Optimizing heart failure treatment following cardiac resynchronization therapy
Anders Jorsal1, Kasper Pryds2,3,4, John J V McMurray5,6
1Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
Insights
Many heart failure patients remain symptomatic after cardiac resynchronization therapy (CRT). A significant portion could benefit from optimizing medical therapy with sacubitril/valsartan or ivabradine.
Area of Science:
- Cardiology
- Heart Failure Management
- Medical Device Therapy
Background:
- Cardiac resynchronization therapy (CRT) improves outcomes for select heart failure patients.
- Persistent symptoms or disease progression can occur despite CRT.
- Optimizing medical therapy may further benefit patients post-CRT.
Purpose of the Study:
- To determine the proportion of patients eligible for sacubitril/valsartan and/or ivabradine after CRT.
- To assess the need for medical therapy optimization in symptomatic patients post-CRT.
Main Methods:
- Post hoc analysis of a randomized controlled trial.
- Evaluated 182 patients undergoing CRT.
- Assessed eligibility for sacubitril/valsartan and/or ivabradine at baseline and 6 months post-CRT.
Main Results:
- 80% of patients had an indication for medical therapy optimization at baseline.
- At 6 months, 38% of symptomatic survivors were eligible for sacubitril/valsartan, ivabradine, or both.
- 18% of patients initially without indication developed one by 6 months.
Conclusions:
- A substantial proportion of symptomatic patients post-CRT are candidates for enhanced medical therapy.
- Systematic follow-up and medical treatment evaluation are crucial for CRT patients.
Background:
Device therapy in addition to medical treatment improves prognosis in a subset of patients with heart failure and reduced ejection fraction. However, some patients remain symptomatic or their heart failure even progresses despite cardiac resynchronization therapy (CRT). The aim of the study was to evaluate the proportion of patients who could benefit from optimization of medical therapy using sacubitril/valsartan, ivabradine, or both following CRT implantation.
Methods:
We conducted a post hoc analysis of a single-centre, patient and outcome-assessor blinded, randomized-controlled trial, in which patients scheduled for CRT were randomized to empiric (n = 93) or imaging-guided left-ventricular lead placement (n = 89). All patients underwent clinical evaluation and blood sampling at baseline and 6 months following CRT implantation. The proportion of patients meeting the indication for sacubitril/valsartan (irrespective of angiotensin-converting enzyme inhibitor or angiotensin 2 receptor blocker dosage) and/or ivabradine according to current guidelines was evaluated at baseline and after 6 months.
Results:
Of 182 patients with an indication for CRT, 146 (80%) also had an indication for optimization of medical therapy at baseline by adding sacubitril/valsartan, ivabradine, or both. Of the 179 survivors at 6 months, 136 (76%) were still symptomatic after device implantation; of these, 51 (38%) patients had an indication for optimization of medical therapy: sacubitril/valsartan in 37 (27%), ivabradine in 7 (5%), and both drugs in 7 (5%) patients. Seven (18%) patients without indication at baseline developed an indication for medical optimization 6 months after CRT implantation.
Conclusion:
In the present study, 38% of those who remained symptomatic 6 months after CRT implantation were eligible for optimization of medical therapy with sacubitril/valsartan, ivabradine, or both. Patients with CRT may benefit from systematic follow-up including evaluation of medical treatment.
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