CRT Today: US Updates Guidelines; Transatlantic Focus on Follow-up

September 10, 2012

September 10, 2012 (Washington, DC)— US societies have jointly released a guidelines update for cardiac resynchronization therapy (CRT) that refines criteria for a class I indication by including patients in NYHA functional class 2 but requiring a longer QRS duration than before as well as the presence of left-bundle-branch block (LBBB) [1].

The new document from the American College of Cardiology (ACC), American Heart Association (AHA), and the Heart Rhythm Society (HRS) elaborates on a similar document published by the Heart Failure Society of America (HFSA) [2] in February and mirrors one released by the European Society of Cardiology (ESC) in May [3].

The documents complement a novel consensus statement from the HRS and the European Heart Rhythm Association (EHRA), formally unveiled at last month's European Society of Cardiology (ESC) 2012 Congress, and provide a blueprint for the management of patients before, during, and after implantation of a CRT device.

LBBB Central to New Indications in US Focused Update

In the new document, for patients with an LVEF <35% who are in sinus rhythm:

  • A class I recommendation ("is indicated") extends to patients with LBBB and a QRS interval >150 ms who are in NYHA class 2, 3, or (ambulatory) 4.

  • A class IIa recommendation ("can be useful") includes patients with LBBB but with a QRS interval of 120 to 149 ms, who can be in NYHA class 2, 3, or (ambulatory) 4; without LBBB, the QRS interval must be >150 ms.

A class IIb recommendation ("may be considered") applies to patients in NYHA class 1 at the more depressed LVEF of <30% if the heart failure is ischemic in nature; there also must be LBBB with a QRS interval >150 ms.

As previously reported, the European guidelines require an LVEF of <30% for a class I indication.

The new ACC/AHA/HRS document, with writing-group chair Dr Cynthia Tracy (George Washington University, Washington, DC), states it will be published in all three groups' flagship journals and posted on their websites. But they were developed in collaboration with the HFSA, American Association for Thoracic Surgery, and Society of Thoracic Surgeons.

First Consensus-Based Management Recommendations

"This is the first consensus statement on all of the practical aspects involved in managing CRT patients throughout their entire journey on CRT," said task-force cochair Prof Jean-Claude Daubert (University of Rennes, France) in a press release from the ESC, which includes the EHRA [4].

Also in the press release, task force cochair Dr Leslie A Saxon (University of Southern California, Los Angeles) said the consensus-statement writers "attempted to fill in the gaps in clinical evidence and provide practical recommendations for the evaluation and management of the CRT patient that could be applied to patients implanted anywhere in the world."

The transatlantic document covers, in separate sections:

  • Preimplantation management, including medical therapy--particularly antibiotics and antithrombotics--for which there had previously been no consensus, according to Daubert.

  • The implantation process, including anesthesia, the order of lead placement, and criteria for LV lead placement and defibrillation testing.

  • Predischarge management of acute complications and device programming.

  • Follow-up management, with special emphasis on managing the patient's heart failure and including the use of remote monitoring and hemodynamic monitoring; "the need for strong cooperation between the heart-failure specialist and the electrophysiologist is stressed," according to the press release.

  • Assessing CRT response and management of nonresponders; recommendations in patients with atrial fibrillation; CRT with or without defibrillation capability; and cost-effectiveness and end-of-life issues.

The statement, which is published in the HRS and EHRA official journals, was developed in collaboration with the AHA, HFSA, American Society of Echocardiography, and the ESC-backed European Association of Echocardiography and Heart Failure Association.

Tracy is noted as having no relevant relationships to disclose; disclosures for the other writing-group members and coauthors and for the document reviewers are listed in the paper. Daubert discloses having received speaker fees, honoraria, and consultancy or advisory-board fees or receiving payment for serving as an investigator or committee member from Boehringer Ingelheim, Sanofi, Medtronic, Sorin Group, St Jude Medical, EBR Systems, Novartis, and; and reports his institution received such payments from Medtronic. Saxon discloses receiving payments in the form of speaker fees, honoraria, or consultancy or advisory-board fees or receiving payment for serving as an investigator or committee member from Boston Scientific; her institution has received payments from Medtronic; and she has received royalties for intellectual property from St Jude Medical.