GDMT if a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) AV nodal ablation or pharmacologic rate control will allow near 100% ventricular pacing with CRT. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) | |||
'''4)''' CRT can be useful for patients on GDMT who have LVEF less than or equal to 35% and are undergoing new or replacement device placement with anticipated requirement for significant (<40%) ventricular pacing. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) | |||
==='''[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]'''=== | ==='''[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]'''=== | ||
'''1)''' | '''1)''' CRT may be considered for patients who have LVEF less than or equal to 30%, ischemic etiology of heart failure, sinus rhythm, LBBB with a QRS duration of greater than or equal to 150 ms, and NYHA class I symptoms on GDMT. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) | ||
'''2)''' CRT may be considered for patients who have LVEF less than or equal to 35%, sinus rhythm, a non-LBBB pattern with QRS duration 120 to 149 ms, and NYHA class III/ambulatory class IV on GDMT. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) | |||
'''3)''' CRT may be considered for patients who have LVEF less than or equal to 35%, sinus rhythm, a non-LBBB pattern with a QRS duration greater than or equal to 150 ms, and NYHA class II symptoms on GDMT. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) | |||
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Revision as of 13:27, 11 September 2012
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Cardiac resynchronization therapy Microchapters |
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Cardiac resynchronization therapy indications On the Web |
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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] Synonyms and Keywords: CRT
Overview
Cardiac resynchronization therapy (CRT) with or without an ICD is indicated in patients who have an LVEF less than or equal to 35%, a QRS duration greater than or equal to 0.12 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
2012 American College of Cardiology Foundation/American Heart Association Task Force/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities [1] (DONOT EDIT)
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New Joint Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities |
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For ACC/AHA Level of evidence and classes click here.
ACC / AHA Guidelines - Recommendations for Cardiac Resynchronization Therapy in Patients with Severe Systolic Heart Failure (DO NOT EDIT)[2]
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Class I1) CRT is indicated for patients who have LVEF less than or equal to 35%, sinus rhythm, LBBB with a QRS duration greater than or equal to 150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT. (Level of Evidence: A for NYHA class III/IV (16–19); Level of Evidence: B for NYHA class II) Class IIa1) CRT can be useful for patients who have LVEF less than or equal to 35%, sinus rhythm, LBBB with a QRS duration 120 to 149 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT. (Level of Evidence: B) 2) CRT can be useful for patients who have LVEF less than or equal to 35%, sinus rhythm, a non-LBBB pattern with a QRS duration greater than or equal to 150 ms, and NYHA class III/ambulatory class IV symptoms on GDMT. (Level of Evidence: A) 3) CRT can be useful in patients with atrial fibrillation and LVEF less than or equal to 35% on GDMT if a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) AV nodal ablation or pharmacologic rate control will allow near 100% ventricular pacing with CRT. (Level of Evidence: B) 4) CRT can be useful for patients on GDMT who have LVEF less than or equal to 35% and are undergoing new or replacement device placement with anticipated requirement for significant (<40%) ventricular pacing. (Level of Evidence: C) Class IIb1) CRT may be considered for patients who have LVEF less than or equal to 30%, ischemic etiology of heart failure, sinus rhythm, LBBB with a QRS duration of greater than or equal to 150 ms, and NYHA class I symptoms on GDMT. (Level of Evidence: C) 2) CRT may be considered for patients who have LVEF less than or equal to 35%, sinus rhythm, a non-LBBB pattern with QRS duration 120 to 149 ms, and NYHA class III/ambulatory class IV on GDMT. (Level of Evidence: B) 3) CRT may be considered for patients who have LVEF less than or equal to 35%, sinus rhythm, a non-LBBB pattern with a QRS duration greater than or equal to 150 ms, and NYHA class II symptoms on GDMT. (Level of Evidence: B)
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Class I1) For patients who have LVEF less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and sinus rhythm, CRT with or without an ICD is indicated for the treatment of NYHA functional Class III or ambulatory Class IV heart failure symptoms with optimal recommended medical therapy. (Level of Evidence: A) Class IIa1) For patients who have LVEF less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and AF, CRT with or without an ICD is reasonable for the treatment of NYHA functional Class III or ambulatory Class IV heart failure symptoms on optimal recommended medical therapy. (Level of Evidence: B) 2) For patients with LVEF less than or equal to 35% with NYHA functional Class III or ambulatory Class IV symptoms who are receiving optimal recommended medical therapy and who have frequent dependence on ventricular pacing, CRT is reasonable. (Level of Evidence: C) Class IIb1) For patients with LVEF less than or equal to 35% with NYHA functional Class I or II symptoms who are receiving optimal recommended medical therapy and who are undergoing implantation of a permanent pacemaker and/or ICD with anticipated frequent ventricular pacing, CRT may be considered. (Level of Evidence: C)
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Unanswered Questions
Unanswered questions regarding the indications for CRT include:
- The identification of patients who would definitely benefit from CRT (i.e. reducing the number of non-responders). Different imaging modalities and dyssynchrony parameters may accurately reveal mechanical dyssynchrony and therefore predict a CRT responder, especially in patients with a narrow QRS complex.
- Further confirmatory evidence regarding the benefit of atrioventricular ablation versus pharmacological rate control in optimizing the clinical benefits is needed. In addition to atrioventricular and Ventricular-Ventricular optimization, other device based changes need to be explored so as to optimize the benefits of CRT.
References
- ↑ "American College of Cardiology Foundation | Journal of the American College of Cardiology | 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm AbnormalitiesA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Retrieved 2012-09-11.
- ↑ Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Smith SC, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Faxon DP, Halperin JL, Hiratzka LF, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW (2008). "ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons". Circulation. 117 (21): e350–408. doi:10.1161/CIRCUALTIONAHA.108.189742. PMID 18483207. Retrieved 2011-01-15. Unknown parameter
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