Predictors of patient-perceived functional improvement after cardiac resynchronization therapy: a real-world
Ahmad Samir1,2, Amr Yosry Emam3, Rehab Elnagar3,4
1Cardiac Center Hail, Hail, Saudi Arabia.
Insights
Cardiac resynchronization therapy (CRT) response is best predicted by renal function, left ventricular global longitudinal strain, and diastolic indices, not just traditional measures. These factors improve patient selection for better outcomes.
Area of Science:
- Cardiology
- Heart Failure Management
- Medical Imaging
Background:
- A significant portion of patients undergoing cardiac resynchronization therapy (CRT) do not experience clinical benefits, despite meeting guideline criteria.
- Traditional metrics for CRT response, such as left ventricular (LV) end-systolic volume (ESV), ejection fraction (EF), and QRS duration, often do not correlate with patient-perceived improvement.
Purpose of the Study:
- To identify predictors of patient-perceived functional improvement following CRT.
- To incorporate a comprehensive set of clinical, biochemical, electrocardiographic (ECG), and imaging variables to predict functional improvement.
Main Methods:
- A retrospective single-center study involving 97 heart failure (HF) patients meeting CRT guidelines.
- Patients were assessed for changes in New York Heart Association (NYHA) functional class 6-9 months post-CRT.
- Analysis included baseline and follow-up clinical, biochemical, ECG, echocardiographic, and cardiac magnetic resonance (CMR) parameters, with logistic regression used to identify predictors.
Main Results:
- 70% of patients achieved at least one NYHA class improvement.
- Non-improved patients had higher baseline NT-proBNP, creatinine, longer PR intervals, shorter QTc intervals, and worse LV/RV global longitudinal strain (GLS) on CMR.
- While traditional CRT response criteria were met more often in improved patients, only baseline renal function, LV GLS, and follow-up E/A ratio independently predicted functional improvement.
Conclusions:
- Patient-perceived functional improvement after CRT is best predicted by a multi-dimensional assessment.
- Renal function, LV GLS, and LV diastolic indices are independently associated with better functional outcomes post-CRT.
- Integrating these additional factors into CRT selection and prognostication may enhance patient outcomes.
Introduction:
Up to one-third of appropriately selected patients undergoing cardiac resynchronization therapy (CRT) fail to achieve meaningful clinical benefit despite fulfilling guidelines' criteria. Traditional CRT response definitions [left ventricular (LV) end-systolic volume (ESV), ejection fraction (EF), and QRS duration] frequently diverge and occasionally fail to reflect patient-perceived clinical improvement.
Objective:
To identify predictors for patient-perceived functional improvement after CRT, incorporating various clinical, biochemical, electrocardiographic (ECG), and imaging variables. Functional improvement was defined as the changes in New York Heart Association (NYHA) functional class 6-9 months after CRT implantation.
Methods:
This retrospective single-center study included 97 heart failure (HF) patients meeting guideline-based CRT indications. Patients were categorized according to ≥1 NYHA class improvement at 6-9 months. Baseline and follow-up clinical, biochemical, ECG, echocardiographic, and cardiac magnetic resonance (CMR) parameters were compared between groups. Predictors of functional improvement were assessed using univariate and multivariate logistic regression.
Results:
Sixty-eight patients (70%) achieved ≥1 NYHA class improvement. At baseline, the non-improved group was characterized by higher NT-proBNP and creatinine levels, longer PR and shorter QTc intervals, and worse LV and RV global longitudinal strain (GLS) on CMR. At follow-up, NT-proBNP remained elevated in the non-improved group. Traditional CRT response criteria were more frequently met in the improved compared to the non-improved group (>15% LV ESV reduction: 94.7% vs. 5.3%, >10% LV EF improvement: 98.1% vs. 1.9%, and >20 ms QRS shortening: 86.2% vs. 13.8%); but none independently predicted functional improvement in multivariate analysis. Independent predictors for ≥1 NYHA class improvement included baseline renal function (OR 1.19, 95% CI 1.00-1.39, p = 0.034), baseline LV GLS (OR 0.62, 95% CI 0.41-0.96, p = 0.030), and follow-up E/A ratio (OR 0.28, 95% CI 0.09-0.87, p = 0.028).
Conclusion:
Functional improvement after CRT is best predicted by multi-dimensional assessment incorporating clinical, biochemical, and imaging parameters. In addition to the traditional response definitions, renal function, LV GLS, and LV diastolic indices were independently associated with a better patient-perceived functional improvement after CRT. Incorporating these factors into CRT eligibility and prognostication may enhance patient selection and improve outcomes.
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