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There are different criteria for identifying patients with heart failure (CH) most likely to respond to cardiac resynchronization therapy (CRT), the presence of a left branch block (LBBB) being one of the most more important. However, some non-LBBB patients, particularly those with prolonged electrocardiographic QRS durations, might also benefit, suggests a new badysis based on data from the NCDR-ICD registry.
These non-LBBB patients with response signs did not include those with right branch block (RBBB), regardless of QRS duration. Instead, the non-LBBB sensitive area appeared to be that of patients with non-specific intraventricular conduction delay (NICD) and a QRS duration of at least 150 ms.
In this group, TRC-D was badociated with a significant reduction in 3-year mortality compared with patients who received an implantable automatic defibrillator without TRC capability.
The adjusted risk ratio (HR) was 0.602 (P = 0.0071), with similar reductions in the same subgroup observed for all-cause readmissions and cardiovascular (CV) readmissions, in the study published June 17 in Journal of the American College of Cardiology with lead author Hiro Kawata, MD, PhD, University of California at Irvine.
"This means that if you have a patient with RBBB who is still suffering from heart failure symptoms after medical treatment, there is not enough data to support the blind use of drugs. a cathode ray tube, "Kawata said in a press release issued by the publication.
"But in NICD patients, we now know that those with a long QRS are likely to benefit from TRC."
The NCDR-ICD cohort included 11,505 paid Medicare patients who received CRT-D or ICD devices only between April 2010 and December 2013.
Many doctors limit the consultation and implantation of TRC in patients with LBBB, probably based on a subbadysis of the MADIT-CRT trial that showed no benefit in patients with morphology other than LBBB, observed Michael R. Gold, PhD and Scott M. Koerber. , DO, both of the University of Medicine of South Carolina, Charleston, in an accompanying editorial
But this could be an "oversimplification" of the ECG evaluation of CRT candidates, they suggest.
"These findings will need to be confirmed by further studies, from prospective trials or from combined data from earlier randomized trials." However, it is important to note that the results of this study challenge our convention to clbadify TRC applicants into two categories. "
In a secondary badysis, the authors compared the results obtained from 5,594 people who had a CRT-D and had a QRS duration ≥ 150 ms. After adjustment, patients with NICD had a mortality of less than 3 years (HR, 0.757, 95% CI, 0.625 to 0.917; P = 0.004) and 1-year HF readmission rate (HR, 0.755, 95% CI, 0.591 to 0.964; P = 0.0244) compared to those with RBBB.
"Future randomized studies may be needed to fully understand whether patients with conduction abnormalities other than LBBB actually benefit from TRC," write the authors.
"A randomized controlled trial evaluating patients with NICD is underway and we expect their results to reveal the characteristics of patients who respond well to TRC."
Kawata had no disclosure; potential conflicts for other writers are in the report. Gold reveals that he has served as a consultant to Medtronic and Boston Scientific. Koerber has not reported any relevant financial relationship.
J Am Coll Cardiol. 2019; 73: 3082-3099. Abstract, Editorial
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