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Cardiac Cardiac Resynchronization Resynchronization Therapy (CRT)KRISTY GAMA, NP, INSTRUCTOR OF MEDICINE, DIVISION OF CARDIOLOGY
Discuss indications for CRT placemen, including situations where device may not be indicated
Provide an overview of cardiac device therapy, along with NASPE/BPEG codingId tif h t f ti t t i li t f Identify when to refer patient to specialist for consideration of device therapy
What next steps would you take to help Sir EJ’s symptoms
A. Increase lisinopril 40 mg B check labs (i e CBC CMP) B. check labs (i.e CBC, CMP) C. Switch lisinopril to subactril/valsartan (Entresto) D Consider cardiac resynchronization therapy D. Consider cardiac resynchronization therapy
Example: single-chamber pacemaker with lead in the RV
VVI/VVIO PACE in V SENSE in V SENSE in V Inhibit in response to sensed V Rate responsiveness OFF http://www.ohsu.edu/xd/health/services/heart-vascular/getting-
Like ¼ HFrEF patients, he has an LBBB that has been associated with dyssynchrony and bee assoc a ed dyssy c o y a d deleterious effects of heart failure
He has evidence of AV block that may require permanent pacing
Diminished SV and CO Due:R d d di t li filli tiReduced diastolic filling timeWeakened contractilityWorsening Mitral RegurgitationPost systolic regional contraction
A. Revision of dual chamber pacemaker B Increase losartan to 150 mg daily B. Increase losartan to 150 mg daily C. Consider CRT D Refer for transplant evaluation D. Refer for transplant evaluation
Why is RV pacing detrimental with LV d f i ?dysfunction?
Ventricular dyssynchrony Frequent RV pacing (> 40% of the time)
https://www.scgov.net/parks/Pages/Rowing.aspx
can worsen HF symptoms What to do?
R f t di l / l t h i l Refer to cardiology/electrophysiologyInterrogation of the device Optimize timingOptimize timingConsider Cardiac Resynchronization
78 / l 78 y/o male HFrEF 25% NYHA l III “I ’t lk d ith t f li NYHA class III – “I can’t walk around my room without feeling
short of breath!” Atrial Fibrillation with multiple hospitalizations for RVR and ADHF Atrial Fibrillation with multiple hospitalizations for RVR and ADHF s/p several failed cardioversions and antiarrhythmic therapies GDMT: carvedilol 100 mg bid, sacubitril/valsartan 97mg/103 GDMT: carvedilol 100 mg bid, sacubitril/valsartan 97mg/103
mg, spironolactone 25 mg BP 110/76, HR 110, weight 89 kg
Mi d i Mixed reviews…. Limited data on patients with AF and HF with CRT Some data shows benefit but less than pt’s with NSR Some data shows benefit but less than pt s with NSR
Higher rate of CRT failure Some LVEF improvement Better for pt’s with AV node ablation
Most large RCTs did not include AF patientsF th d t i d d i 10 t 50% f HF t’ h it t Further data is needed since 10 to 50% of HF pt’s have concomitant AF
CRT Indications in atrial fibrillation CRT Indications in atrial fibrillation Society Guidelines
The 2012 focused update to the 2008 American Collegeof Cardiology/American Heart AssociationCo egeo Ca d o ogy/ e ca ea ssoc a o/Heart Rhythm Society (ACC/AHA/HRS) guidelines
for device-based therapy, as well as the 2013 ACC/AHA heart failure (HF) guidelines 2013 ACC/AHA heart failure (HF) guidelines, include the following recommendations that
CRT Indications in Atrial FibrillationCRT Indications in Atrial FibrillationSociety Guidelines
CRT can be useful in patients with AF and LVEF ≤35% on GDMT a) patient requires ventricular pacing or otherwise meets CRT
criteria b) atrioventricular nodal ablation or pharmacologic rate
control will allow near 100 percent ventricular pacing with CRT. Otherwise meets CRT criteria Otherwise meets CRT criteria
a) has LBBB and a QRS duration ≥ 120 ms and NYHA class II, III or ambulatory IV onoptimal GDMT
b) has a non LBBB pattern with a QRS duration ≥150 and NYHA b) has a non-LBBB pattern with a QRS duration ≥150 and NYHA class III or ambulatory class IV HF symptoms.
Sh d d i i ki i k t f d t d NCD G id li Shared decision making is key –part of updated NCD Guidelines and 2017 ACC/AHA/HRS Guidelines for Ventricular Arrhythmias and SCD DECIDE- ICD (led by Colorado’s own Daniel Matlock, MD, MPH)
Benefits ICD include 23 54% reduction in mortality in several randomized trials 23-54% reduction in mortality in several randomized trials
Cons ICD include Expensive Cost of $30,000 – 50,000 per patient for first implant p $ , , p p p
Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., . . . Westlake, C. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Journal of the ACCF/AHA Guideline for the Management of Heart Failure. Journal of the American College of Cardiology, 70(6), 776-803. doi:10.1016/j.jacc.2017.04.025
Normand, C., Linde, C., Singh, J., & Dickstein, K. (2018). Indications for Cardiac Resynchronization Therapy. JACC: Heart Failure, 6(4), 308-316. y py , ( ),doi:10.1016/j.jchf.2018.01.022