crt-p or crt-d from north alberta to nairobi dr mzee ... crt-p or crt-d - from...crt-p or crt-d...

CRT-P or CRT-D – From North Alberta to Nairobi

Dr Mzee Ngunga

Aga Khan University Hospital Nairobi

CONTACT: Tel. +254 735 833 803 | Email: kcardiacs@gmail.com | Web: www.kenyacardiacs.org

KCS Congress: Impact through collaboration

Disclosures

I have no conflicts of interest for this talk

I have no relationships to disclose

Case 1

A 58 year old woman is seen with exertional dyspnoea NYHA class IIb,

associated with dizziness and presyncope

Had received chemotherapy for ca breast 5 years ago

Currently on enalapril 10mg bid, aldactone 25mg, Lasix 80mg od,

carvediolol 6.25mg bid

BP is 92/56mmHG and HR 106bpm

Echo shows dilated LV 68mm, EF 25%, moderate MR, mild AR

ECG is shown

Pt MBA

Which of the following is the best strategy in his management?

A. Advise on single chamber PPM

B. Implant a dual chamber PPM

C. Implant a dual chamber ICD

D. Implant an CRT-P

E. Implant an CRT-D

ECG diagnosis?

1. Heart Block 2. LBBB

What do the guidelines say?

Therapeutic algorithm for a patient with symptomatic HF with reduced ejection fraction.

LCZ CRT Ivabradine

15

What about ICD?

• ICD Class I Recommendation

• Patients at least 40 days post-MI

• LVEF ≤ 30 – 40%

• NYHA class II or III

• Non-ischemic patients

• LVEF ≤ 30 – 35%

• NYHA class II or III

• Patients at risk of SCA due to genetic disorders

• Long QT syndrome

• Brugada syndrome with syncope. Family hx, resuscitated CA

• Hypertrophic cardiomyopathy (HCM) – Resuscitated CA, high risk group

• Arrhythmogenic right ventricular dysplasia (ARVD)

Note: This list includes the current major indications for an ICD

Show me the evidence?

??? CRT

CRT IN CHF( MIRACLE, CARE-HF and RAFT

TRIALS)

453 patients randomized

NYHA III and IV

EF< 35 %

QRS > 130 mSecs

Optimal medical management for HF

William et al ,CARDIAC RESYNCHRONIZATION IN CHRONIC HEART FAILURE, NEJM 2002

LVEF <35%, sinus rhythm, and NYHA III or IV despite optimal

medical therapy and in cardiac dys-synchrony a QRS >0.12 S,

should receive CRT, +/- ICD.

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Multicenter Automatic Defibrillator Implantation

Trial with Cardiac Resynchronization

Therapy (MADIT-CRT trial …companion trial)

1820 patients with ischemic or non-ischemic cardiomyopathy

EF of < 30%

QRS > 130 msec

NYHA I and II

Randomized to CRT-D or ICD alone.

Reduction in heart failure events not overall

mortality

Arthur Moss eta al Cardiac-Resynchronization Therapy for the Prevention of Heart-Failure Events NEJM 2009

CRM6-4403-0810© 2010 Boston Scientific. All rights reserved. 19

MADIT-CRT trial

• MADIT-CRT met its endpoint in June 2009 and results were published in the September 2009 NEJM online addition.

• Results showed that CRT-D was associated with a 34%reduction in the relative risk of the primary endpoint

• Primary effectiveness endpoint achieved

• The FDA requested to see additional 6 months of data analyzed (through December 2009)

• It was subsequently discovered and validated that in the LBBB subgroup, patients received substantial benefit from CRT-D. Non-LBBB patients did not show evidence of benefit. The LBBB sub-group made up approximately 70% of the total MADIT-CRT population.

N Engl J Med. 2009 Oct 1;361(14):1329-38. Epub 2009 Sep 1. Cardiac-resynchronization therapy for the prevention of heart-failure events.

Moss AJ, Hall WJ, Cannom DS, Klein H, Brown MW, Daubert JP, Estes NA 3rd, Foster E, Greenberg H, Higgins SL, Pfeffer MA, Solomon SD, Wilber D, Zareba W; MADIT-CRT

Trial Investigators.

34% 57%

CRM6-4403-0810© 2010 Boston Scientific. All rights reserved.

MADIT CRT LONG TERM OUTCOMES

20

CRM6-4403-0810© 2010 Boston Scientific. All rights reserved.

What about Heart Block and Heart Failure?

21

The primary outcome was the time to death

from any cause, an urgent care visit for heart

failure that required intravenous therapy, or a

15% or more increase in the left ventricular

end-systolic volume index

CRM6-4403-0810© 2010 Boston Scientific. All rights reserved.

Can I avoid the ICD?

22

CRM6-4403-0810© 2010 Boston Scientific. All rights reserved. 23

CRM6-4403-0810© 2010 Boston Scientific. All rights reserved.

Which of the following is the best strategy in his management?

A. Advise on single chamber PPM

B. Implant a dual chamber PPM

C. Implant a dual chamber ICD

D. Implant an CRT-P

E. Implant an CRT-D

CRM6-4403-0810© 2010 Boston Scientific. All rights reserved. 25