Cardiac Resynchronization Therapy in Heart Failure: Do Evidence-Based Guidelines Follow the Evidence?

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Cardiac resynchronization therapy (CRT) for ventricular dyssynchrony in patients with heart failure has seen a steady increase worldwide; yet evidence of its effectiveness in certain subgroups is unclear. Given the high cost and risk of complications associated with these implants and their replacements, there is a need for clear clinical practice guidelines. In this report, we explore the variability of recommendations in published clinical practice guidelines and determine the extent of their evidential support. We conducted an electronic search for the most recent clinical practice guidelines and health technology assessments (HTAs) pertaining to a first implant of CRT in patients with heart failure and a systematic review of all published randomized controlled trials (RCTs) that evaluated the efficacy of CRT in heart failure patients with left ventricular dyssynchrony.1 We evaluated the concordance between recommendations on CRT use and evidence from the corresponding RCTs and meta-analyses of these RCTs. Because most recommendations were made within patient subgroups (such as New York Heart Association [NYHA] class, QRS morphology, and QRS interval), we determined how well represented these subgroups were in the major trials. We identified 4 clinical practice guidelines and 4 HTAs (Table I in the Data Supplement). Figure compares the guidelines for first-time use of CRT issued by the 4 professional societies and 2 of the HTAs. Two other HTAs were not included in Figure because they did not make recommendations by subgroups. Figure. Comparison of guidelines issued by the professional societies and health technology assessments (HTAs) for the use of cardiac resynchronization therapy (CRT) in heart failure. *For patients who have left ventricular ejection fraction ≤30%, †for patients who have left ventricular ejection fraction ≤35%, and ‡strong statistical and clinical evidence of benefit. ACCF/AHA indicates American College of Cardiology Foundation/American Heart Association; CCS, Canadian Cardiovascular Society; CRT-D, cardiac resynchronization therapy …