Importance of Adjunctive Heart Failure Optimization Immediately After Implantation to Improve Long-Term Outcomes With Cardiac Resynchronization Therapy

Abstract

Despite improvement in morbidity and mortality with cardiac resynchronization therapy (CRT), disease progression continues to affect a subset of patients and there is limited effort to identify contributing factors. Our objective was to investigate if a protocol-driven approach incorporated in a management strategy of heart failure immediately after implantation would provide incremental benefits beyond usual care after implantation. We reviewed 114 consecutive patients with CRT implanted from 2005 through 2009 who received usual care after implantation or underwent protocol-driven CRT care after implantation. Preimplantation characteristics in patients receiving usual versus protocol-driven care were similar in left ventricular (LV) dimension (LV internal diastolic diameter 6.2 ± 0.8 vs 6.4 ± 1.0 cm), LV ejection fraction (26 ± 8% vs 25% ± 8%), QRS width, and medication usage. Major adjustments during the protocol-driven approach were uptitration of neurohormonal blockers (64%), echocardiographically guided atrioventricular optimization (50%), heart failure education (42%), arrhythmia management (19%), and LV lead repositioning (7%). Although positive LV remodeling was noted in the 2 groups at 6 months, extent was significantly greater in the protocol-driven approach compared to usual care (change in LV internal diastolic diameter 0.7 ± 0.6 cm vs 0.2 ± 1.2 cm, p = 0.01; change in LV ejection fraction 11 ± 7% vs 7 ± 9%, p = 0.01), which was associated with fewer major adverse events (14% vs 53%, p <0.001). In conclusion, a protocol-driven approach for patients with CRT started immediately after implantation is associated with incremental favorable effects on reverse remodeling and fewer adverse events compared to usual care after implantation. These effects appeared to be driven not only by changes in device settings and arrhythmia management but also by concomitant medication optimization and heart failure education.

Cardiac resynchronization therapy outcomes in patients under nonoptimal medical therapy

“…A small study reported a major reduction in hospitalizations and mortality with increasing dosages of ACEIs/ARBs after CRT 23. Mullens et al24 demonstrated, in a nonrandomized, single‐center study with 114 patients, that optimization of device programming, arrhythmia management, lead reposition, or up‐titration of medical therapy after CRT improved long‐term outcomes and reverse remodeling.…”

Implementation of transmural disease management in patients admitted with advanced heart failure

“…Afterwards, the HF specialist would consider the need and strategy for decongestive therapy, advanced HF therapy, and check indications for cardiac devices. At Ziekenhuis Oost-Limburg, patients with cardiac devices are followed through cooperation between the HF specialist, electrophysiologist, cardiac imaging specialist, and dedicated nurses in a multidisciplinary clinic as described before [26][27][28] .…”

Cardiac Resynchronization Therapy

“…Mullens et al 70 were the first to describe potential reasons for non-response during follow-up and showed that a protocoldriven treatment can improve reverse remodeling (Figure 8). 71 Recently, a large retrospective study showed a 38% relative risk reduction for HF hospitalization, cardiac transplant, or mortality by using systematic multidisciplinary follow-up. 72 Essential in the evaluation of nonresponders is the analysis of the ECG of the underlying rhythm, identifying the presence of typical LBBB or a QRS duration >150ms 3,4 ( Figure 8).…”

“…14,74 There is an important role for optimization for AV and VV intervals, because it was shown that careful optimization of device settings could induce CRT response in 50% of the initial nonresponders. 71 Pharmacological HF treatment may be uptitrated after CRT implantation because the improved hemodynamic status after implantation often provides space to increase HF medication doses. 71 In addition, the patient should be educated to comply to medication and to diet, such as salt and fluid intake restriction.…”

“…71 Pharmacological HF treatment may be uptitrated after CRT implantation because the improved hemodynamic status after implantation often provides space to increase HF medication doses. 71 In addition, the patient should be educated to comply to medication and to diet, such as salt and fluid intake restriction. Also, structured exercise training programs have been shown to be of additional benefit for CRT patients and referral should be considered.…”