update on indications for cardiac resynchronization therapy maria rosa costanzo, m.d., f.a.c.c.,...
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- Slide 1
- Update on Indications for Cardiac Resynchronization Therapy Maria Rosa Costanzo, M.D., F.A.C.C., F.A.H.A. Medical Director, Midwest Heart Specialists-Advocate Medical Group Heart Failure and Pulmonary Arterial Hypertension Programs Heart Failure and Pulmonary Arterial Hypertension Programs Medical Director, Edward Hospital Center for Advanced Heart Failure Naperville, Illinois, U.S.A.
- Slide 2
- ACC/AHA DBT guidelines, 2012
- Slide 3
- 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities Class I CRT is indicated for pts. who have LVEF 35%, SR, LBBB with a QRS duration 150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT. CRT is indicated for pts. who have LVEF 35%, SR, LBBB with a QRS duration 150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT. Level of Evidence: A for NYHA class III/IV (MIRACLE, COMPANION, CARE-HF); Level of Evidence: A for NYHA class III/IV (MIRACLE, COMPANION, CARE-HF); Level of Evidence: B for NYHA class II (MADIT- CRT) Level of Evidence: B for NYHA class II (MADIT- CRT)Comments Modified recommendation specifying CRT in pts with LBBB of 150 ms expanded to include those with NYHA class II symptoms Tracy CM et al. JACC 2012:60:1297-1311
- Slide 4
- 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities Class IIa CRT can be useful for pts. with LVEF 35%, Sr, LBBB with a QRS duration 120 to 149 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT. (Level of Evidence: B) CRT can be useful for pts. with LVEF 35%, Sr, LBBB with a QRS duration 120 to 149 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT. (Level of Evidence: B) CRT can be useful for pts who have LVEF 35%, SR, a non-LBBB pattern with a QRS duration 150 ms, and NYHA class III/ambulatory class IV symptoms on GDMT. (Level of Evidence: A) CRT can be useful for pts who have LVEF 35%, SR, a non-LBBB pattern with a QRS duration 150 ms, and NYHA class III/ambulatory class IV symptoms on GDMT. (Level of Evidence: A) CRT can be useful in pts. with AF and LVEF 35% on GDMT (Level of Evidence: B) if CRT can be useful in pts. with AF and LVEF 35% on GDMT (Level of Evidence: B) 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. CRT can be useful for pts. on GDMT who have LVEF 35% and are undergoing new or replacement device placement with anticipated requirement for significant (>40%) ventricular pacing). (Level of Evidence: C) CRT can be useful for pts. on GDMT who have LVEF 35% and are undergoing new or replacement device placement with anticipated requirement for significant (>40%) ventricular pacing). (Level of Evidence: C)Comments New recommendation Modified recommendation (wording changed to indicate benefit based on EF rather than NYHA class; level of evidence changed from C to B). Modified recommendation (wording changed to indicate benefit based on EF and need for pacing rather than NYHA class); class changed from IIb to IIa).
- Slide 5
- 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities Class IIb CRT may be considered for pts. who have LVEF 30%, ischemic HF etiology SR, LBBB with a QRS duration 150 ms, and NYHA class I symptoms on GDMT. (Level of Evidence: C) CRT may be considered for pts. who have LVEF 30%, ischemic HF etiology SR, LBBB with a QRS duration 150 ms, and NYHA class I symptoms on GDMT. (Level of Evidence: C) CRT may be considered for pts. who have LVEF 35%, SR, a non-LBBB pattern with QRS duration 120 to 149 ms, and NYHA class III/ambulatory class IV on GDMT). (Level of Evidence: B) CRT may be considered for pts. who have LVEF 35%, SR, a non-LBBB pattern with QRS duration 120 to 149 ms, and NYHA class III/ambulatory class IV on GDMT). (Level of Evidence: B) CRT may be considered for pts. who have LVEF 35%, SR, a non-LBBB pattern with a QRS duration 150 ms, and NYHA class II symptoms on GDMT. (Level of Evidence: B) CRT may be considered for pts. who have LVEF 35%, SR, a non-LBBB pattern with a QRS duration 150 ms, and NYHA class II symptoms on GDMT. (Level of Evidence: B)Comments New recommendation New recommendations Tracy CM et al. JACC 2012:60:1297-1311
- Slide 6
- 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities Class III CRT is not recommended for pts. with NYHA class I or II symptoms and non- LBBB pattern with QRS duration < 150 ms. (Level of Evidence: B) CRT is not recommended for pts. with NYHA class I or II symptoms and non- LBBB pattern with QRS duration < 150 ms. (Level of Evidence: B) CRT is not indicated for pts whose comorbidities and/or frailty limit survival with good functional capacity to less than 1 year ). (Level of Evidence: C) CRT is not indicated for pts whose comorbidities and/or frailty limit survival with good functional capacity to less than 1 year ). (Level of Evidence: C)Comments New recommendation Modified recommendation (wording changed to include cardiac as well as noncardiac comorbidities). Tracy CM et al. JACC 2012:60:1297-1311
- Slide 7
- The Influence of Left Ventricular Ejection Fraction on the Effectiveness of Cardiac Resynchronization Therapy: MADIT-CRT Kutyifa V et al. JACC. 2013;61:936-944
- Slide 8
- The Influence of Left Ventricular Ejection Fraction on the Effectiveness of Cardiac Resynchronization Therapy: MADIT-CRT Kutyifa V et al. JACC. 2013;61:936-944
- Slide 9
- The Influence of Left Ventricular Ejection Fraction on the Effectiveness of Cardiac Resynchronization Therapy: MADIT-CRT Kutyifa V et al. JACC. 2013;61:936-944
- Slide 10
- Device Therapy in Heart Failure: Has CRT Changed the Sickest Benefit the Most to the Healthiest Benefit the Most? JACC 2013;61(9):945-947
- Slide 11
- Differential Response to CRT by QRS Morphology and Duration Dupont M et al. JACC 2012; 60: 592-8
- Slide 12
- Histogram of QRS Duration in the Study Population Dupont M et al. JACC 2012; 60: 592-8
- Slide 13
- Echocardiographic and Clinical Response to CRT by QRS Morphology and Duration After CRT, patients with LBBB morphology and/or QRS duration 150 ms had statistically significantly greater improvement in: EF EF LVEDD LVEDD LVESD LVESD MR grade change MR grade change % of super-responders % of super-responders NYHA functional class NYHA functional class Dupont M et al. JACC 2012; 60: 592-8
- Slide 14
- Survival after CRT Implantation Dupont M et al. JACC 2012; 60: 592-8
- Slide 15
- Cox Proportional Hazards Models for Death, Heart transplantation and LAVD Placement VariableAdjusted HRP Value LBBB and QRS 150 ms 1.00 LBBB and QRS
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