Cardiac resynchronization therapy in heart failure patients with less severe left ventricular dysfunction

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124

118

Despite improvements in medical therapy and device‐based treatment, heart failure (HF) continues to impose enormous burdens on patients and health care systems worldwide. Alterations in autonomic nervous system (ANS) activity contribute to cardiac disease progression, and the recent development of invasive techniques and electrical stimulation devices has opened new avenues for specific targeting of the sympathetic and parasympathetic branches of the ANS. The Heart Failure Association of the European Society of Cardiology recently organized an expert workshop which brought together clinicians, trialists and basic scientists to discuss the ANS as a therapeutic target in HF. The questions addressed were: (i) What are the abnormalities of ANS in HF patients? (ii) What methods are available to measure autonomic dysfunction? (iii) What therapeutic interventions are available to target the ANS in patients with HF, and what are their specific strengths and weaknesses? (iv) What have we learned from previous ANS trials? (v) How should we proceed in the future?

Section: Discussionmentioning

confidence: 88%

The autonomic nervous system as a therapeutic target in heart failure: a scientific position statement from the Translational Research Committee of the Heart Failure Association of the European Society of Cardiology

Bilsen

Patel

Bauersachs

et al. 2017

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124

118

“…Treatment with ICD and CRT‐D devices has specific indications, validated by randomized clinical trials in terms of efficacy and with acceptable cost‐effectiveness Use of registries has been advocated in order to evaluate ‘real world’ effectiveness, in less ‘selected’ populations compared with randomized trials, even if registries have recognized limitations mainly because of internal validity (selection bias) and missing data . In the present study, we evaluated patient outcomes at a 4‐year median follow‐up in two cohorts of patients implanted with an ICD or a CRT‐D device.…”

Section: Discussionmentioning

confidence: 99%

Cardiac device therapy in patients with left ventricular dysfunction and heart failure: ‘real‐world’ data on long‐term outcomes (mortality, hospitalizations, days alive and out of hospital)

Boriani

Berti

Belotti

et al. 2016

Background The impact on long‐term outcomes of implantable cardioverter defibrillators (ICDs) and biventricular defibrillators for cardiac resynchronization (CRT‐D) devices in ‘real world’ patients with heart failure (HF) needs to be assessed in terms of clinical effectiveness. Methods and results A registry including consecutive HF patients who underwent a first implant of an ICD (891 patients) or a CRT‐D device (709 patients) in 2006–2010 was followed (median 1487 days and 1516 days, respectively), collecting administrative data on survival, all‐cause hospitalizations, cardiovascular or HF hospitalizations, and days alive and out of hospital (DAOH). Survival free from death/cardiac transplant was 61.9% and 63.8% at 5 years for ICD and CRT‐D patients, respectively. Associated comorbidities (Charlson Comorbidity Index) had a significant impact on death/cardiac transplant, as well as on hospitalizations. The median values of DAOH% were 97.4% for ICD and 97.7% for CRT‐D patients, but data were highly skewed, with the lower quartile of DAOH% values including values ranging between 0% and 52.8% for ICD and between 0% and 56.1% for CRT‐D patients. Charlson Comorbidity Index was a very strong predictor of DAOH%. Conclusions Patients who were implanted in ‘real world’ clinical practice with an ICD or a CRT‐D device have, on average, a relatively favourable outcome, with a survival of around 62–64% at 5 years, but with an important burden of hospitalizations. Comorbidities, as evaluated by means of the Charlson Comorbidity Index, have a significant impact on outcomes in terms of mortality/heart transplant, hospitalizations and days spent alive and out of hospital.

“…Remarkably, however, CRT trials have so far been restricted to patients with severe LV dysfunction (LVEF <30–35%). In this issue of the journal, Hai et al discuss the evidence supporting the use of CRT in patients with higher LVEF and also propose methods for finding the ‘sweet spot’ for CRT implantation . CRT efficacy might be diminished if we are too late (lack of contractile reserve) but being too early might expose the patient to unnecessary risk of intervention‐related complications if the expected benefit is small.…”

mentioning

confidence: 99%

Cardiac resynchronization therapy in mild heart failure should be reserved for true dyssynchronopathy

Maass

Westenbrink

2015