Cardiac resynchronization therapy indications

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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], 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.

2021 ESC Guideline for management of acute heart failure

Abbreviations: AHF: Acute heart failure; LMWH: Low-molecular-weight heparin; PaO2: Partial pressure of oxygen ; SBP: Systolic blood pressure; SpO2: Transcutaneous oxygen saturation;

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. ❑ CRT rather than RV pacing is recommended for patients with HFrEF regardless of NYHA class or QRS duration who have an indication for ventricular pacing for high degree AV block in order to reducemorbidity including AF

(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 ❑ CRT should be considered for symptomatic patients with HF in sinus rhythm with a QRS duration of130-149 ms and LBBB QRS morphology and with LVEF <_35% despite optimal medical therapy in order to improve symptoms and reduce morbidity and mortality ❑ Patients with an LVEF <_35% who have received a conventional pacemaker or an ICD and subsequently develop worsening HF despite optimal medical therapy and who have a significant proportion of RV pacing should be considered for upgrade to CRT

Diuretics :(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

Diuretics : (Class IIa, Level of Evidence B)

❑ In patients with resistant edema who do not respond to an increase in loop diuretic doses, combination of a loop diuretic with thiazide type diuretic should be considered

Vasodilators: (Class IIb, Level of Evidence B)

❑ In order to improve symptoms and reduce congestion in patients with AHF and SBP >110 mmHg, vasodilators may be considered as initial therapy

Inotropic agents : (Class 2b, Level of Evidence C)

❑ Inotropic agents may be considered in patients with SBP <90 mmHg and evidence of hypoperfusion without response to fluid challenge, to improve peripheral perfusion and maintain end-organ function

Inotropic agents (Class III, Level of Evidence C):

❑ Routinely administration of inotropic agents are not recommended , due to safety concerns, unless the patient has symptomatic hypotension and evidence of hypoperfusion

Vasopressors: (ClassIIb, Level of Evidence B)

❑ In patients with cardiogenic shock, a vasopressor, preferably norepinephrine, may be indicated to increase blood pressure and vital organ perfusion

Anticoagulant therapy: (ClassI, Level of Evidence A)

❑ Thromboembolism prophylaxis such as LMWH is recommended in patients not already anticoagulated and no contraindication to anticoagulation, to prevent the risk of deep venous thrombosis and pulmonary embolism

Opiates: (ClassIII, Level of Evidence C)

❑ Opiates is not routinely recommended, unless in selected patients with severe, intractable pain or anxiety

The above table adopted from 2021 ESC Guideline