Cardiac Resynchronization Therapy...

Cardiac Cardiac Resynchronization Resynchronization Therapy (CRT)KRISTY GAMA, NP, INSTRUCTOR OF MEDICINE, DIVISION OF CARDIOLOGY

UNIVERSITY OF COLORADO

KRISTY GAMA@UCDENVER [email protected]

Cardiac Resynchronization Therapy (CRT) Kristy Gama, MSN, APRN, NP-BC B6

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Disclosures

No disclosures


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ObjectivesObjectives

Discuss indications for CRT placemen, including situations where device may not be indicated

Provide an overview of cardiac device therapy, along with NASPE/BPEG codingId tif h t f ti t t i li t f Identify when to refer patient to specialist for consideration of device therapy

Venturebeat.com


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Sir EJ

72 y/o male HFrEF TTE 2019 EF 33%

NYHA class III Vitals:

100/60 % GDMT:

Carvedilol 25 mg BID Lisinopril 20 mg

100/60 75 175lbs (dry weight)

Googleimages.com

Lisinopril 20 mg Spironolactone 25 mg

daily Isordil 20 mg BID

175lbs (dry weight)

ECG – sinus brady 40, PR 280, Isordil 20 mg BID Hydralazine 25 mg TID

LBBB, QRS 150


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Normal ECG


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Left Bundle Branch Block (LBBB)


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LBBB ECG


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Question

What next steps would you take to help Sir EJ’s symptoms

A. Increase lisinopril 40 mg B check labs (i e CBC CMP) B. check labs (i.e CBC, CMP) C. Switch lisinopril to subactril/valsartan (Entresto) D Consider cardiac resynchronization therapy D. Consider cardiac resynchronization therapy


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Sir EJ

Patient tells you he has history of angioedema with losartan

CBC and CMP come back normal He’s tried to increase lisinopril in the past but SBP drops

t 80 d h / “di i ”to 80 and he c/o “dizziness”

What next? What next?


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What next?

Cardiac Device Therapy?Wh t t f d i th d EJ What type of device therapy does EJ

need?


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Brief Device Overview

http://mortgageengineer.ca/mortgage-broker-versus-bank-choose/


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Families of Devices

Bradycardia devices T h di + b d di d i Tachycardia + bradycardia devices Implantable Cardioverter DefibrillatorCardiac resynchronization devices


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Bradycardia devices

Pacemakers treat sinus node dysfunction and AV block


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Tachy/brady devices

Implantable Cardioverter/Defibrillator Brady therapy

All ICDs can Pace Tachy therapy

Main feature is shock therapy Main feature is shock therapyHigh energy discharge (shock)Anti-tachycardia pacingy p g

Requires special lead with coils

http://www.cardiachealth.org/


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Naspe/bpeg coding: what does it all Naspe/bpeg coding: what does it all mean?

Chamber PACED (A V D O) Chamber SENSED (A V D O) Chamber SENSED (A V D O) Response mode (I T D O) Rate responsiveness (R O) Rate responsiveness (R O)

http://asperkids.com/a-sense-alphabet-soup/


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Naspe/bpeg coding

Example: single-chamber pacemaker with lead in the RV

VVI/VVIO PACE in V SENSE in V SENSE in V Inhibit in response to sensed V Rate responsiveness OFF http://www.ohsu.edu/xd/health/services/heart-vascular/getting-

treatment/test-procedures/pacemaker-placement.cfm


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Naspe/bpeg coding

Example: dual-chamber pacemaker DDDR DDDR

PACE in dual (A + V) SENSE in dual (A + V)( ) Inhibit or trigger in response to A and/or VRate responsiveness ON

http://www.bostonscientific.com/templatedata/imports/multimedia/CRM/pro_pacemaker_us.jpg


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And just because it comes up….

http://levdxs.com/jokes.html


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When to get a holter

Question of arrhythmia Palpitations, dizziness, syncope

Types of monitoring systemsDaily symptoms 24-48 hour holterDaily symptoms 24 48 hour holter1x/week or 1x/month 30 day event

recorder http://afibtreatment.com/holter-monitoring.html

Very infrequent consider implantable loop recorder


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Okay now back to Sir EJ….

https://www.google.com/search?q=elton+john&source


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Heart Failure and Device Therapy

Need to consider:EFEFNYHA Functional ClassificationQRS widthEtiology of heart failure


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Which Device Do you think pt needs?

A. Dual Chamber Pacemaker? B Single Chamber Pacemaker? B. Single Chamber Pacemaker? C. Cardiac Resynchronization Pacemaker

(CRT)?( )


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Why would he need CRT?

Like ¼ HFrEF patients, he has an LBBB that has been associated with dyssynchrony and bee assoc a ed dyssy c o y a d deleterious effects of heart failure

He has evidence of AV block that may require permanent pacing

What does this mean….


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Definitions of dyssynchrony

El t i l D h Electrical DyssynchronyProlonged conduction time in ventricles resulting in a

prolonged QRSprolonged QRS

Mechanical DyssynchronyMechanical DyssynchronyMechanical discoordination, usually associated with

simultaneous contraction and stretch in difference regions of the LV as well as delays in the time of peak contraction from one segment to another


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Why is LV dyssychrony bad?

Diminished SV and CO Due:R d d di t li filli tiReduced diastolic filling timeWeakened contractilityWorsening Mitral RegurgitationPost systolic regional contraction


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CRT to the rescue….

How does CRT help

http://www.inspiredexpos.com/5k-run/superhero-heart/


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CRT overview – what is it

Restores appropriate electrical timing and contraction in the heart

Improves pumping efficiency Improves pumping efficiency ↓ Oxygen use by the heart

muscle ↓ Pressures in the heart ↓ Leakiness of the mitral valve

C l d t i d h t Can lead to improved heart function and reverse remodelingGoogle images


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CRT DevicesCRT Devices

Rationale: to improve electromechanical LV contractile synchrony

Optimize timing of RA, RV, and LV activation

Three leads: RA, RV, and LV (via the coronary sinus)sinus)


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CRT DevicesCRT Devices

Benefits of CRT:MortalityMortalityReduced risk of HF hospitalizationNYHA functional classNYHA functional classSix-minute walkLVEFLVEFQuality of life


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www.googleimages.com


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Courtesy of Sonja Fauchet, PA


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RA LVRA LV

RV

Courtesy Sonja Fauchet, PA


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CRT RCTs

COMPANION Bristow. NEJM 2004;350:2140-50CARE-HF Cleland. NEJM 2005;352:1539-1549

MADIT-CRT Moss. NEJM 2009;361:1329-38RAFT Tang. NEJM 2010;363:2385-2395

RethinQ Beshai. NEJM 2007;357:2461-71EchoCRT Ruschitzka. NEJM 2013;Sept 2.


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Copyrights apply Uptodate.com


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Ms. B

TTE 2019 – EF 35% 55 y/o female with pacemaker

and ischemic GDMT for 6 months

and ischemic Cardiomyopathy

NYHA class II symptoms - “I’d like to be able to walk more

Metoprolol XL 100 mg Losartan 100 mg Spironolactone 50 mglike to be able to walk more

than a block without feeling short of breath”I t ti l RV

Spironolactone 50 mg BP 90/60 K 5.2 NA 138 Cr 2.0

Interrogation reveals RV pacing 80%, with 1 year battery life expected


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What would you choose next?

A. Revision of dual chamber pacemaker B Increase losartan to 150 mg daily B. Increase losartan to 150 mg daily C. Consider CRT D Refer for transplant evaluation D. Refer for transplant evaluation


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RV Pacing


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Why is RV pacing detrimental with LV d f i ?dysfunction?

Ventricular dyssynchrony Frequent RV pacing (> 40% of the time)

https://www.scgov.net/parks/Pages/Rowing.aspx

can worsen HF symptoms What to do?

R f t di l / l t h i l Refer to cardiology/electrophysiologyInterrogation of the device Optimize timingOptimize timingConsider Cardiac Resynchronization

Therapyhttp://3.bp.blogspot.com


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Mr. DC

78 / l 78 y/o male HFrEF 25% NYHA l III “I ’t lk d ith t f li NYHA class III – “I can’t walk around my room without feeling

short of breath!” Atrial Fibrillation with multiple hospitalizations for RVR and ADHF Atrial Fibrillation with multiple hospitalizations for RVR and ADHF s/p several failed cardioversions and antiarrhythmic therapies GDMT: carvedilol 100 mg bid, sacubitril/valsartan 97mg/103 GDMT: carvedilol 100 mg bid, sacubitril/valsartan 97mg/103

mg, spironolactone 25 mg BP 110/76, HR 110, weight 89 kg


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What would you choose next?

A. AV nodal ablation?B I dil l 150 BIDB. Increase carvedilol 150 mg BIDC. CRTD. Both A and C


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AF exampleAF example


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CRT Indications in Atrial Fibrillation

Mi d i Mixed reviews…. Limited data on patients with AF and HF with CRT Some data shows benefit but less than pt’s with NSR Some data shows benefit but less than pt s with NSR

Higher rate of CRT failure Some LVEF improvement Better for pt’s with AV node ablation

Most large RCTs did not include AF patientsF th d t i d d i 10 t 50% f HF t’ h it t Further data is needed since 10 to 50% of HF pt’s have concomitant AF

Yancy, et al., 2017


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CRT Indications in atrial fibrillation CRT Indications in atrial fibrillation Society Guidelines

The 2012 focused update to the 2008 American Collegeof Cardiology/American Heart AssociationCo egeo Ca d o ogy/ e ca ea ssoc a o/Heart Rhythm Society (ACC/AHA/HRS) guidelines

for device-based therapy, as well as the 2013 ACC/AHA heart failure (HF) guidelines 2013 ACC/AHA heart failure (HF) guidelines, include the following recommendations that

apply to certain patients with AF


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CRT Indications in Atrial FibrillationCRT Indications in Atrial FibrillationSociety Guidelines

CRT can be useful in patients with AF and LVEF ≤35% on GDMT a) patient requires ventricular pacing or otherwise meets CRT

criteria b) atrioventricular nodal ablation or pharmacologic rate

control will allow near 100 percent ventricular pacing with CRT. Otherwise meets CRT criteria Otherwise meets CRT criteria

a) has LBBB and a QRS duration ≥ 120 ms and NYHA class II, III or ambulatory IV onoptimal GDMT

b) has a non LBBB pattern with a QRS duration ≥150 and NYHA b) has a non-LBBB pattern with a QRS duration ≥150 and NYHA class III or ambulatory class IV HF symptoms.

Yancy, et al., 2017


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Comparison of Major Society Comparison of Major Society Guidelines

Normand, Linde, Singh, & Dickstein, 2018


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Queen D

30 y/o female EF 35% diagnosed 2 weeks ago NYHA class I – “I’m not limited -just want to

focus on taking the throne with my dragon” GDMT carvedilol 25 mg BID lisinopril 20 mg

https://www.marieclaire.co

GDMT- carvedilol 25 mg BID, lisinopril 20 mg, spironolactone 12.5 mg

BP 130/80, HR 87 BP 130/80, HR 87 Cr 1.2, NA 140, K 3.5 , Hgb 8


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What would you choose to do?

A. Increase carvedilolB W k iB. Work up anemiaC. Refer for CRTD. Increase lisinopril


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Queen D

3 month repeat TTE – EF 30% GDMT was increased to maximum tolerated GDMT was increased to maximum tolerated

therapy Anemia workup revealed stage IV p g

adenocarcinoma of the colonSurvival expectancy ~1 year

Repeat ECG showed NSR with LBBB, QRS 160


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Would you consider CRT?

Memegenerator.net


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Mr. WW

52 y/o male with NICM, initial EF 15%Aft 3 th f ti l GDMT t After 3 months of optimal GDMT repeat

TTE shows EF 15%A friend brought him to the hospital when A friend brought him to the hospital when

he had a syncopal event – found down in his RVhis RV

Monitor in the ED showed this rhythm


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WW’s Baseline ECG


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What therapy would you choose?

A. ICDB CRT DB. CRT-DC. CRT-P


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Who should be considered for CRT-D?

Sh d d i i ki i k t f d t d NCD G id li Shared decision making is key –part of updated NCD Guidelines and 2017 ACC/AHA/HRS Guidelines for Ventricular Arrhythmias and SCD DECIDE- ICD (led by Colorado’s own Daniel Matlock, MD, MPH)

Benefits ICD include 23 54% reduction in mortality in several randomized trials 23-54% reduction in mortality in several randomized trials

Cons ICD include Expensive Cost of $30,000 – 50,000 per patient for first implant p $ , , p p p

alone Slightly higher procedure risks with CRT-D


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Dr. Matlock’s Decision Aid https://patientdecisionaid org/icd/https://patientdecisionaid.org/icd/


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What about EF’s >35%

The evidence to support use of CRT in selected patients with LVEF >35 and <50 percent is limited.

BLOCK HF Trial BLOCK-HF Trial

PAVE RCT PAVE RCT

Yancy, et al., 2017


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What about EF’s >35%

LVEF >35 and <50 percent with QRS duration ≥150 ms with LBBB (native or paced)

NYHA functional class III or IV despite optimal GDMT for 3 months, the efficacy of CRT is not established. established.

The rationale for CRT in this setting indirect evidence from trials with patients LVEF ≤35 percent + BLOCK-HF trial in candidates for a pacemaker.

Yancy, et al., 2017


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Copyrights apply


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Bottom Line: CRT Indications

Tracy et al. Circulation,2012;126:1784Yancy, et al., 2017


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QUESTIONS?

• Kristy Gama, NP• Structural and • Structural and

Interventional Nurse Practitioner 720 848 5300• 720-848-5300

• [email protected]


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References

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., . . . Westlake, C. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Journal of the ACCF/AHA Guideline for the Management of Heart Failure. Journal of the American College of Cardiology, 70(6), 776-803. doi:10.1016/j.jacc.2017.04.025

Normand, C., Linde, C., Singh, J., & Dickstein, K. (2018). Indications for Cardiac Resynchronization Therapy. JACC: Heart Failure, 6(4), 308-316. y py , ( ),doi:10.1016/j.jchf.2018.01.022

https://www-uptodate-com.proxy.hsl.ucdenver.edu/contents/cardiac-resynchronization-therapy-in-heart-failure-indications


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Cardiac Resynchronization Therapy...

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