Heart Failure Management
 

Heart Failure Management

Cardiac resynchronization therapy is a proven treatment for selected heart failure patients with a wide QRS. When used in combination with optimal medical therapy, cardiac resynchronization therapy improves symptoms and extends survival.1-5

Clinical Issue – Poor Prognosis for Heart Failure Patients with a Wide QRS

Heart failure – related morbidity and mortality remains a major problem6-9

  • Heart failure patients with a wide QRS have poor prognoses6-9
  • Heart failure accounts for over 3.4 million visits to physician offices, hospital outpatient, and emergency departments annually6
  • Heart failure hospitalizations are especially problematic, with one year readmission rates of 50% and mortality rates of approximately 30% 7,8
  • In patients with heart failure, sudden death occurs at four times the rate of the general population9

QRS duration and Left Ventricular Ejection Fraction: Predictors of morbidity and mortality

  • Wide QRS duration is a powerful independent predictor of poor clinical outcomes in patients with HF and reduced left ventricular ejection fraction (LVEF)10
  • QRS durations ≥ 120 ms are associated with a 33% increased risk of all-cause mortality (38% from worsening HF and 31% from sudden death)11
  • Clinical studies show that a low EF is a key predictor of sudden cardiac arrest and an effective way to determine a patient's risk for sudden cardiac arrest (SCA).9,12,13

References

  1. Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. April 15, 2005;352(15)1539-1549.
  2. Cleland JG, Daubert JC, Erdmann E, et al. Longer-term effects of cardiac resynchronization therapy on mortality in heart failure [the CArdiac REsynchronization-Heart Failure (CARE-HF) trial extension phase]. Eur Heart J. August 2006;27(16):1928-1932.
  3. Bristow MR, Feldman AM, Saxon LA. Heart failure management using implantable devices for ventricular resynchronization: Comparison of Medical Therapy, Pacing, and Defibrillation in Chronic Heart Failure (COMPANION) trial. COMPANION Steering Committee and COMPANION Clinical Investigators. J Card Fail. September 2000;6(3):276-285.
  4. Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med. June 13, 2002;346(24):1845-1853.
  5. Young JB, Abraham WT, Smith AL, et al. Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial. JAMA. May 28, 2003;289(20):2685-2694.
  6. Burt CW, Schappert SM. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1999-2000. Vital Health Stat 13. September 2004;(157):1-70.
  7. Kosiborod M, Lichtman JH, Heidenreich PA, et al. National trends in outcomes among elderly patients with heart failure. Am J Med. July 2006;119(7):616.e1-7.
  8. Rathore SS, Masoudi FA, Wang Y, et al. Socioeconomic status, treatment, and outcomes among elderly patients hospitalized with heart failure: findings from the National Heart Failure Project. Am Heart J. August 2006;152(2):371-378.
  9. Adabag AS, Therneau TM, Gersh BJ, Weston SA, Roger VL. Sudden death after myocardial infarction. JAMA. 2002;300(17):2022-2029.
  10. Hawkins NM, Wang D, McMurray JJ, et al. Prevalence and prognostic impact of bundle branch block in patients with heart failure: evidence from the CHARM programme. Eur J Heart Fail. 2007;9(5):510-517.
  11. Wang NC, Maggioni AP, Konstam MA, et al. Clinical implications of QRS duration in patients hospitalized with worsening heart failure and reduced left ventricular ejection fraction. JAMA. 2008;299(22):2656-2666.
  12. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18(12):1440-1463.
  13. Priori SG, Aliot E, Blomstrom-Lundqvist C, et al. Task Force on Sudden Cardiac Death of the European Society of Cardiology [published correction appears in Eur Heart J. 2002;23:257]. Eur Heart J. August 2001;22(16):1374-1450.

Cardiac Resynchronization Therapy

CRT_AP4195labeled-bth

Detail

Cardiac resynchronization therapy provides atrial-synchronized, biventricular pacing using standard pacing technology combined with a special third lead that is implanted via the coronary sinus and positioned in a cardiac vein to sense and/or pace the left ventricle.1-5

Following a sensed atrial contraction or atrial-paced event, both ventricles are stimulated to synchronize their contraction.

Cardiac Resynchronization Therapy Reduces Mortality and Morbidity1-5

Cardiac resynchronization therapy extends survival, reduces heart failure hospitalizations and improves symptoms.

Important Safety Information

Changes in a patient's disease and/or medications may alter the efficacy of a device's programmed parameters or related features.

View a resynchronization animation. (0:17, 1.5 MB)

Implantable Cardiac Resynchronization Therapy Devices Available

  • Cardiac resynchronization therapy device (CRT-P) or in combination with an implantable cardiovertor defibrillator (CRT-D)
  • Cardiac resynchronization therapy defibrillator (CRT-D) has painless anti-tachycardia pacing (ATP) and shock therapy capability to prevent sudden cardiac death
concertobcopy 

Cardiac Resynchronization Defibrillator

Cardiac Resynchronization Therapy: ACC/AHA Class I Indication6

The Cardiac Resynchronization Therapy current indications have been created based on the results of eight randomized clinical studies including nearly 4,000 patients.6 The level of evidence is so compelling that Cardiac Resynchronization Therapy is recommended as a Class I therapy for the treatment of symptomatic heart failure.6

  • LVEF ≤ 35%
  • QRS duration ≥ 120 ms
  • NYHA Functional Class III or ambulatory IV
  • Optimal medical therapy

Note: The use of an ICD in combination with cardiac resynchronization therapy should be based on the indications for ICD therapy in the prevention of sudden cardiac death.

Consider Cardiac Resynchronization Therapy

Screen your patients for cardiac resynchronization therapy indications.

References

  1. Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. April 14, 2005;352(15):1539-1549.
  2. Cleland JG, Daubert JC, Erdmann E, et al. Longer-term effects of cardiac resynchronization therapy on mortality in heart failure [the CArdiac REsynchronization-Heart Failure (CARE-HF) trial extension phase]. Eur Heart J. August 2006;27(16):1928-1932.
  3. Bristow MR, Feldman AM, Saxon LA. Heart failure management using implantable devices for ventricular resynchronization: Comparison of Medical Therapy, Pacing, and Defibrillation in Chronic Heart Failure (COMPANION) trial. COMPANION Steering Committee and COMPANION Clinical Investigators. J Card Fail. September 2000;6(3):276-285.
  4. Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med. June 13, 2002;346(24):1845-1853.
  5. Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med. June 13, 2002;346(24):1845-1853.
  6. Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation. May 27, 2008;117(21):e350-408.

Medtronic Implantable Cardiac Resynchronization Therapy Devices With Therapies and Diagnostics

Medtronic implantable CRT devices include:

  • Cardiac resynchronization therapy pacemakers (CRT-P)
  • Cardiac resynchronization therapy defibrillator (CRT-D) with automatic painless anti-tachycardia pacing (ATP) and shock therapy capability to prevent sudden cardiac death

Heart failure (HF) patients with CRT devices should receive cardiac resynchronization therapy more than 92% of the time for maximum benefit of the therapy and are at significant risk for thoracic congestion.6

Medtronic implantable devices have unique diagnostics to provide clinicians with information, including Optivol® Fluid Status Monitoring for congestion, to assess their patients’ clinical status and intervene if necessary.

Consider Cardiac Resynchronization Therapy

Screen your patients for cardiac resynchronization therapy indications:

  • Moderate to severe heart failure (Class III/IV)
  • Ventricular dysynchrony (QRS ≥ 120 ms)
  • LVEF ≤ 35%
  • Symptomatic despite stable, optimal medical therapy

CRT Therapy Operation (:20, 1.7 MB)
CRT Therapy restores the mechanical sequence of ventricular activation and contraction by pacing both ventricles.

Important Safety Information

Changes in a patient's disease and/or medications may alter the efficacy of a device's programmed parameters or related features.

References

  1. Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. April 14, 2005;352(15):1539-1549.
  2. Cleland JG, Daubert JC, Erdmann E, et al. Longer-term effects of cardiac resynchronization therapy on mortality in heart failure [the CArdiac REsynchronization-Heart Failure (CARE-HF) trial extension phase]. Eur Heart J. August 2006;27(16):1928-1932.
  3. Bristow MR, Feldman AM, Saxon LA. Heart failure management using implantable devices for ventricular resynchronization: Comparison of Medical Therapy, Pacing, and Defibrillation in Chronic Heart Failure (COMPANION) trial. COMPANION Steering Committee and COMPANION Clinical Investigators. J Card Fail. September 2000;6(3):276-285.
  4. Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med. June 13, 2002;346(24):1845-1853.
  5. Young JB, Abraham WT, Smith AL, et al. Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial. JAMA. May 28, 2003;289(20):2685-2694.
  6. Koplan BA, Kapla AJ, Weiner S, et al. Heart Faiure Decompensation and All-Cause Mortality in Relation to Percent Biventricular Pacing in Patients with Heart Failure Is a Goal of 100% Biventrecular Pacing Necessary? J Am Coll Cardiol 2009 53:355-60.

Cardiac Resynchronization Therapy Is Proven 1-5

There is overwhelming clinical evidence supporting the fact that cardiac resynchronization therapy reverses the course of heart failure progression in moderate to severe heart failure patients. 1-5

  Mortality HF or CV Hospitalizatons Quality of Life Exercise Capacity NYHA Class
CARE-HF + +
Reported improvement, but not blinded
COMPANION + +
MIRACLE
Not powered for mortality or hospitalization
 + + +
MIRACLE ICD + – +

Cardiac Resynchronization Therapy Reduces Morbidity and Mortality

CARE-HF Trial1

Cardiac resynchronization therapy:

  • Reduces risk of all-cause mortality or unplanned CV hospitalizations by 37%
  • Reduces risk of all-cause mortality by 36%
  • Reduces risk of unplanned hospitalizations for worsening HF by 52%

CARE-HF Extension Phase2

Cardiac resynchronization therapy:

  • Reduces risk of all-cause mortality by 40%
  • Reduces risk of HF mortality by 45%
  • Reduces risk of sudden death by 46%
AllCauseChrtEXT

References

  1. Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. April 14, 2005;352(15):1539-1549.
  2. Cleland JG, Daubert JC, Erdmann E, et al. Longer-term effects of cardiac resynchronization therapy on mortality in heart failure [the CArdiac REsynchronization-Heart Failure (CARE-HF) trial extension phase]. Eur Heart J. August 2006;27(16):1928-1932.
  3. Bristow MR, Feldman AM, Saxon LA. Heart failure management using implantable devices for ventricular resynchronization: Comparison of Medical Therapy, Pacing, and Defibrillation in Chronic Heart Failure (COMPANION) trial. COMPANION Steering Committee and COMPANION Clinical Investigators. J Card Fail. September 2000;6(3):276-285.
  4. Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med. June 13, 2002;346(24):1845-1853.
  5. Young JB, Abraham WT, Smith AL, et al. Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial. JAMA. May 28, 2003;289(20):2685-2694.

Implant Procedure

Cardiac Resynchronization Therapy and Lead Placement

Detail - Cardiac Resynchronization Therapy and Lead Placement

The implant procedure of a cardiac resynchronization therapy device is much the same as that for a pacemaker or implantable defibrillator, although additional time is required to place the left ventricular lead in a suitable cardiac vein via the coronary sinus.1-5

It is important to note that coronary venous anatomy varies significantly between patients, and in a small percentage of cases, it may not be possible to place the left ventricular lead transvenously. In such situations, some centers are opting for an epicardial approach if the transvenous approach is unsuccessful.

Coronary venogram

Coronary venogram

 

Fluoroscopic view of the three leads used for CRT

Fluoroscopic view of the three leads used for CRT

Implanting a Cardiac Resynchronization Therapy Device (:30, 2.9 MB)
Animation showing the implant procedure for a CRT device.

Cardiac Resynchronization Therapy Device Implant Steps (42 slides, 7.5 MB)

CRT Implant challenges

Implanters can face multiple challenges with CRT implant procedures, due to the complexity of a patient’s anatomy:

  • LV lead positioning can be a challenging, time consuming task.6
  • Accuracy of lead location by implanting physicians can be problematic.7
  • In up to 43 percent of cases, procedure times run long (2 hours or more), which may increase fluoroscopy exposure.8

Medtronic CardioGuide™ Implant System: A Real-Time Navigation System for CRT Implants

Now there is a way to guide LV lead placement. By creating 3D images of coronary vessels, the CardioGuide™ Implant System provides real-time navigation to a targeted location for LV lead placement. The imaging software projects the target location from the venogram model onto an overlay and tracks the electrodes’ location using live or recorded fluoroscopy.

The CardioGuide Implant System helps implanters:

  • Determine their preferred lead location
  • Identify proper delivery tools
  • Confirm that a lead is placed in the targeted location, using the system’s lead navigation and tracking capability under live fluoroscopy

201205047_28_tap_to_select_target_MM_Tab  201205047_27_3d_MM_MM_Tab

An Easy Fit into the CRT Implant Workflow

The CardioGuide System operates as a dedicated PC workstation inside the control room, and within the procedure room on a tablet computer. The application consists of four core phases: system setup, vein analysis, planning, and navigation. It also archives, imports, and exports files and provides database management.

201205047_System-Setup-Diagram

The information provided by the CardioGuide Implant System is intended to serve as an adjunct to information available from venograms and other sources. The information presented by the system is not intended for use as the sole basis of planning and therapeutic decisions. In case of discrepancy between venogram data and system results, the user should use the venograms or other standard clinical practice.

References

  1. Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. April 15, 2005;352(15)1539-1549.
  2. Cleland JG, Daubert JC, Erdmann E, et al. Longer-term effects of cardiac resynchronization therapy on mortality in heart failure [the CArdiac REsynchronization-Heart Failure (CARE-HF) trial extension phase]. Eur Heart J. August 2006;27(16):1928-1932.
  3. Bristow MR, Feldman AM, Saxon LA. Heart failure management using implantable devices for ventricular resynchronization: Comparison of Medical Therapy, Pacing, and Defibrillation in Chronic Heart Failure (COMPANION) trial. COMPANION Steering Committee and COMPANION Clinical Investigators. J Card Fail. September 2000;6(3):276-285.
  4. Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med. June 13, 2002;346(24):1845-1853.
  5. Young JB, Abraham WT, Smith AL, et al. Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial. JAMA. May 28, 2003;289(20):2685-2694.
  6. Giannola G, Iacopino S, Lombardo E, et al. Efficacy of a tool combining guide-wire and stylet for the left ventricular lead positioning. Europace. February 2011;13(2):244-250.
  7. Singh JP, Hummel JD, Coppess MA, et al. LV Lead Location: Do We Know Where We Are? Abstract Presentation, HRS 2012.
  8. PPDA Q3FY12/Q4FY12/Q1FY13/Q2FY13 - (Waves 1-4): Economic Considerations for CRT Implants

Cardiac Resynchronization Lifesaving Therapy is Underutilized

201004307_Improve-HF

Recent clinical evidence suggests cardiac resynchronization therapy is underutilized in the United States6:

  • In the IMPROVE HF Registry, less than 40% of eligible patients received a cardiac resynchronization therapy device at baseline treatment6
  • 54% of patient charts lacked documentation of NYHA class or QRS duration6
  • Less likelihood of cardiac resynchronization therapy use was independently predicted by older age, narrower QRS duration6
  • Indicated patients with an ischemic etiology were more likely to have an ICD, while older age, female sex, Black race, or lack of insurance independently predicted that an eligible patient would be less likely to have an ICD7

IMPROVE HF Results

Wide Practice Variation in Guideline Recommended CRT Use (sites with ≥ 5 eligible patients)8

CRTDCRTP chart

What Can Be Done?

The ACC/AHA recommends various strategies to implement practice guidelines8:

  • Utilize performance measures
  • Perform chart audits
  • Implement reminder systems

Outpatient practice performance improvement initiatives are available to reduce variations in care and increase guideline adherence.

  • Ask your Medtronic representative about the Sudden Cardiac Arrest Prevention program

References

  1. Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. April 14, 2005;352(15):1539-1549.
  2. Cleland JG, Daubert JC, Erdmann E, et al. Longer-term effects of cardiac resynchronization therapy on mortality in heart failure [the CArdiac REsynchronization-Heart Failure (CARE-HF) trial extension phase]. Eur Heart J. August 2006;27(16):1928-1932.
  3. Bristow MR, Feldman AM, Saxon LA. Heart failure management using implantable devices for ventricular resynchronization: Comparison of Medical Therapy, Pacing, and Defibrillation in Chronic Heart Failure (COMPANION) trial. COMPANION Steering Committee and COMPANION Clinical Investigators. J Card Fail. September 2000;6(3):276-285.
  4. Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med. June 13, 2002;346(24):1845-1853.
  5. Young JB, Abraham WT, Smith AL, et al. Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial. JAMA. May 28, 2003;289(20):2685-2694.
  6. Fonarow GC, Yancy CW, Albert NM, et al. Heart failure care in the outpatient cardiology practice setting: findings from IMPROVE HF. Circ Heart Fail. 2008;1:98-106. Available at: circheartfailure.ahajournals.org. Accessed July 16, 2008.
  7. Mehra MR, Yancy CW, Albert NM. Evidence of clinical practice heterogeneity in the use of implantable cardioverter-defibrillators in heart failure and postmyocardial infarction left ventricular dysfunction: Findings from IMPROVE HF. Heart Rhythm. December 2009;6(12):1727-1734.
  8. Curtis AB, Yancy CW, Albert NM, et al. Cardiac resynchronization therapy utilization for heart failure: Findings from IMPROVE HF. Am Heart J. 2009;158:956-64
Last updated: 3 Jun 2013

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