Increased use of CRT could help reduce hospitalizations for HF

For patients with HF, poor dietary and alcohol choices can lead to increased risk for hospitalization. In fact, recent research has demonstrated that hospitalization for HF spikes after holidays and major sporting events, such as the Super Bowl, which is being played Sunday.

Many patients whose cardiac function is too poor to overcome temporary dietary and alcohol indiscretions can benefit from cardiac resynchronization therapy, but the technology is underused in the United States, according to an expert Cardiology Today interviewed.

“The spike in HF hospitalizations after holidays and major sporting events is related to dietary indiscretion and excessive alcohol consumption. Patients who are healthy for much of the year may show poor judgment during the holidays and eat more salty food than typical or may unintentionally eat salty food by dining out rather than dining in. That plus additional alcohol intake are the reasons that HF hospitalizations spike after holidays and major sporting events,” David Frankel, MD, cardiac electrophysiologist and assistant professor of medicine at Perelman School of Medicine at the University of Pennsylvania, said in an interview.

David Frankel

“CRT can improve HF symptoms throughout the year. By improving cardiac function, the patient would certainly be able to tolerate a little excess sodium better without going into HF decompensation,” Frankel said.

A study of 22,728 patients with congestive HF admitted to Einstein Medical Center, Philadelphia, from 2003 to 2013 indicated that hospitalization rates for HF were more frequent in the 4 days after Christmas (+14%), the Fourth of July (+11.4%), the Super Bowl (+11%), New Year’s Day (+3.3%) and Thanksgiving (+2%) compared with the rest of the month of the event.

Underutilization persists

Unfortunately, Frankel said, findings from the IMPROVE HF study published in 2008 suggested that CRT is used in only 39% of appropriate patients in the United States. By contrast, the study showed high utilization of other therapies shown to be effective, such as ACE inhibitors/angiotensin receptor blockers (80%) and beta-blockers (86%).

According to Frankel, “CRT is massively underutilized.”

The underutilization can be divided into two major problems, he said. “The first, and more significant, is under-referral. Many patients with HF are not under the care of HF specialists or cardiologists, but rather primary care physicians. And there may not be adequate awareness of the benefits of and guideline indications for CRT in patients with HF. The second consideration is that some implanters may not be trained to do CRT implants. Because the procedure has increased difficulty and time and a slightly higher rate of complications, some operators may not be comfortable performing CRT implants, and instead opt for regular defibrillator implants.”

Strong evidence

The evidence for CRT is strongest in patients with NYHA class II, III, or ambulatory class IV HF symptoms, left ventricular ejection fraction of 35% or less, and left bundle branch block (LBBB) greater than 150 ms, according to Frankel.

“CRT has been shown in multiple randomized clinical trials to reduce mortality, reduce HF hospitalizations and improve HF symptoms,” he said.

There is also evidence that CRT may benefit patients with NYHA class I HF symptoms, those with LBBB less than 150 ms or those with non-LBBB QRS complexes greater than 150 ms, and the BLOCK HF trial showed that patients with reduced LVEF and frequent right ventricular pacing can also benefit from the technology, according to Frankel.

“Any time a patient is being considered for a device implant, one needs to look at the QRS morphology and assess the HF symptoms, and if NYHA class II or greater symptoms and a wide LBBB are present, then CRT is the device of choice,” Frankel said.

He encouraged widespread guideline awareness in the entire community of physicians who care for patients with HF to better communicate the benefits of CRT.

“If implanting physicians encounter a patient who meets the criteria for CRT, but are not comfortable implanting CRT, then they should refer that patient to an operator who does perform CRT. There is a lot of room to improve the health of patients with HF by utilizing CRT more appropriately. It is something we should all think about more.” – by Erik Swain

For more information:

Curtis AB. N Engl J Med. 2013;368:1585-1593.

Fonarow GC. Circ Heart Fail. 2008;1:98-106.

Shah M. J Cardiac Fail. 2014;20:S98-S99.

David Frankel, MD, can be reached at 3400 Spruce St., 9 Founders Pavilion, Philadelphia, PA 19104; email: david.frankel@uphs.upenn.edu.

Disclosure: Frankel reports no relevant financial disclosures.