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The promise of resynchronization therapy. Who (and how many) will benefit?
Angelo Auricchio1, Julio C Spinelli
1Department of Cardiology, University Hospital, Otto-von-Guericke Universität, Magdeburg, Germany. angelo.auricchio@medizin.uni-magdeburg.de
Insights
Cardiac resynchronization therapy (CRT) can help many heart failure patients. Identifying the best candidates using multivariate models is key for effective treatment and improved outcomes in eligible heart failure populations.
Area of Science:
- Cardiology
- Medical Devices
- Heart Failure Management
Background:
- An estimated 320,000 to 400,000 US patients may be candidates for cardiac resynchronization therapy (CRT) based on recent guidelines and the COMPANION trial.
- Selecting the optimal patient for CRT/CRTD remains a significant challenge and subject to ongoing debate.
- Numerous clinical, invasive, and non-invasive criteria have been proposed for CRT candidate selection.
Purpose of the Study:
- To characterize patients in sinus rhythm who are most likely to benefit from CRT.
- To validate the effectiveness of CRT in specific heart failure subgroups compared to optimal medical therapy.
- To explore the potential benefits of biventricular pacing over right ventricular pacing in patients requiring ventricular pacing with heart failure.
Main Methods:
- Review and analysis of existing clinical, invasive, and non-invasive criteria for CRT candidate selection.
- Characterization of patient subgroups benefiting from CRT, particularly those in sinus rhythm.
- Evaluation of COMPANION trial data to identify specific heart failure patient subgroups.
- Discussion of the potential application of biventricular pacing in broader patient populations.
Main Results:
- Specific patient profiles in sinus rhythm who benefit most from CRT have been identified.
- The COMPANION trial demonstrated that CRT can improve outcomes in a select group of heart failure patients compared to optimal medical therapy.
- The study highlights the need for further research into multivariate regression models for objective candidate selection.
Conclusions:
- CRT is a valuable non-pharmacological approach for selected heart failure patients.
- Further randomized trials are needed to confirm the benefits of biventricular pacing in patients requiring ventricular pacing with heart failure (NYHA class II/III/IV).
- Objective, multivariate-based selection criteria are crucial for optimizing CRT outcomes.
Abstract:
It has been estimated that about 320,000 to 400,000 patients in the USA alone are possible candidates to cardiac resynchronization therapy according to the recently published AHA/ACC/NASPE guidelines for pacing and the results of the COMPANION trial. The selection of the most suitable candidate for CRT/CRTD is a crucial issue, but still a matter of debate. A large variety of clinical, invasive and non-invasive criteria have been proposed for appropriately selecting candidates for CRT. However, in all the studies the parameters have been retrospectively identified and none has reported their results in the form of a multivariate regression model. We have now well characterized the patients in sinus rhythm who most likely benefit from this non-pharmacological approach. The fact that the COMPANION trial was able to single out a specific subgroup of heart failure patients that can be treated better than what was very short time ago best medical therapy validates the large body of research that investigators worldwide have created about this therapy. Finally, the concept that any patients that require ventricular pacing, who have heart failure class II/III or IV may benefit from receiving biventricular rather than right ventricular pacing as much as the other patients with more classical indication for CRT is still open to discussion and needs to be tested in a randomized multicenter trial.