Shifts in Eligibility For CRT in Heart Failure Patients Characterized in Analysis of Guideline Criteria

A smaller proportion of patients with heart failure and a left ventricular ejection fraction (LVEF) ≤35 percent were eligible for cardiac resynchronization therapy (CRT) using criteria from the current 2013 American College of Cardiology Foundation/American Heart Association (AHA) heart failure guidelines compared with those from the 2009 guidelines. The first analysis of the influence of the new CRT criteria on eligibility was presented by Kristin J. Lyons, MDCM, as an oral abstract on March 17 at ACC.17 in Washington, DC and simultaneously published in JACC: Heart Failure.

In a population of 25,102 patients from 238 hospitals, identified in the Get With the Guidelines-HF database, eligibility for CRT was 33.1 percent and 49.1 percent, respectively, based on the 2013 and 2009 criteria (p < 0.0001). Of note, the 2013 guidelines expanded the criteria for CRT to include NYHA Class II patients, but limited the criteria to patients with LVEF ≤35 percent, sinus rhythm, and a left bundle branch block (LBBB) or a non-LBBB and a QRS ≥ 150 msec.

QRS duration and morphology were the only significant differences in the baseline characteristics of the patients classified as eligible for CRT based on the 2013 and 2009 criteria. In both groups, patients were 73 years old and most were men and white (70 percent each). Their LVEF was 23 percent and 43 percent had atrial fibrillation/flutter; the etiology of heart failure was hypertension for 78 percent and ischemic for 70 percent.

Among the 5,303 patients with a QRS duration of 120-149 msec, only 21.3 percent were eligible with the new criteria versus 78.7 percent with the old criteria. For a QRS ≥150 msec, nearly all patients were eligible for CRT using both criteria. Likewise, nearly all patients with a LBBB were eligible using both criteria. However, using the new criteria, non-LBBB limited eligibility to 56.8 percent versus nearly all patients using the old criteria.

Low adherence to guideline recommendations for CRT was found using both criteria: only 57.8 percent and 54.9 percent of those eligible based on the 2013 and 2009 criteria respectively had a CRT prescribed or placed at the time of hospital discharge. The investigators stated that although there is the potential for health care costs to be reduced because fewer patients are eligible for CRT, improvement is needed in adherence to device therapy for eligible patients with heart failure.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Implantable Devices, EP Basic Science, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Hypertension

Keywords: ACC17, ACC Annual Scientific Session, American Heart Association, Atrial Fibrillation, Bundle-Branch Block, Cardiac Resynchronization Therapy, Heart Failure, Hypertension, Stroke Volume, Ventricular Function, Left

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