Congestive heart failure biventricular pacing or cardiac resynchronization therapy
Editor(s)-In-Chief: James Chang, M.D., Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School [1] and C. Michael Gibson, M.S., M.D. [2], Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [3]
Overview
- Cardiac resynchronization therapy should only be undertaken if the blood pressure is low and if the heart failure medicines have been optimized
- CRT is indicated for symptomatic patients with NYHA III-IV heart failure and wide QRS complex (>120ms) who are him normal sinus rhythm.
- 70% of patients receiving synchronous ventricular contraction report significant symptomatic improvements.
Indications for Cardiac Resynchronization Therapy
1. The left ventricular ejection fraction (LVEF) is ≤ 35%
and
2. There is evidence of left bundle branch block (LBBB) or QRS ≥ 120 msec
and
3. Left ventricular end-diastolic diamter (LVEDD) ≥ 5.5 cms
Background
- Cardiac resynchronization therapy (CRT) is recommended for all patients with LVEF ≤ 35%, dilated LV (LVEDD > 5.5 cm), left bundle branch block (QRS duration > 120 msec), and sinus rhythm. CRT improves functional status and decreases mortality in the majority of these patients.
- In the REVERSE[1] and MADIT-CRT[2] trials patients with NYHA I or II had decreased heart failure events and increased reverse remodeling of the left ventricle. This is not yet an AHA guideline but should be considered in this group of patients based on the available evidence.
ACC/AHA Guidelines- Cardiac Resynchronization Recommendation [3]
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Class I1. Patients with left ventricular ejection fraction (LVEF) of less than or equal to 35%, sinus rhythm, and NYHA functional class III or ambulatory class IV symptoms despite recommended, optimal medical therapy and who have cardiac dyssynchrony, which is currently defined as a QRS duration greater than or equal to 0.12 seconds, should receive cardiac resynchronization therapy, with or without an implantable cardioverter defibrillator (ICD), unless contraindicated. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] (Level of Evidence: A) Class IIa1. For patients who have left ventricular ejection fraction less than or equal to 35%, a QRS duration of greater than or equal to 0.12 seconds, and atrial fibrillation, cardiac resynchronization therapy (CRT) with or without an implantable cardioverter defibrillator (ICD) is reasonable for the treatment of NYHA functional class III or ambulatory class IV heart failure symptoms on optimal recommended medical therapy. [20][21] (Level of Evidence: B) 2. For patients with left ventricular ejection fraction of 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, cardiac resynchronization therapy is reasonable. [20] (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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Vote on and Suggest Revisions to the Current Guidelines
Guidelines Resources
- The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult [22]
- 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation [23]
References
- ↑ Daubert C, Gold MR, Abraham WT, Ghio S, Hassager C, Goode G, Szili-Török T, Linde C (2009). "Prevention of disease progression by cardiac resynchronization therapy in patients with asymptomatic or mildly symptomatic left ventricular dysfunction: insights from the European cohort of the REVERSE (Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction) trial". Journal of the American College of Cardiology. 54 (20): 1837–46. doi:10.1016/j.jacc.2009.08.011. PMID 19800193. Retrieved 2012-04-03. Unknown parameter
|month=ignored (help) - ↑ Moss AJ, Hall WJ, Cannom DS, Klein H, Brown MW, Daubert JP, Estes NA, Foster E, Greenberg H, Higgins SL, Pfeffer MA, Solomon SD, Wilber D, Zareba W (2009). "Cardiac-resynchronization therapy for the prevention of heart-failure events". The New England Journal of Medicine. 361 (14): 1329–38. doi:10.1056/NEJMoa0906431. PMID 19723701. Retrieved 2012-04-03. Unknown parameter
|month=ignored (help) - ↑ 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
|month=ignored (help) - ↑ Beshai JF, Grimm RA, Nagueh SF, Baker JH, Beau SL, Greenberg SM, Pires LA, Tchou PJ (2007). "Cardiac-resynchronization therapy in heart failure with narrow QRS complexes". The New England Journal of Medicine. 357 (24): 2461–71. doi:10.1056/NEJMoa0706695. PMID 17986493. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, Tavazzi L (2005). "The effect of cardiac resynchronization on morbidity and mortality in heart failure". The New England Journal of Medicine. 352 (15): 1539–49. doi:10.1056/NEJMoa050496. PMID 15753115. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Higgins SL, Hummel JD, Niazi IK, Giudici MC, Worley SJ, Saxon LA, Boehmer JP, Higginbotham MB, De Marco T, Foster E, Yong PG (2003). "Cardiac resynchronization therapy for the treatment of heart failure in patients with intraventricular conduction delay and malignant ventricular tachyarrhythmias". Journal of the American College of Cardiology. 42 (8): 1454–9. PMID 14563591. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Xiao HB, Roy C, Fujimoto S, Gibson DG (1996). "Natural history of abnormal conduction and its relation to prognosis in patients with dilated cardiomyopathy". International Journal of Cardiology. 53 (2): 163–70. PMID 8682602. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Shamim W, Francis DP, Yousufuddin M, Varney S, Pieopli MF, Anker SD, Coats AJ (1999). "Intraventricular conduction delay: a prognostic marker in chronic heart failure". International Journal of Cardiology. 70 (2): 171–8. PMID 10454306. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Unverferth DV, Magorien RD, Moeschberger ML, Baker PB, Fetters JK, Leier CV (1984). "Factors influencing the one-year mortality of dilated cardiomyopathy". The American Journal of Cardiology. 54 (1): 147–52. PMID 6741806. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Blanc JJ, Etienne Y, Gilard M, Mansourati J, Munier S, Boschat J, Benditt DG, Lurie KG (1997). "Evaluation of different ventricular pacing sites in patients with severe heart failure: results of an acute hemodynamic study". Circulation. 96 (10): 3273–7. PMID 9396415. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Kass DA, Chen CH, Curry C, Talbot M, Berger R, Fetics B, Nevo E (1999). "Improved left ventricular mechanics from acute VDD pacing in patients with dilated cardiomyopathy and ventricular conduction delay". Circulation. 99 (12): 1567–73. PMID 10096932. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Toussaint JF, Lavergne T, Ollitraut J, Hignette C, Darondel JM, De Dieuleveult B, Froissart M, Le Heuzey JY, Guize L, Paillard M (2000). "Biventricular pacing in severe heart failure patients reverses electromechanical dyssynchronization from apex to base". Pacing and Clinical Electrophysiology : PACE. 23 (11 Pt 2): 1731–4. PMID 11139911. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Nelson GS, Berger RD, Fetics BJ, Talbot M, Spinelli JC, Hare JM, Kass DA (2000). "Left ventricular or biventricular pacing improves cardiac function at diminished energy cost in patients with dilated cardiomyopathy and left bundle-branch block". Circulation. 102 (25): 3053–9. PMID 11120694. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E, Kocovic DZ, Packer M, Clavell AL, Hayes DL, Ellestad M, Trupp RJ, Underwood J, Pickering F, Truex C, McAtee P, Messenger J (2002). "Cardiac resynchronization in chronic heart failure". The New England Journal of Medicine. 346 (24): 1845–53. doi:10.1056/NEJMoa013168. PMID 12063368. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Young JB, Abraham WT, Smith AL, Leon AR, Lieberman R, Wilkoff B, Canby RC, Schroeder JS, Liem LB, Hall S, Wheelan K (2003). "Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial". JAMA : the Journal of the American Medical Association. 289 (20): 2685–94. doi:10.1001/jama.289.20.2685. PMID 12771115. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ McAlister FA, Stewart S, Ferrua S, McMurray JJ (2004). "Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials". Journal of the American College of Cardiology. 44 (4): 810–9. doi:10.1016/j.jacc.2004.05.055. PMID 15312864. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T, Carson P, DiCarlo L, DeMets D, White BG, DeVries DW, Feldman AM (2004). "Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure". The New England Journal of Medicine. 350 (21): 2140–50. doi:10.1056/NEJMoa032423. PMID 15152059. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Leclercq C, Walker S, Linde C, Clementy J, Marshall AJ, Ritter P, Djiane P, Mabo P, Levy T, Gadler F, Bailleul C, Daubert JC (2002). "Comparative effects of permanent biventricular and right-univentricular pacing in heart failure patients with chronic atrial fibrillation". European Heart Journal. 23 (22): 1780–7. PMID 12419298. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Leon AR, Greenberg JM, Kanuru N, Baker CM, Mera FV, Smith AL, Langberg JJ, DeLurgio DB (2002). "Cardiac resynchronization in patients with congestive heart failure and chronic atrial fibrillation: effect of upgrading to biventricular pacing after chronic right ventricular pacing". Journal of the American College of Cardiology. 39 (8): 1258–63. PMID 11955841. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ 20.0 20.1 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW (2009). "2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation". Journal of the American College of Cardiology. 53 (15): e1–e90. doi:10.1016/j.jacc.2008.11.013. PMID 19358937. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Cazeau S, Leclercq C, Lavergne T, Walker S, Varma C, Linde C, Garrigue S, Kappenberger L, Haywood GA, Santini M, Bailleul C, Daubert JC (2001). "Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay". The New England Journal of Medicine. 344 (12): 873–80. doi:10.1056/NEJM200103223441202. PMID 11259720. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
- ↑ Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967