CRT-P or CRT-D From North Alberta to Nairobi
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1 CRT-P or CRT-D From North Alberta to Nairobi Dr Mzee Ngunga Aga Khan University Hospital Nairobi KCS Congress: Impact through collaboration CONTACT: Tel Web:
2 Disclosures I have no conflicts of interest for this talk I have no relationships to disclose
3 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
4 Pt MBA
5 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
6 ECG diagnosis? 1. Heart Block 2. LBBB
7 What do the guidelines say?
8 Therapeutic algorithm for a patient with symptomatic HF with reduced ejection fraction. LCZ CRT Ivabradine
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15 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
16 Show me the evidence???? CRT
17 CRT IN CHF( MIRACLE, CARE-HF and RAFT TRIALS) I IIa IIb III 453 patients randomized 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. 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
18 Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT trial companion trial) 1820 patients with ischemic or nonischemic cardiomyopathy Reduction in heart failure events not overall mortality EF of < 30% QRS > 130 msec NYHA I and II Randomized to CRT-D or ICD alone. Arthur Moss eta al Cardiac-Resynchronization Therapy for the Prevention of Heart-Failure Events NEJM 2009
19 MADIT-CRT trial 34% 57% 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 Oct 1;361(14): 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 Boston Scientific. All rights reserved. CRM
20 MADIT CRT LONG TERM OUTCOMES 2010 Boston Scientific. All rights reserved. CRM
21 What about Heart Block and Heart Failure? 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 2010 Boston Scientific. All rights reserved. CRM
22 Can I avoid the ICD? 2010 Boston Scientific. All rights reserved. CRM
23 2010 Boston Scientific. All rights reserved. CRM
24 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 2010 Boston Scientific. All rights reserved. CRM
25 2010 Boston Scientific. All rights reserved. CRM
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