Cardiac resynchronization--a heart failure perspective

Over the past 15-20 years the development of new heart failure pharmacologic therapy has lowered mortality by 30-40% for this serious and prevalent clinical syndrome, within clinical trials conducted in patients with a dilated cardiomyopathy phenotype. However, over the past 5 years progress in the development of additional effective drugs has slowed, in part due to the success of neurohormonal inhibitors, on which background new therapies must be developed. That there is not an absolute ceiling on the development of new heart failure therapies has been convincingly recently demonstrated in electrophysiologic device trials, conducted on the background of maximal neurohormonal inhibition. Two trials, COMPANION and CARE-HF, have demonstrated unambiguously that in advanced heart failure patients with a marker of mechanical intraventricular dyssynchrony, increased QRS duration, cardiac resynchronization therapy in the form of biventricular pacing can improve major clinical outcomes including mortality. In addition, COMPANION also demonstrated that the addition of an ICD further improved mortality reduction, by lowering the incidence of sudden death. These trials indicate that device/drug therapy is at least additive in the treatment of heart failure, and they herald a new era in the multi-modality approach to therapeutics.