EU, U.S. consensus offers advice on managing CRT patients

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Experts from the U.S. and Europe released recommendations for the practical management of cardiac resynchronization therapy (CRT) patients Aug. 28 at the European Society of Cardiology Congress in Munich, launching the first international collaboration on a consensus statement on CRT in heart failure.  

“The 2012 Expert Consensus Statement on Cardiac Resynchronization Therapy (CRT) in Heart Failure: Implant and Follow-up Recommendations and Management” was developed by the European Heart Rhythm Association, a registered branch of the European Society of Cardiology, and the Heart Rhythm Society in the U.S. It will be published in their respective journals, EP Europace and HeartRhythm.

“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,” said Leslie A. Saxon, MD, U.S. joint task force co-chair, in a release. Saxon is chief of the division of cardiovascular medicine at the University of Southern California in Los Angeles.

The document is in six sections:

Pre-implant evaluation
This section includes recommendations on how to manage patients just before CRT implantation. It focuses on potential temporary contraindications to the intervention, and how to manage medications, particularly anticoagulants and antibiotics, just before and during the implantation procedure.

CRT implantation
This section covers how to implant the CRT device. It describes all steps of the procedure such as anesthesia, lead implant sequence, left ventricular lead placement and defibrillation testing.

Pre-discharge evaluation and device programming
This section includes 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
This section outlines how follow-up should be organized and what assessments should be made. The complementary role of remote monitoring is discussed, with a special focus on how remote hemodynamic monitoring can be used. The need for strong cooperation between the heart failure specialist and the electrophysiologist (EP) is stressed. “We have to keep in mind that the CRT patient is primarily a heart failure patient,” said Jean-Claude Daubert, MD, joint task force co-chair and an electrophysiologist at University of Rennes in France. “Follow-up has to concern not only the technical follow-up of the device, but also—and primarily—the heart failure status of the patient. It is essential to optimize the heart failure management of the patient.”

Response to CRT management of the non-responder
This section discusses how to assess the response to CRT and how to manage non-responders. The document recommends that a systematic assessment should be conducted to identify and treat reversible causes of non-response.

Special considerations
This section includes recommendations for the management of CRT in particular situations such as patients with atrial fibrillation and patients on renal dialysis. It also discussed are how to choose between the two types of device, resynchronization alone or resynchronization plus defibrillation, and the relative advantages and disadvantages of each. It provides guidance on issues related to end of life, patient education and engagement and cost effectiveness.

The clinical indications for CRT are outlined in the 2007 ESC guidelines, which were updated in 2010, and U.S. guidelines from 2008. These guidelines are supported by robust evidence from randomized clinical trials.

“We have very strong recommendations regarding clinical indications based on the clinical evidence and these are covered in multiple guidelines,” Daubert said. “[U]ntil now we did not have a consensual document on the practical aspects of this therapy. Our goal was to establish a consensus statement on how to manage CRT patients before, during and after the implantation procedure. We do not discuss clinical indications.”