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CRT consensus set to standardize and improve patient care
MUNICH — A new consensus statement developed by the Heart Rhythm Society and European Heart Rhythm Association outlines recommendations for the practical management of cardiac resynchronization therapy.
The international statement was created due to the rising popularity of cardiac resynchronization therapy (CRT) as a major HF therapy during the past two decades, as well as multiple guidelines for CRT in Europe and the United States and a lack of solid clinical evidence for all aspects of management.
“We have very strong recommendations regarding clinical indications based on the clinical evidence and these are covered in multiple guidelines,” Jean-Claude Daubert, MD, joint task force co-chair and professor of cardiology and vascular disease, University of Rennes 1, France, stated in a press release. “Until now, we did not have a consensual document on the practical aspects of this therapy.”
The document is divided into six sections:
- Pre-implant evaluation, including potential temporary contraindications to CRT and how to manage medications, including anticoagulants and antibiotics, before and during the implantation procedure.
- CRT implantation, with description of all steps of the procedure, including anesthesia, lead implant sequence, left ventricular lead placement and defibrillation testing.
- Pre-discharge evaluation and device programming, including how to recognize and handle acute complications, initial programming of the device just after the operation and before hospital discharge, and atrioventricular and ventriculoventricular optimization.
- CRT follow-up, with recommendations for the organization of follow-up, discussion of the complementary role of remote monitoring, and cooperation between the HF specialist and the electrophysiologist.
- Response to CRT management of the non-responder, with details on how to assess the response to CRT, how to manage non-responders and recommendations for a systematic assessment to identify and treat reversible causes of non-response.
- Special considerations, including recommendations for the management of CRT in particular situations such as AF and renal dialysis, how to choose between the two types of device — resynchronization alone or resynchronization plus defibrillation — and the relative advantages and disadvantages of each. Issues related to end of life, patient education and engagement, and cost effectiveness are considered.
According to Daubert, “this is the first consensus statement on all of the practical aspects involved in managing CRT patients throughout their entire journey on CRT therapy.”
“In this document we attempted to fill in the gaps in clinical evidence and provide practical recommendations for the evaluation and management of the CRT patient that could be applied to patients implanted anywhere in the world,” Leslie A. Saxon, MD, joint task force co-chair and chief of the division of cardiovascular medicine, University of Southern California, stated in the release. – by Katie Kalvaitis
For more information:
Daubert JC. Europace. 2012;14(9):1236-1286.
Daubert JC. HeartRhythm. 2012;9:1524-1576.
Perspective
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The ESC statement provides a comprehensive guide to the pre-implant evaluation, operative strategies and implant techniques, and post-implantation management of patients with HF considered for and receiving a CRT cardiac rhythm management device (CRMD). The document is broad in scope and provides a ready resource for those managing patients with HF, whether a general cardiologist, HF specialist or electrophysiologist. It is truly complementary to the recently released Device-based Therapy Guideline Update of the ACCF/AHA/HRS and the ESC Guidelines for the Diagnosis and Management of Acute and Chronic Heart Failure 2012.