Cardiac resynchronization therapy indications: Difference between revisions

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__NOTOC__
{{Cardiac resynchronization therapy}}
{{Cardiac resynchronization therapy}}
{{CMG}}; {{AOEIC}}: Bhaskar Purushottam, M.D. [mailto:bpurushottam@gmail.com]
{{CMG}}; {{AOEIC}}: Bhaskar Purushottam, M.D. [mailto:bpurushottam@gmail.com]
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==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 <ref name="urlAmerican 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">{{cite web |url=http://content.onlinejacc.org/article.aspx?articleid=1357576 |title=American College of Cardiology Foundation &#124; Journal of the American College of Cardiology &#124; 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 |format= |work= |accessdate=2012-09-11}}</ref> (DO NOT EDIT)==
==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 <ref name="urlAmerican 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">{{cite web |url=http://content.onlinejacc.org/article.aspx?articleid=1357576 |title=American College of Cardiology Foundation &#124; Journal of the American College of Cardiology &#124; 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 |format= |work= |accessdate=2012-09-11}}</ref> (DO NOT EDIT)==


{{cquote|
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]


==='''[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]'''===
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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; [[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]] for NYHA class II)'' <nowiki>"</nowiki>
|}


'''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)
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)


==='''[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]'''===
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' CRT is not recommended for patients with NYHA class I or II symptoms and non-LBBB pattern with QRS duration less than 150 ms.20,21,30 ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>


'''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]])
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' CRT is not indicated for patients whose comorbidities and/or frailty limit survival with good functional capacity to less than 1 year.19 (Level of Evidence: C)[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}


'''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]])
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]


'''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]])
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]])'' <nowiki>"</nowiki>


'''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]])
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]])'' <nowiki>"</nowiki>


==='''[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]'''===
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]])'' <nowiki>"</nowiki>


'''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]])
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]])'' <nowiki>"</nowiki>


'''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]])
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]


'''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]])
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]])'' <nowiki>"</nowiki>


}}
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]])'' <nowiki>"</nowiki>
 
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]])'' <nowiki>"</nowiki>
|}


'''For ACC/AHA Level of evidence and classes click [[ACC AHA Guidelines Classification Scheme|here]].'''
'''For ACC/AHA Level of evidence and classes click [[ACC AHA Guidelines Classification Scheme|here]].'''

Revision as of 19:16, 4 October 2012

Cardiac resynchronization therapy Microchapters

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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

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] (DO NOT EDIT)

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; Level of Evidence: B for NYHA class II) "
Class III (No Benefit)
"1. CRT is not recommended for patients with NYHA class I or II symptoms and non-LBBB pattern with QRS duration less than 150 ms.20,21,30 (Level of Evidence: B) "
"2. CRT is not indicated for patients whose comorbidities and/or frailty limit survival with good functional capacity to less than 1 year.19 (Level of Evidence: C)Level of Evidence: C) "
Class IIa
"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. (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 IIb
"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. (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) "

For ACC/AHA Level of evidence and classes click here.

Unanswered Questions

Unanswered questions regarding the indications for CRT include:

  1. 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.
  2. 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

  1. ↑ "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.

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