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Don't just fit and forget: incremental benefit of optimisation of medical therapy post-cardiac resynchronisation therapy

Christopher O Osagie, Dibbendhu Kharan and Sanjiv Petkar
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DOI: https://doi.org/10.7861/clinmed.22-4-s27
Clin Med July 2022
Christopher O Osagie
AThe Royal Wolverhampton NHS Trust, Wolverhampton, UK
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Dibbendhu Kharan
BLiverpool Heart and Chest Hospital, Liverpool, UK
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Sanjiv Petkar
AThe Royal Wolverhampton NHS Trust, Wolverhampton, UK
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Introduction

Cardiac resynchronisation therapy (CRT) is recommended for suitable patients with heart failure (HF) who continue to be symptomatic despite optimal medical therapy (OMT).1 In reality, only a minority of patients are able to tolerate target dosages of guideline-directed medical therapy (GDMT) prior to receiving CRT.2 Common reasons for the same include low blood pressure, bradycardia, pauses, kidney injury or a combination of these factors.2 The aim was to assess whether a review by the heart failure team (HFT) post-CRT resulted in further optimisation of medical therapy for HF. The effect of this intervention on hospitalisation for HF, incidence of ventricular arrhythmias and mortality was also assessed.

Materials and methods

Retrospective analysis of records of consecutive patients undergoing CRT implantation (n=83; CRT defibrillator 70/83 (84.3%); CRT pacemaker 13/83 (15.7%)) between March 2017 and February 2019. Follow-up duration was 12 months. Baseline medical therapy prior to CRT was assessed. Patients reviewed by the HFT within six months of receiving CRT were compared with those who were not. Optimisation was defined as upward adjustment of dosages of GDMT or introduction of a new disease-modifying drug that the patient was not initially suitable for pre-CRT.

Results and discussion

Mean age was 71.1±11.1 years and there were 58/83 (70%) men. Prior to CRT, the proportion of those on target dosages of angiotensin inhibitors, betablockers, mineralocorticoid receptor antagonist and sacubitril–valsartan was 27.7% (23/83), 24.0% (20/83), 8.4% (7/83) and 6.0% (5/83), respectively. Twenty-five (72%) patients reviewed by the HFT post-CRT had their medications optimised. Of the remainder (58/83; 69.9%), only 5.2% had their medications optimised. Beta-blockers were the most optimised medication. The proportion of patients experiencing ventricular arrhythmias (VTs) treated by the device, hospitalisation for HF and mortality was higher among those not reviewed by the HFT (Fig 1).

Fig 1.
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Fig 1.

The 12-month outcomes for those reviewed and not reviewed by the heart failure team. ATP = anti-tachycardia pacing; GDMT = guideline-directed medical therapy; HF = heart failure.

The low proportion of patients on target dosages of GDMT is a reflection of the difficulty attaining the optimal recommended dosages prior to CRT.3 Our findings show that, in a vast majority of patients, there is room for optimisation of GDMT post-CRT. This may be because of an improvement in blood pressure following CRT as found in the COMPANION and CARE-HF trials.4,5 It may also be from protection against bradycardia, sinoatrial nodal pauses and slowing of atrio-ventricular conduction offered by CRT.2 The difference in VTs between the two study groups may have resulted from the higher proportion of beta blocker optimisation among those reviewed by the HFT. Background severity of HF, response to CRT, short duration of follow-up and other comorbid conditions may have contributed to the attenuation of differences in other clinical outcomes observed between the study groups.

Conclusion

We strongly recommend that all patients receiving CRT should have their medications optimised post-implant. In view of their expertise, this is best done by the HFT as attaining target dosages of GDMT remains a cornerstone of heart failure treatment, favourably influencing symptoms as well as possible prognosis.

  • © Royal College of Physicians 2022. All rights reserved.

References

  1. ↵
    1. McDonagh TA
    , Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. European Heart Journal 2021;42:3599–726.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Mullens W
    , Auricchio A, Martens P, et al. Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: a joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology. European Journal of Heart Failure 2020;22:2349–69.
    OpenUrl
  3. ↵
    1. Heywood JT
    , Fonarow GC, Yancy CW, et al. Comparison of medical therapy dosing in outpatients cared for in cardiology practices with heart failure and reduced ejection fraction with and without device therapy: report from IMPROVE HF. Circulation: Heart Failure 2010;3:596–605.
    OpenUrlAbstract/FREE Full Text
  4. ↵
    1. Salukhe TV
    , Francis DP Sutton R. Comparison of medical therapy, pacing and defibrillation in heart failure (COMPANION) trial terminated early; combined biventricular pacemaker-defibrillators reduce all-cause mortality and hospitalization. International Journal of Cardiology 2003;87:119–20.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Cleland JGF
    , Daubert JC, Erdmann E, et al. The CARE-HF study (CArdiac REsynchronisation in Heart Failure study): rationale, design and end-points. European Journal of Heart Failure 2001;3:481–9.
    OpenUrlCrossRefPubMed
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Don't just fit and forget: incremental benefit of optimisation of medical therapy post-cardiac resynchronisation therapy
Christopher O Osagie, Dibbendhu Kharan, Sanjiv Petkar
Clinical Medicine Jul 2022, 22 (Suppl 4) 27-28; DOI: 10.7861/clinmed.22-4-s27

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Don't just fit and forget: incremental benefit of optimisation of medical therapy post-cardiac resynchronisation therapy
Christopher O Osagie, Dibbendhu Kharan, Sanjiv Petkar
Clinical Medicine Jul 2022, 22 (Suppl 4) 27-28; DOI: 10.7861/clinmed.22-4-s27
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