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  1. 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.

  2. CANADIAN CARDIOVASCULAR SOCIETY GUIDELINES ON THE USE OF CARDIAC RESYNCHRONIZATION THERAPY: EVIDENCE AND PATIENT SELECTION R Parkash, F Philippon, D Exner, and D Birnie on behalf of the CRT Guidelines Panels.

  3. Disclosures www.ccs.ca Guidelines are available on line www.ccsguidelineprograms.ca Can J Cardiol 2013; 29(2):182-195

  4. CCS CRT Guidelines 2012 Primary Panel • David Birnie • Derek Exner (co-chair) • Jeff Healey • Eric LaRose • Gordon Moe • Ratika Parkash (co-chair) • François Philippon • Anthony Tang • Bernard Thibault Secondary Panel • Lyall Higginson • Jonathan Howlett • Aaron Low • Robert McKelvie • John Sapp • Miriam Shanks • Mario Talajic • Michel White • Raymond Yee

  5. 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

  6. Objectives At the end of this session: • Review the appropriate selection of patients for CRT • Discuss the role of CRT-pacing • Describe the risks and benefits related to patients with AF, RBBB and chronic RV pacing • Understand technical issues related to CRT including lead placement • Discuss the role of imaging in assessment of CRT

  7. GRADE Approach • Development of guidelines through: • Critical evaluation of literature • Expert consensus • Use of Grading of Recommendations Assessment, Development, and Evaluation • Quality of Evidence: • High, Moderate, Low or Very Low 2. Strength of Recommendations • Strong or Weak Guyatt et al. 2011 J Clin Epi 64: 383-94

  8. 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).

  9. Case 1 - ECG

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

  11. Case 1 - continued • Continued up-titration of medical therapy • Carvedilol (25 mg BID), ramipril (5 mg OD) & spironolactone (25mg OD) • Remains class III, LVEF now 30%

  12. 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.

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

  14. Clinical Trial Evidence Can J Cardiol 2013; 29(2):182-195

  15. Clinical Trial Evidence

  16. 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

  17. 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.

  18. 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).

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

  20. Clinical Trial Evidence Can J Cardiol 2013; 29(2):182-195

  21. Summary: CRT-P & CRT-D CARE HF Death or hospitalisation CRT-P: 0.73 p<0.001 Death CRT-P: 0.74 p<0.0002 COMPANION Death 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

  22. Risk Factors • NYHA > II • Age > 70 years • BUN > 26 mg/dl • QRSd > 120 ms • AF • MADIT II cohort • 1191 pts • F-UP 8 years

  23. JACC 2012; 59:2075-9

  24. 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.

  25. 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.

  26. Case 2 - ECG

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

  28. 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

  29. Greater non-response (34.5% AF vs. 26.7% NSR) Wilton et al. Heart Rhythm 2011;8:1088-94

  30. Higher annual mortality (10.8% AF vs. 7.1% NSR) Wilton et al. Heart Rhythm 2011;8:1088-94

  31. RAFT – AF Subset ~ 34% of CRT-treated patients had ≥95% & ~ 47% had ≥90% biventricular pacing. Healey et al. Circulation Heart Failure 2012;5:566-70.

  32. RAFT – AF Subset Healey et al. Circulation Heart Failure 2012;5:566-70.

  33. 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.

  34. Case 2 – continued (amiodarone added)

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

  36. CRT in Patients with RBBB Five studies, with 259 patients randomized to CRT and 226 randomized to non-CRT. Nery et al. Heart Rhythm 2011;8:1083-87

  37. RAFT Birnie et al CCS Conference , Vancouver 2011 LBBB NIVCD RBBB CRT-D HR (95% CI): 1.0 (0.60, 1.66) Log rank p = 0.84 HR (95% CI): 1.24 (0.65, 2.36) Log rank p = 0.48 ICD HR (95% CI): 0.58 (0.46, 0.74) Log rank p < 0.0001

  38. Systematic review and meta-analysis Severely prolonged QRS Moderately prolonged QRS

  39. 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.

  40. Echo Dyssynchrony Assessment

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

  42. Mechanical Dyssynchrony Mostly echo; some nuclear & MRI Single 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”

  43. 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.

  44. 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.

  45. Case 3 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

  46. Case 3 - ECG

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

  48. 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 months Results 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)

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