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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EIn 2012, the American Heart Association (AHA), American College of Cardiology (ACC), and the Heart Rhythm Society (HRS) published updated clinical practice guidelines for the management of cardiac resynchronization therapy (CRT) [Tracy CM et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2012]. The new guideline proposes several changes in recommendations for CRT, compared with the 2008 guideline, and this article discusses the most significant changes.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHeart Failure\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology \u0026amp; Cardiovascular Medicine\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHeart Failure\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EExclusive Article - For home page\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EIn 2012, the American Heart Association (AHA), American College of Cardiology (ACC), and the Heart Rhythm Society (HRS) published updated clinical practice guidelines for the management of cardiac resynchronization therapy (CRT) [Tracy CM et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe new guideline proposes several changes in recommendations for CRT, compared with the 2008 guideline. The most significant changes are\u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n            \n            \u003Cp id=\u0022p-4\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u25aa \u003C\/span\u003ELimitation of the Class I indication to patients with QRS duration \u2265150 ms\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n            \n            \u003Cp id=\u0022p-5\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u25aa \u003C\/span\u003ELimitation of the Class I indication to patients with left bundle branch block (LBBB)\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n            \n            \u003Cp id=\u0022p-6\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u25aa \u003C\/span\u003EExpansion of Class I indication to NYHA Class II (and with LBBB with QRS duration \u2265150 ms)\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n            \n            \u003Cp id=\u0022p-7\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u25aa \u003C\/span\u003EAddition of a Class lib recommendation for patients who have left ventricular ejection fraction \u226430%, ischemic etiology of heart failure (HF), sinus rhythm, LBBB with a QRS duration \u2265150 ms, and NYHA Class I symptoms.\u003C\/p\u003E\n         \u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-8\u0022\u003EThe AHA\/ACC\/HRS guidelines recommend CRT over medical therapy for the treatment of HF patients based on evidence from multiple trials. Mark Link, MD, Tufts University School of Medicine, Boston, Massachusetts, USA, highlighted several trials that specifically analyzed results for patients with LBBB or non-LBBB. In the CARE-HF trial, 813 HF patients were randomized to receive CRT or medical therapy with a mean follow-up time of 29.4 months [Cleland JG et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2005]. The primary endpoint of death or unplanned hospitalization in the cardiac synchronization arm was 39%, compared with 55% in the medical therapy arm (HR, 0.63; 95% CI, 0.51 to 0.77; p\u0026lt;0.001).\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EIn the RAFT trial, 1798 patients were randomized to receive an implantable cardioverter-defibrillator (ICD) alone or an ICD in combination with CRT and followed for a mean of 40 months [Tang AS et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2010]. The primary endpoint of death or hospitalization was reached by 33.2% of patients in the ICD plus CRT arm, as compared with 40.3% of patients in the ICD arm (HR, 0.075; 95% CI, 0.64 to 0.87; p\u0026lt;0.001) for the ICD plus CRT arm. In the MADIT-CRT trial, 1820 patients were randomized 3:2 to receive an ICD plus CRT or an ICD only and were followed for a mean of 2.4 years [Moss AJ et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009]. The primary endpoint of death or hospitalization was reached by 17.2% of patients in the ICD plus CRT arm, as compared with 25.3% in the ICD-only arm (HR, 0.66; 95% CI, 0.52 to 0.84; p=0.001). Dr. Link pointed out that in all of these trials, LBBB and\/or the QRS duration of 150 ms or longer was extremely important in determining patient benefit of CRT treatment [Cleland JG et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2005; Tang AS et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2010; Moss AJ et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003ELynne Warner Stevenson, MD, Brigham and Women\u0027s Hospital, Boston, Massachusetts, USA, discussed the importance of HF classification in regards to CRT. Dr. Stevenson pointed out that although CRT has been demonstrated to be beneficial for many patients, those patients with advanced Class IV HF do not appear to benefit from CRT, particularly if they have received inotropic therapy [Bhattacharya S et al. \u003Cem\u003EJ Card Fail\u003C\/em\u003E 2010]. However, she emphasized the strength of data that supports use of CRT to decrease disease progression in patient with Class II symptoms. As an HF clinician, she pointed out the difficulty of distinguishing between Class I and Class II symptoms, which may become less relevant as LBBB is increasingly appreciated as a cause, not just a result, of worsening heart failure.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EIbrahim Almasry, MD, Stony Brook Heart Rhythm Center, Stony Brook, New York, USA, discussed the importance of QRS duration in CRT therapy. Longer QRS duration and width of QRS are associated with poorer HF outcomes, including total mortality [Kashani A et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2005; Bleeker GB et al. \u003Cem\u003EJ Cardiovasc Electrophysiol\u003C\/em\u003E 2004]. In the REVERSE trial, only patients with QRS duration of at least 152 ms experienced a benefit from CRT. Dr. Almasry noted that in the MADIT-CRT trial, patients with QRS duration of at least 150 ms experienced a benefit from CRT, whereas patients with QRS duration of \u0026lt;150 ms did not [Moss AJ et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009]. Similar findings were demonstrated in the RAFT trial; however, patients with a paced QRS duration of 200 ms or longer did not receive benefit from CRT [Tang AS et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EDerek Exner, MD, MPH, Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada, discussed CRT in patients with atrial fibrillation (AF), which is common in patients with HF. Multiple trials have demonstrated that patients with AF tend to respond less to therapy and have a greater annual mortality rate, as compared with patients with sinus rhythm [Wilton SB et al. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2011]. In addition, patients with AF are more likely to experience mortality following CRT than patients without AF(p=0.0038; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Bogale N et al. \u003Cem\u003EEur J Heart Fail\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/3\/8\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Patients With Atrial Fibrillation Experience Greater Risk of Death Following CRT\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1391204191\u0022 data-figure-caption=\u0022Patients With Atrial Fibrillation Experience Greater Risk of Death Following CRT\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/3\/8\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/3\/8\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/3\/8\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13188\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003EPatients With Atrial Fibrillation Experience Greater Risk of Death Following CRT\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ECRT=cardiac resynchronization therapy.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Bogale N et al. The European CRT Survey: 1 year (9\u201315 months) follow-up results. \u003Cem\u003EEur J Heart Failure\u003C\/em\u003E 2012;4(1):61\u201373. With permission from Oxford University Press.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-14\u0022\u003EWhether the benefits observed with CRT are similar in patients with versus without AF is unclear. A meta-analysis of 23 observational studies by Wilton et al. found that AF was associated with an increased risk of nonresponse to CRT (34.5% vs 26.7%; pooled relative risk [RR] 1.32; 95% CI, 1.12 to 1.55; p=0.001) and all-cause mortality (10.8% vs 7.1% per year; pooled RR 1.50; 95% CI, 1.08 to 2.09; p=0.015) [Wilton SB et al. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2011]. The percentage of biventricular pacing (BiV) that is required for optimal survival rates appears to be \u0026gt;98.47%, as reported by an observational study [Hayes DL et al. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2011]. In the AF subset in the RAFT trial, there was no significant difference in the primary endpoint between patients that received an ICD plus CRT or an ICD alone (HR, 0.96; 95% CI, 0.65 to 1.41;p=0.82) [Healey et al. \u003Cem\u003ECirc Heart Fail\u003C\/em\u003E 2012]. However, Dr. Exner pointed out that the BiV in the RAFT trial was inadequate, as \u223c47% of AF patients had a BiV of \u223c90%. Dr. Exner concluded by stating that there is questionable benefit of CRT in patients with AF, although a higher BiV may improve outcomes, and additional randomized controlled trials are required.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EPamela Karasik, MD, Georgetown University, Washington, District of Columbia, USA, presented the updates to the AHA\/ACC\/HRS guidelines for CRT in HF patients who require pacing. Several studies, including the more recent MADIT-CRT and RAFT, have demonstrated that a greater frequency of pacing is associated with worsening HF and greater mortality [Sweeney MO et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2003; Steinberg JS et al. \u003Cem\u003EJ Cardiovasc Electrophysiol\u003C\/em\u003E 2005; Tang AS et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EAmit Shanker, MD, Columbia University College of Physicians and Surgeons, New York, New York, USA, discussed the in-person and remote monitoring of patients with HF that have received CRT. The PARTNERS HF trial demonstrated that patients at risk of HF-associated hospitalization could be effectively identified by an integrated diagnostic algorithm (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Whellan DJ et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2010]. Dr. Shanker highlighted that patients prefer remote monitoring over in-clinic follow-ups and there is an improvement in operational efficiency, which ultimately leads to lower costs.\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/3\/8\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Combined Device Diagnostics Can Accurately Predict Heart Failure Patients at Risk for Hospitalization\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1391204191\u0022 data-figure-caption=\u0022Combined Device Diagnostics Can Accurately Predict Heart Failure Patients at Risk for Hospitalization\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/3\/8\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/3\/8\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/3\/8\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13189\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-17\u0022 class=\u0022first-child\u0022\u003ECombined Device Diagnostics Can Accurately Predict Heart Failure Patients at Risk for Hospitalization\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EReproduced from Whellan DJ et al. Combined Heart Failure Device Diagnostics Identify Patients at Higher Risk of Subsequent Heart Failure Hospitalizations. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2010;55(17):1803. With Permission from Elsevier.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-18\u0022\u003EBruce Wilkoff, MD, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA, discussed the current gaps in evidence for CRT. Although there are areas where evidence is strong for the use of CRT, such as in patients with a QRS \u2265150 ms and the presence of LBBB, there are other areas where evidence is lacking. Dr. Wilkoff pointed out that more evidence is needed in areas such as indications for CRT implantation, how to measure success, the definition of \u201cnonresponse,\u201d and the role of comorbidities such as AF.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/3\/8.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nznyf1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nznyf1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}