Adherence to ESC cardiac resynchronization therapy guidelines: findings from the ESC CRT Survey II

Stefan D Anker,Kenneth Dickstein,Chris Plummer,Nedim Umutay Sarigul,Christoph Stellbrink,Carina Blomström-Lundqvist,Camilla Normand,Svetoslav Iovev,Giorgi Papiashvili,Maurizio Gasparini,Cecilia Linde

doi:10.1093/europace/euaa067

Abstract

Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in patients with heart failure (HF) and electrical dyssynchrony. The European Society of Cardiology (ESC) Guidelines provide evidence-based recommendations indicating optimal patient selection for CRT implantation in both the 2013 European Heart Rhythm Association (EHRA) and the 2016 Heart Failure Association (HFA) Guidelines. We assessed the adherence to guidelines and identified factors associated with guideline adherence. In 2016, the HFA and EHRA conducted the CRT Survey II in 42 ESC countries. The data collected were sufficient to evaluate adherence to guidelines in 8021 patients. Of these, 67% had a Class I guideline indication for CRT implantation, which was significantly correlated with female gender (1.70, P < 0.0001), age <75 years (1.55, P < 0.0001), non-ischaemic HF aetiology (1.22, P < 0.0001), and elective admission (1.87, P < 0.0001). A further 26% of implants had a Class IIa indication, 5% IIb and only 2% a contraindication to CRT-a Class III indication. Patients implanted under Level IIa indications were much more likely to have more comorbidities than patients implanted under Level I indications. However, there were large variations in guideline adherence between ESC countries. Implanters in ESC member states demonstrate a high degree of adherence to ESC guidelines with 98% of implants having a documented Class I, IIa or IIb indication. Cardiac resynchronization therapy implantation without a Class I indication was more likely in men, patients age ≥75 years, with HF of ischaemic origin and in patients admitted to hospital acutely.

Highlights

1.1 Heart Failure and Electrical DyssynchronyHeart failure (HF) is a complex clinical syndrome characterized by symptoms and signs includ ing breathlessness, fatigue and fluid retention
This paper summarizes the most recent international guideline recommendations for Cardiac resynchronization therapy (CRT) and their corresponding levels of evidence
In the CRT Survey II we demonstrated that the majority of patients selected for CRT implantations in Europe had the clinical characteristics shown to be amenable to CRT and recommended by the guidelines, such as sinus rhythm, wide QRS, left bundle branch block (LBBB), low ejection fraction and symptomatic heart failure

Summary

Introduction

1.1 Heart Failure and Electrical DyssynchronyHeart failure (HF) is a complex clinical syndrome characterized by symptoms and signs includ ing breathlessness, fatigue and fluid retention. Certain patients with systolic heart failure show signs of electrical dyssynchrony on their electrocardiogram (ECG) exhibited by a prolonged QRS duration. The first CRT survey showed considerable regional and national differences in implantation practices.13 Since this survey was published, several important modifications of ESC guideline recommendations concerning CRT indications have been made by both the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA).. Since this survey was published, several important modifications of ESC guideline recommendations concerning CRT indications have been made by both the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA).8,9,12 These two ESC Associations decided to collaborate and undertake a pan-European survey designed to describe current clinical practice regarding implantation of CRT devices in a larger sample of patients and greater number of ESC member countries. It is challenging for the guideline committees to review the impact of newer evidence in a timely fashion

Objectives

Methods

Results

Discussion

Conclusion