Is cardiac resynchronisation therapy feasible, safe and beneficial in the very elderly?

Interamerican Society of Cardiology (CIFACAH - ELECTROSIAC)/Latin American Heart Rhythm Society (LAHRS): multidisciplinary review on the appropriate use of cardiac resynchronization therapy in heart failure

Epidemiological studies suggest that approximately half of the patients with heart failure (HF) have reduced ejection fraction, while the other half have normal ejection fraction (EF). Currently, international guidelines consider QRS duration greater than 130 ms, in the presence of ventricular dysfunction (EF < 35%), as a criterion for selecting patients for cardiac resynchronization therapy (CRT). CRT helps restore intraventricular and auriculoventricular synchrony, improving left ventricular (LV) performance, reducing functional mitral regurgitation, and inducing reverse LV remodeling. This is evidenced by increased LV filling time and left ventricular ejection fraction, decreased LV end-diastolic and end-systolic volumes, mitral regurgitation, and septal dyskinesia. Because the mechanisms of dyssynchrony may be heterogeneous, no single measure may accurately predict response to CRT. Finally, CRT has been progressively shown to be safe and feasible, improves functional status and quality of life, reversely remodels the LV, decreases the number of hospitalizations, total mortality in patients with refractory HF, LV dysfunction, and intraventricular conduction disorders; is a pacemaker-based therapy for HF and thanks to current technology, safe remote monitoring of almost all types of cardiac devices is possible and provides useful alerts in clinical practice.

Sex, Race, and Age Differences of Cardiovascular Outcomes in Cardiac Resynchronization Therapy RCTs: A Systematic Review and Meta-analysis

Background

Cardiac resynchronization therapy (CRT) is beneficial in patients who have heart failure with reduced ejection fraction or arrhythmic events. However, most randomized controlled trials (RCTs) showing survival benefits primarily enrolled older white men. This study aims to evaluate CRT efficacy by sex, race, and age in RCTs.

Methods

Five electronic databases (CINAHL, Embase, Emcare, Medline, and PubMed) were searched from inception to July 12, 2021 for RCTs with CRT in adult patients. Data were analyzed for clinical outcomes including all-cause or cardiovascular (CV) death, worsening heart failure (HF), and HF hospitalization (HFH) according to sex, race, and age.

Results

Among six RCTs with up to moderate risk of bias, 54% (n = 3,630 of 6,682; mean age 64 years, 22% female, 8% black patients) had CRT device implantation. All-cause death (odds ratio [OR], 0.51; P = 0.053) was reduced in female versus male CRT patients, whereas CV death, HFH, or all-cause death with worsening HF or HFH did not differ significantly. No difference was seen in CRT patients for all-cause death and worsening HF (OR, 1.32; P = 0.46) among white vs black patients or for all-cause death and HFH (OR, 1.19; P = 0.55) among ≥ 65 versus < 65 years.

Conclusions

Whereas all-cause death was lower in female CRT patients, other reported outcomes did not significantly differ by sex, race, or age. Only 6 studies partially reported outcomes. Thus, enhanced reporting and analyses are required to overcome such paucity of data to evaluate the impact of these factors on clinical outcomes in distinct patient cohorts with CRT indication.

Clinical outcomes and mortality in old and very old patients undergoing cardiac resynchronization therapy

Aim

Cardiac resynchronization therapy (CRT) is a valid therapeutic option for patients with heart failure (HF). However, the elderly population was not well represented in the guidelines. The primary end point was to evaluate the impact of advanced age on clinical response and cardiovascular and total mortality of patients undergoing CRT. The secondary end point was to assess the rate of acute complications related to the procedure.

Methods and results

A total of 249 consecutive patients with HF and optimized treatment, QRS ≥ 120 ms, ejection fraction (EF) ≤ 35% and functional class (FC) III/ IV (NYHA) underwent CRT and divided into 3 groups: Group I—< 65 years—88/ 249 (35%); Group II– 65 to 75 years (old)– 72/ 249 (29%); Group III—≥ 75 years (very old)– 89/ 249 (36%). The improvement in FC and increase in EF (>10%) and/ or decrease in the left ventricular end systolic diameter (LVESD) >15% were the criteria of responsiveness. The favorable clinical response (p = ns) and cardiovascular mortality (p = 0.737) was similar in the 3 groups. In the group of very old patients, a significant increase in total mortality was observed (p = 0.03). The rate of acute complications related to the procedure did not differ between the groups (p = ns).

Conclusion

The response to CRT and cardiovascular mortality were not affected by the advanced age and should not be an exclusion factor of this therapy. The procedure has been shown to be safe in elderly patients due to low rate of acute complications.

Precision Medicine for Cardiac Resynchronization: Predicting Quality of Life Benefits for Individual Patients-An Analysis From 5 Clinical Trials

BACKGROUND

Clinical trials have established the average benefit of cardiac resynchronization therapy (CRT), but estimating benefit for individual patients remains difficult because of the heterogeneity in treatment response. Accordingly, we created a multivariable model to predict changes in quality of life (QoL) with and without CRT.

METHODS AND RESULTS

Patient-level data from 5 randomized trials comparing CRT with no CRT were used to create a prediction model of change in QoL at 3 months using a partial proportional odds model for no change, small, moderate, and large improvement, or deterioration of any magnitude. The C statistics for not worsening or obtaining at least a small, moderate, and large improvement were calculated. Among the 3614 patients, regardless of assigned treatment, 33.3% had a deterioration in QoL, 9.2% had no change, 9.2% had a small improvement, 13.5% had a moderate improvement, and the remaining 34.9% had a large improvement. Patients undergoing CRT were less likely to have a decrement in their QoL (28.2% versus 38.9%; P<0.001) and more likely to have a large QoL improvement (38.7% versus 30.6%; P<0.001). A partial proportional odds model identified baseline QoL, age, and an interaction of CRT with QRS duration as predictors of QoL benefits 3 months after randomization. C statistics of 0.65 for not worsening, 0.68 for at least a small improvement, 0.69 for at least a moderate improvement, and 0.73 for predicting a large improvement were observed.

CONCLUSIONS

There is marked heterogeneity of treatment benefit of CRT that can be predicted based on baseline QoL, age, and QRS duration.

Device Management in Heart Failure

PURPOSE OF REVIEW

Medical devices have become an integral part of comprehensive heart failure management. Not all heart failure patients, however, accrue benefit from every new device, and even with extensive practice guidelines, this remains an evolving field.

RECENT FINDINGS

The addition of implantable devices, like internal cardioverter defibrillators (ICDs), and novel pacing technologies, including cardiac resynchronization therapy (CRT), have helped to compliment goal-directed medical therapy and positively impact prognosis in multiple high-quality clinical trials. This review attempts to summarize the rapidly evolving literature with respect to existing device guidelines for routine implantable devices as well as some available and future technologies that are not yet a part of routine guidelines. ICD, CRT, and other implantable devices continue to save lives, decrease hospitalizations, and evolve the management of patients with heart failure beyond the capabilities of optimal guideline-directed medical therapy alone.

Overview of implantable cardioverter defibrillator and cardiac resynchronisation therapy in heart failure management

Clinical trials have established the benefits of implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy (CRT) in the treatment of heart failure patients. As adjuncts to guideline-directed medical therapy, ICDs confer mortality benefits from sudden cardiac arrest, while CRT reduces mortality, hospitalisation rates and improves functional capacity. This review discusses the use of ICDs and CRT devices in heart failure management, outlining the evidence supporting their use, indications and contraindications.

Should MRAs be at the front row in heart failure? A plea for the early use of mineralocorticoid receptor antagonists in medical therapy for heart failure based on clinical experience

The brand new 2016 ESC guidelines for the treatment of acute and chronic heart failure continue to give a prominent place to mineralocorticoid receptor antagonists in the treatment of chronic heart failure with reduced ejection fraction (HFrEF). In the prevention of HF hospitalization and death, a class I, level of recommendation A, is given to MRAs for patients with HFrEF, who remain symptomatic despite treatment with an ACE-inhibitor and a beta-blocker and have an LVEF below 35 %. This recommendation is primarily based on two landmark trials, the RALES trial (for spironolactone) and the EMPHASIS-HF trial (for eplerenone). A crucial question is, however, why MRAs are advised only in "third place," i.e., after optimal up-titration of ACE-inhibitors and beta-blockers. We wonder whether MRAs could not or should not be given earlier in the treatment of HFrEF, namely before or together with the up-titration of ACE-inhibitors and beta-blockers. Several arguments to support this plea are described in this short paper.