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Management Of Heart Failure Beyond Drugs: Role of ICD and CRT Anil Saxena Director Cardiac Pacing & Electrophysiology Fortis Escorts Heart Institute, New Delhi How to manage heart failure? Remove precipitating factor Correct the underlying etiology Drug therapy Additionally… Salt and fluid management Life style change Optimize weight Exercise, Reduction of Stress Yoga, Meditation CRT ICD (Implantable Defibrillator) What Is CRT? Heart Failure with Wide QRS PR interval 280 msec QRS width 160 msec 15-30% Patients with heart failure have conduction system disease Wide QRS– Increased Mortality Vesnarinone Study1 (VEST study analysis) QRS Duration (msec) 100% Cumulative Survival 96% 92% 220 64% 60% Gottipaty et al JACC Feb 1999 supplement 145A 60 120 180 240 300 360 Days in Trial Ventricular Dysynchrony Paradoxical movement of the septum ✦ Dilated Cardiomyopathy ✦ LBBB ✦ LVEF 20% ✦ Paradoxical Septal Motion Underlying Arrhythmia of Sudden Death Primary VF Torsades de Pointes 8% 13% VT 62% Adapted from Bayés de Luna A Am Heart J 1989;117:151-159 17% Bradycardia Sudden Cardiac Death Died one morning after a cardiac arrest Sudden Cardiac Death The Chain Of Survival ICD: Placement Implantable Cardioverter Defibrillator CRT-P versus CRT-D • CRT-D is often chosen on premise, that all patients fulfilling criteria for CRT also have approved indication for ICD • In western countries, fraction of CRT-D is 60-80% among patients receiving cardiac resynchronisation therapy CRT-P versus CRT-D • Does CRT alone improve survival by reducing mortality? • Will addition of ICD backup to CRT further improve survival significantly? Cardiac Resynchronization: Trials All cause mortality reduction Baseline Clinical Characteristics of Randomized CRT (± ICD) Trials Characteristic CONTAK CD InSync ICD MIRACLE MUSTIC No of pts (n) 490 554 532 58 Age, mean (yrs) 66 66 64 63 Men (%) 421 (84) 448 (81) 370 (70) 50 (75) LVEF (%) 21 21 22 23 NYHA Class II-IV II-IV III-IV III QRS duration (msec) 158 165 166 176 LBBB (%) 271 (54) 382 (69) 426 (80) 58 (87) Beta-blocker use (%) 236 (47) 335 (60) 296 (56) 19 (28) Pooled data from trials involving a total of 1634 patients CRT was associated with a 51% reduction in death from progressive CHF relative to controls Trend toward improvement in all-cause mortality (23% improvement), which did not reach statistical significance because of the short follow-up and small sample size CRT reduced hospitalization for CHF by 29% (n = 1497) Investigators concluded that CRT reduces mortality from progressive HF and HF-related hospitalizations in patients with symptomatic left ventricular dysfunction and ventricular dyssynchrony and also shows a trend toward reducing all-cause mortality Bradley et al JAMA 2003;289:730-740 Care HF Trial: All cause mortality reduction ❖ 814 patients ❖ Randomised to (Medical therapy) or (Medical therapy + CRT) ❖ Significant reduction in all cause mortality observed with CRT Death or hospitalization All cause mortality Care HF Trial: Extension Phase All cause mortality reduction Follow-up 37.4 months (range 26.1–52.6 months) 40% Reduction in mortality Companion Trial: CRT vs CRT-D: Mortality Reduction All Cause Mortality Bristow M et al N Engl J Med 2004;350:21, 2140-50 ESC 2013 Guidelines for CRT-P versus CRT-D Thank You anil.saxena@hotmail.com ... underlying etiology Drug therapy Additionally… Salt and fluid management Life style change Optimize weight Exercise, Reduction of Stress Yoga, Meditation CRT ICD (Implantable Defibrillator)