Copyright © 2013, Canadian Cardiovascular Society 13/11/2015 1 Anderson TJ, Gregoire J et al., Can...

Copyright © 2013, Canadian Cardiovascular Society23-04-21 1

Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

Disclaimer

The Canadian Cardiovascular Society (CCS) welcomes reuse of our educational slide deck for medical institution internal education or training (i.e. grand rounds, medical college/classroom education, etc.). However, if the material is being used in an industry sponsored CME program, permission must be sought through our publisher Elsevier (www.onlinecjc.com). If your reuse request qualifies as medical institution internal education, you may reuse the material under the following conditions:

• You must cite the Canadian Journal of Cardiology and the Canadian Cardiovascular Society as references.

• You may not use any Canadian Cardiovascular Society logos or trademarks on any slides or anywhere in your presentation or publications.• Do not modify the slide content.• If repeating recommendations from the published guideline, do not modify the recommendation wording.

23-04-21 2Copyright © 2013, Canadian Cardiovascular Society

Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195

CANADIAN CARDIOVASCULAR SOCIETY GUIDELINES ON THE USE OF CARDIAC

RESYNCHRONIZATION THERAPY: EVIDENCE AND PATIENT SELECTION

R Parkash, F Philippon, D Exner, and D Birnieon behalf of the CRT Guidelines Panels.



Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection

Disclosures

www.ccs.ca

Guidelines are available on line

www.ccsguidelineprograms.ca

Can J Cardiol 2013; 29(2):182-195




CCS CRT Guidelines 2012Secondary Panel•Lyall Higginson•Jonathan Howlett•Aaron Low•Robert McKelvie•John Sapp•Miriam Shanks •Mario Talajic•Michel White•Raymond Yee

Primary Panel•David Birnie•Derek Exner (co-chair)•Jeff Healey•Eric LaRose•Gordon Moe•Ratika Parkash (co-chair)•François Philippon•Anthony Tang•Bernard Thibault




Session Overview

• Focus on evidence-based prescription of CRT, based on scientific data

• Review of GRADE process

• Case-based presentation of guidelines

– Eight recommendations

– Practical Tips




Objectives

At the end of this session:1. Review the appropriate selection of patients for CRT2. Discuss the role of CRT-pacing3. Describe the risks and benefits related to patients with

AF, RBBB and chronic RV pacing4. Understand technical issues related to CRT including

lead placement5. Discuss the role of imaging in assessment of CRT




GRADE Approach• Development of guidelines through:

– Critical evaluation of literature– Expert consensus– Use of Grading of Recommendations Assessment,

Development, and Evaluation 1. Quality of Evidence:

High, Moderate, Low or Very Low2. Strength of Recommendations

Strong or WeakGuyatt et al. 2011 J Clin Epi 64: 383-94




Case 1

• 78 year old woman– sinus rhythm, – dilated cardiomyopathy (NYHA III), &– LVEF 25%– Co-morbidities – DM, PVD, & eGFR 33 ml/min

• Medications:– Carvedilol (6.125 mg BID) & ramipril (1.25 mg OD)

initiated 5 weeks ago (not on spironolactone).




Case 1 - ECG




Recommendation One Strength Quality

Adequate medical therapy be

implemented prior to the

initiation of CRT, that each

patient’s suitability for CRT be

thoroughly assessed, and the

details of that assessment be

recorded in their medical record.

Strong Low

Can J Cardiol 2013; 29(2):182-195




• Continued up-titration of medical therapy– Carvedilol (25 mg BID), ramipril (5 mg OD) &

spironolactone (25mg OD)

• Remains class III, LVEF now 30%

Case 1 - continued




Recommendation One - Practical Tips

• The reasons for non-use of recommended heart failure medications or the prescription of lower than the recommended doses of these agents should be recorded.

• Each patient’s functional capacity should be assessed, the QRS duration measured from a standard 12 lead ECG, and the LVEF quantified using a validated assessment method.




Recommendation Two Strength Quality

CRT is recommended for patients

in sinus rhythm with NYHA class

II / III / ambulatory IV heart failure

symptoms, a LVEF ≤ 35%, and

QRS duration ≥ 130 ms due to

left bundle branch block.

Strong High

Can J Cardiol 2013; 29(2):182-195




Clinical Trial Evidence

Can J Cardiol 2013; 29(2):182-195








Summary of Evidence

• Very few NYHA I or non-ambulatory IV patients• Mean QRS: 153-173 ms• Most had LBBB• Patients with severe comorbidities excluded:

– Severe pulmonary disease– Severe liver disease– Severe renal disease– Limited life expectancy




Recommendation Two - Practical Tips

• There is insufficient evidence to recommend CRT for patients with NYHA class I or patients non-ambulatory class IV NYHA symptoms.

• There is also insufficient data to recommend CRT in patients with QRS duration < 130 ms.

• Patients with LBBB and QRS duration ≥ 150 ms appear more likely to benefit from CRT than patients with non-LBBB conduction and/or less QRS prolongation.




Review of Case 1

• 78 year old woman– sinus rhythm, – dilated cardiomyopathy (NYHA III), &– LVEF 30%– Co-morbidities - DM, PVD, & eGFR 33 ml/min– Carvedilol (25 mg BID), ramipril (5 mg OD) &

sprionolactone (25 mg OD).




Recommendation Three Strength Quality

A CRT pacemaker is

recommended for patients

who are suitable for

resynchronization therapy,

but not for an ICD.

Strong Moderate

Can J Cardiol 2013; 29(2):182-195





Can J Cardiol 2013; 29(2):182-195




Summary: CRT-P & CRT-D

COMPANIONDeath or hospitalisation

• CRT-P: HR 0.81 p<0.01• CRT-D: HR 0.80 p<0.01

Death• CRT-P: HR 0.76 p=0.059• CRT-D: HR 0.64 p=0.003

CARE HFDeath or hospitalisation

• CRT-P: 0.73 p<0.001

Death• CRT-P: 0.74 p<0.0002




Risk Factors•NYHA > II•Age > 70 years•BUN > 26 mg/dl•QRSd > 120 ms•AF

• MADIT II cohort• 1191 pts• F-UP 8 years




JACC 2012; 59:2075-9







Recommendation Three - Practical Tips

• CRT-P has been shown to reduce morbidity and mortality in patients with NYHA class III and ambulatory class IV heart failure symptoms.

• Therapy should be individualized in accordance with the overall goals of care.




Case 2

• 57 year old man– Paroxysmal atrial fibrillation, – Ischemic cardiomyopathy (NYHA II), & LVEF 28%– Co-morbidities - HTN

• Medications:– EC ASA 81 mg OD, bisoprolol (10 mg OD),

perindopril (8 mg OD), spironolactone (25 mg OD) & rosuvastatin 20 mg OD.




Case 2 - ECG




Recommendation Five Strength Quality

CRT may be considered for

patients in permanent AF

who are otherwise suitable

for this therapy.

Weak Low

Can J Cardiol 2013; 29(2):182-195




Utility of CRT in Patients with AF

Systematic review and meta-analysis

Death, CRT non-response, LV remodeling, quality of life, & six-min walk distance.

23 observational studies, 7,495 CRT recipients

25.5% with AF,

Mean follow-up of 33 months. Wilton et al. Heart Rhythm 2011;8:1088-94




Greater non-response (34.5% AF vs. 26.7% NSR)

Wilton et al. Heart Rhythm 2011;8:1088-94




Higher annual mortality (10.8% AF vs. 7.1% NSR)

Wilton et al. Heart Rhythm 2011;8:1088-94




RAFT – AF Subset

Healey et al. Circulation Heart Failure 2012;5:566-70.

~ 34% of CRT-treated patients had ≥95% & ~ 47% had ≥90% biventricular pacing.




RAFT – AF Subset

Healey et al. Circulation Heart Failure 2012;5:566-70.




Recommendation Five - Practical Tips• The amount of biventricular pacing needs to be

evaluated.

• Arrhythmia device counters alone may not accurately reflect the true percent biventricular pacing.

• It is important to ensure a very high percentage of biventricular pacing.

• AV junctional ablation may be necessary to achieve sufficient biventricular pacing.




Case 2 – continued (amiodarone added)




Recommendation Six Strength Quality


patients in sinus rhythm with

NYHA class II / III / ambulatory

IV heart failure, LVEF ≤ 35%,

& QRS duration ≥ 150 msec

not due to LBBB conduction.

Weak Low

Can J Cardiol 2013; 29(2):182-195




CRT in Patients with RBBBFive studies, with 259 patients randomized to CRT and 226 randomized to non-CRT.

RBBB; N (%)MIRACLE 28 (6.2)CONTAK CD 33 (5.7)CARE-HF 35 (4.3)MADIT-CRT 228 (12.5)RAFT 161 (9.0)

Nery et al. Heart Rhythm 2011;8:1083-87



CRT-D

ICD

RBBB

HR (95% CI): 1.24 (0.65, 2.36)Log rank p = 0.48

NIVCD

HR (95% CI): 1.0 (0.60, 1.66)Log rank p = 0.84

RAFTBirnie et al CCS Conference , Vancouver2011







Severely prolonged QRS

Moderately prolonged QRS

Systematic review and meta-analysis




Recommendation Six - Practical Tip

• There is no clear evidence of benefit with CRT among patients with QRS durations < 150 ms due to non-LBBB conduction.




Echo Dyssynchrony Assessment




Recommendation Eight Strength Quality

Routine assessment of

dyssynchrony with present

echocardiographic techniques

is not recommended to guide

the prescription of CRT.

Strong Low

Can J Cardiol 2013; 29(2):182-195




Mechanical Dyssynchrony

Mostly echo; some nuclear & MRISingle center studies: echo mechanical dyssynchrony accurately predicts response to CRT Large multi-centre study (PROSPECT): failed to confirm this.

PROSPECT STUDY (Circulation. 2008;117: 2608-2616.)

Conclusion “no echo measure of mechanical dyssynchrony can be used to improve selection of patients for CRT”




LV scar and response to CRT

• The extent of LV scaring seems important in determining response to CRT

• Some studies have found that it is the global extent of LV scar that is important

• Others found the size of the lateral to be key.




Recommendation Eight - Practical Tips

• Issues of reproducibility and inter- and intra-rater assessment limit the routine role of echo to guide the prescription of CRT.

• The utility of imaging methods is under investigation.




72 year old female

•Dual chamber pacemaker (AVB in 2006)

• Before PM - underlying atrial rhythm with 1° AV block, QRS 80 ms, & LVEF 45%

• Now - 100% RV paced (underlying CHB)

• LVEF now 32%, BNP is 1200

• Progressive DOE (now NYHA III)

•Carvedilol 25 mg BID, Ramipril 10 mg BID, & Spironolactone 25 mg OD

Case 3




Case 3 - ECG




Recommendation Seven Strength Quality


patients who are chronically

RV-paced or are likely to be

chronically paced, have

signs and/or symptoms of

heart failure, and a LVEF ≤

35%.

Weak Low

Can J Cardiol 2013; 29(2):182-195




Biventricular vs. LV Pacing in Patients with LV Dysfunction and AV Block (BLOCK HF)

N = 691; LV dysfunction & heart block CRT versus RV pacing (pacemaker or ICD).Mean LVEF 40%, 84% NYHA class II or III, Average follow-up 37 monthsResults for CRT vs. RV pacing

- 25% reduction in risk of death, need for IV HF therapy, or > 15% LV ESV index (1° outcome)

- 30% reduction in HF hospitalization (2° outcome) - No significant Δ in mortality (2° outcome)




Recommendation Seven - Practical Tips• RV pacing may be harmful and strategies to minimize RV

pacing should be implemented prior to CRT upgrade.• The utility of CRT in patients who do not have a pre-

existing LBBB and are chronically RV paced is uncertain. • Patients undergoing AV junctional ablation with

moderate LV dysfunction may benefit from CRT.• It is often difficult to reliably predict which patients will

be chronically RV paced at the time initiating pacing.• The risks of CRT upgrade need to be considered and

balanced with the potential benefits of CRT upgrade.




Angiogram

1

2

3




Recommendation Four Strength Quality

In patients treated with CRT,

pacing from a non-apical LV

epicardial region may be

considered.

Weak Low

Can J Cardiol 2013; 29(2):182-195




Avoid “apical”Circulation 2011;123:1166




Anterior vs. lateral vs. posteriorCirculation 2011;123:1166




LV Lead Placement




Questions & Review of Objectives

1. Review the appropriate selection of patients for CRT

2. Discuss the role of CRT-pacing

3. Describe the risks and benefits related to patients with AF, RBBB and chronic RV pacing

4. Understand technical issues related to CRT including lead placement

5. Discuss the role of imaging in assessment of CRT

Date post:	13-Jan-2016
Category:	Documents
Upload:	antony-kelly
View:	212 times
Download:	0 times

Copyright © 2013, Canadian Cardiovascular Society 13/11/2015 1 Anderson TJ, Gregoire J et al., Can...

Documents