Αμφικοιλιακή βηματοδότηση: LBBB ή ευρύ QRS;

Transcription

1 ΠΑΝΕΛΛΗΝΙΑ ΣΕΜΙΝΑΡΙΑ ΟΜΑΔΩΝ ΕΡΓΑΣΙΑΣ 2016 ΟΜΑΔΑ ΕΡΓΑΣΙΑΣ ΚΑΡΔΙΑΚΗΣ ΑΝΕΠΑΡΚΕΙΑΣ Στρογγυλό τραπέζι: Χρόνια Καρδιακή Ανεπάρκεια Αμφικοιλιακή βηματοδότηση: LBBB ή ευρύ QRS; Ξυδώνας Σωτήριος, MD, FESC Β Καρδιολογικό Τμήμα, Γ.Ν.Α. «Ο Ευαγγελισμός»

2 Σύγκρουση συμφερόντων με τις χορηγούς εταιρείες: ELPEN, BAYER, BOEHRINGER INGELHEIM GLAXO, MEDTRONIC, NOVARTIS, SERVIER Page 2

3 Prevalence of heart failure by sex and age Page 3 Circulation 2015;131:00-00.

4 HF Epidemics 2% of the adult population in developed countries 1% of emergency hospital admissions Euro Heart Failure Survey: 36% of those had an LVEF 35% of these: 41% had QRS 120 ms 17% had QRS 150 ms 34% had LBBB / IVCD 7% had RBBB The annual incidence of LBBB is about 10% in ambulatory patients with LVSD and CHF 5 10% are indicated for CRT 400 pts/10 6 * year might be suitable for CRT Page 4 Eur Heart J 2006;27:

5 CRT Implantation rates Average implantation rate of devices for CRT in the 16 European countries (units / 10 6 inhabitants) based on reports from major manufacturers. The figures include 1 st implantations and replacements. Page 5 Eur Heart J 2013; 34:

6 Inclusion criteria Page 6 Linde C, et al. Heart Rhythm 2012;9:S3 S13.

7 CRT Meta-analysis III IV : All cause mortality Page 7 Ann Intern Med 2011;154:

8 CRT Meta-analysis III IV : HF hospitalization Page 8 Ann Intern Med 2011;154:

9 Meta-regression analysis: impact of QRS duration on the effect of CRT on composite clinical events Page 9 There was a statistically significant relationship between the QRS duration at baseline and log RR (slope, 0.07 [95% confidence interval, 0.10 to 0.04]; z= 4.60) (P.001). Accordingly, groups with QRS ranges below 150 milliseconds did not benefit from CRT (black circles, log risk ratio close to 0). Clinical benefit appeared when cases with QRS intervals of 150 milliseconds or greater were included (gray circles) and became more prominent with increasing QRS width (white circles). Arch Intern Med 2011;171(16):

10 Meta-analysis of RCTs with CRT: QRS morphology and clinical event reduction Page 10 Am Heart J 2012;163:

11 MADIT CRT: HF or Death n731 ICD; n1,089 CRT-D NYHA I (18%) or II (82%), LVEF<30, QRS>130 ms, 64.7% with QRS>150ms Page 11 Zareba W, et al. Circulation. 2011;123:

12 MADIT CRT: Death Page 12 Zareba W, et al. Circulation. 2011;123:

13 MADIT CRT: VT/VF or Death Page 13 Zareba W, et al. Circulation. 2011;123:

14 CRT Meta-analysis I II : All cause mortality Page 14 Ann Intern Med. 2011;154:

15 CRT Meta-analysis I II : HF hospitalization Page 15 Ann Intern Med. 2011;154:

16 Meta-regression analysis: impact of QRS duration on the effect of CRT on composite clinical events There was a statistically significant relationship between the QRS duration at baseline and log RR (slope, 0.07 [95% confidence interval, 0.10 to 0.04]; z= 4.60) (P.001). Accordingly, groups with QRS ranges below 150 milliseconds did not benefit from CRT (black circles, log risk ratio close to 0). Clinical benefit appeared when cases with QRS intervals of 150 milliseconds or greater were included (gray circles) and became more prominent with increasing QRS width (white circles). Page 16 Arch Intern Med. 2011;171(16):

17 Meta-analysis of RCTs with CRT: QRS morphology and clinical event reduction Page 17 Am Heart J 2012;163:

18 Relative risk of primary end-point (HF or death) by treatment (CRT / CRT-D vs ICD only according to selected clinical characteristics in patients with LBBB top and non-lbbb patients bottom in the MADIT-CRT study USΌUnited States patients; OUSΌoutside United States patients Page 18 Eur Heart J 2013; 34:

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20 CRT in non-lbbb mortality at 5 years HF or death at 5 years Page 20 Circ Heart Fail. 2016;9:e

21 CRT in non-lbbb mortality at 5 years HF or death at 5 years Page 21 Circ Heart Fail. 2016;9:e

22 Cardiac and non-cardiac Death in CRT patients Cardiac Death & LBBB Cardiac Death & non-lbbb Non - Cardiac Death & LBBB Non-Cardiac Death & non-lbbb Page 22 Europace. 2015;17(12):

23 2013 ESC Guidelines on cardiac pacing and CRT Page 23 Eur Heart J 2013; 34:

24 Non LBBB and PR interval Page 24 Circ Heart Fail. 2016;9:e

25 Conclusions LBBB morphology is required in class I recommendation. Sub-analyses of RCTs and meta-analyses have shown that the beneficial effects of CRT were observed in patients with typical LBBB The evidence of benefit in patients with non-lbbb configuration is weak, particularly in patients with QRS<150ms and NYHA I-II. For patients with LVEF<35%, non-lbbb, NYHA II and QRS>150msec the decision to implant a CRT should be individualized and probably based on other clinical/imaging and ECG (PR duration) criteria. Page 25