Update on Indications for
Cardiac Resynchronization Therapy
Maria Rosa Costanzo, M.D., F.A.C.C., F.A.H.A.
Medical Director, Midwest Heart Specialists-Advocate Medical Group
Heart Failure and Pulmonary Arterial Hypertension Programs
Medical Director, Edward Hospital Center for Advanced Heart Failure
Naperville, Illinois, U.S.A.
ACC/AHA DBT guidelines, 2012
2012 ACCF/AHA/HRS Focused Update
of the 2008 Guidelines for
Device-Based Therapy of Cardiac Rhythm Abnormalities
Class I



CRT is indicated for pts.
who have LVEF ≤ 35%,
SR, LBBB with a QRS
duration ≥ 150 ms, and
NYHA class II, III, or
ambulatory IV symptoms
on GDMT.
Level of Evidence: A for
NYHA class III/IV
(MIRACLE, COMPANION,
CARE-HF);
Level of Evidence: B for
NYHA class II (MADITCRT)
Comments

Modified recommendation
specifying CRT in pts with
LBBB of ≥150 ms
expanded to include those
with NYHA class II
symptoms
Tracy CM et al. JACC 2012:60:1297-1311
2012 ACCF/AHA/HRS Focused Update
of the 2008 Guidelines for
Device-Based Therapy of Cardiac Rhythm Abnormalities
Class IIa



CRT can be useful for pts. with LVEF ≤ 35%,
Sr, LBBB with a QRS duration 120 to 149
ms, and NYHA class II, III, or ambulatory IV
symptoms on GDMT. (Level of Evidence: B)
CRT can be useful for pts who have LVEF ≤
35%, SR, a non-LBBB pattern with a QRS
duration ≥ 150 ms, and NYHA class
III/ambulatory class IV symptoms on GDMT.
(Level of Evidence: A)
CRT can be useful in pts. with AF and
LVEF ≤ 35% on GDMT (Level of Evidence:
B) if
Comments

New recommendation

New recommendation

a) the patient requires ventricular pacing or
otherwise meets CRT criteria and
b) AV nodal ablation or pharmacologic rate
control will allow near 100% ventricular
pacing with CRT.

CRT can be useful for pts. on GDMT who
have LVEF ≤ 35% and are undergoing new
or replacement device placement with
anticipated requirement for significant
(>40%) ventricular pacing). (Level of
Evidence: C)

Modified recommendation
(wording changed to indicate
benefit based on EF rather than
NYHA class; level of evidence
changed from C to B).
Modified recommendation
(wording changed to indicate
benefit based on EF and need
for pacing rather than NYHA
class); class changed from IIb
to IIa).
2012 ACCF/AHA/HRS Focused Update
of the 2008 Guidelines for
Device-Based Therapy of Cardiac Rhythm Abnormalities
Class IIb



CRT may be considered for pts. who
have LVEF ≤ 30%, ischemic HF
etiology SR, LBBB with a QRS
duration ≥ 150 ms, and NYHA class I
symptoms on GDMT. (Level of
Evidence: C)
CRT may be considered for pts. who
have LVEF ≤ 35%, SR, a non-LBBB
pattern with QRS duration 120 to 149
ms, and NYHA class III/ambulatory
class IV on GDMT). (Level of
Evidence: B)
CRT may be considered for pts. who
have LVEF ≤ 35%, SR, a non-LBBB
pattern with a QRS duration ≥ 150
ms, and NYHA class II symptoms on
GDMT. (Level of Evidence: B)
Comments

New recommendation

New recommendation

New recommendations
Tracy CM et al. JACC 2012:60:1297-1311
2012 ACCF/AHA/HRS Focused Update
of the 2008 Guidelines for
Device-Based Therapy of Cardiac Rhythm Abnormalities
Class III


CRT is not recommended
for pts. with NYHA class I
or II symptoms and nonLBBB pattern with QRS
duration < 150 ms. (Level
of Evidence: B)
CRT is not indicated for
pts whose comorbidities
and/or frailty limit
survival with good
functional capacity to
less than 1 year ). (Level
of Evidence: C)
Comments


New recommendation
Modified
recommendation
(wording changed to
include cardiac as well as
noncardiac
comorbidities).
Tracy CM et al. JACC 2012:60:1297-1311
The Influence of Left Ventricular Ejection Fraction on the Effectiveness
of Cardiac Resynchronization Therapy: MADIT-CRT
Kutyifa V et al. JACC. 2013;61:936-944
The Influence of Left Ventricular Ejection Fraction on the Effectiveness of
Cardiac Resynchronization Therapy: MADIT-CRT
Kutyifa V et al. JACC. 2013;61:936-944
The Influence of Left Ventricular Ejection Fraction on the Effectiveness of
Cardiac Resynchronization Therapy: MADIT-CRT
Kutyifa V et al. JACC. 2013;61:936-944
Device Therapy in Heart Failure:
Has CRT Changed “the Sickest Benefit the Most”
to “the Healthiest Benefit the Most?”
JACC 2013;61(9):945-947
Differential Response to CRT by
QRS Morphology and Duration
Dupont M et al. JACC 2012; 60: 592-8
Histogram of QRS Duration in the Study Population
Dupont M et al. JACC 2012; 60: 592-8
Echocardiographic and Clinical Response to
CRT by QRS Morphology and Duration
After CRT, patients with LBBB morphology
and/or QRS duration ≥ 150 ms had statistically
significantly greater improvement in:






EF
LVEDD
LVESD
MR grade change
% of super-responders
NYHA functional class
Dupont M et al. JACC 2012; 60: 592-8
Survival after CRT Implantation
Dupont M et al. JACC 2012; 60: 592-8
Cox Proportional Hazards Models for Death,
Heart transplantation and LAVD Placement
Variable
Adjusted HR
P Value
LBBB and
QRS ≥ 150 ms
1.00
LBBB and
QRS <150 ms
1.52 (0.95-2.38)
0.08
Non-LBBB and
QRS ≥ 150 ms
1.01 (0.65-1.55)
0.96
Non-LBBB and
QRS <150 ms
1.42 (0.93-2.15)
0.10
Male
2.17 (1.14-3.44)
0.84 (0.60-1.17)
0.0003
0.30
1.55 (1.09-2.24)
0.98 (0.98-0,99)
0.97 (0.95-0.99)
0.01
< 0.0001
0.01
Age > 70
Ischemic CM
eGFR
Baseline EF
Dupont M et al. JACC 2012; 60: 592-8
Changes in Echocardiographic Parameters in SuperResponder, Responder and Hyporesponder Groups
Hsu JC et al. J Am Coll Cardiol. 2012; 59(25):2366-2373
Multivariable Analysis of Predictors
of LVEF Super-Response
Variable
Odd Ratio
95% CI
P value
Female
1.96
1.32-2.90
0.001
QRS ≥ 150 ms
1.79
1.17-2.73
0.007
LBBB
2.05
1.24-3.40
0.006
BMI < 30 Kg/m2
1.51
1.03-2.20
0.035
No Prior MI
1,80
1.20-2.71
0.005
LAVI
1.47
1.21-1.79
< 0.001
Hsu JC et al. J Am Coll Cardiol. 2012; 59(25):2366-2373
Kaplan-Meier
Estimates of
Cumulative Probability
of Heart Failure or
Death, Death Alone,
and Death or ICD
Therapy for VT or VF
Stratified by Response
Category
Hsu JC et al. J Am Coll Cardiol. 2012; 59(25):2366-2373
Cox Proportional Regression
Analysis of Predictors
of Nonfatal HF Events or Death
Variable
Hazard Ratio
95% CI
P value
LVEF response
Super-responder
Reference
Hypo-responder
5.25
2.01-13.74
0.001
Responder
2.24
0.86-5.83
0.099
LBBB
0.57
0.34-0.94
0.029
Creatinine ≥ 1.4 mg/dL
3.02
1.66-5.49
< 0.001
Hsu JC et al. J Am Coll Cardiol. 2012; 59(25):2366-2373
ACC/AHA DBT guidelines, 2012
Conclusions
Since the publications of the Miracle trial the indications for
CRT have evolved
Measures of mechanical dyssinchrony have been largely
disappointing in predicting response to CRT
QRS duration has endured as the single stronger predictor of
CRT response
The MADIT-CRT trial has extended the indications for CRT to
patients with prolonged QRS and mild HF symptoms
The ability to predict non-responders to CRT remains elusive
The ADVANCED-CRT Registry will help to characterize nonresponders to CRT and to refine selection criteria for CRT