QRS Duration Criteria to Select Patients for Cardiac Resynchronization Therapy

Abstract

Current American College of Cardiology/American Heart Association/Heart Rhythm Society as well as European Society of Cardiology guidelines recommend the use of cardiac resynchronization therapy (CRT) in patients with symptomatic heart failure (HF) and QRS durations >120 ms1,2 (Table 1). However, 2 recent meta-analyses by Sipahi et al6 and Stavrakis et al7 challenged these recommendations. Both studies found that patients with QRS durations between 120 and 150 ms do not benefit from CRT. View this table: Table 1. Indications for Cardiac Resynchronization Therapy Response by Sipahi and Fang on p 435 This is a very important conclusion, from both the clinical and financial standpoints. If the conclusions of these meta-analyses are correct, the guidelines should be revised, and the cutoff for QRS duration indicating the need for CRT should be changed from 120 to 150 ms. From the reimbursement standpoint, these analyses would suggest that the cost of CRT devices implanted in patients with QRS durations shorter than 150 ms should not be covered by insurers. Indeed, the authors of the second meta-analysis state that “the decision to routinely recommend CRT for patients with QRS <150 ms may not be justified.”7 Although not in such categorical terms, some societies are already embracing this idea. In fact, in their recently published update, the Heart Failure Society of America, citing one of the abovementioned meta-analyses,6 definitely recommends CRT only for patients with QRS durations >150 ms (and not because of right bundle-branch block), with severe left ventricular (LV) systolic dysfunction and persistent New York Heart Association (NYHA) functional class II-III symptoms, despite optimal medical therapy. According to the same update, CRT may still be considered for patients with QRS intervals between 120 and 150 ms and severe left ventricular dysfunction who have persistent symptoms on medical treatment.5 However, the wording …