Optimizing heart failure treatment following cardiac resynchronization therapy

Clin Res Cardiol. 2020 May;109(5):638-645. doi: 10.1007/s00392-019-01553-4. Epub 2019 Sep 26.

Abstract

Background: Device therapy in addition to medical treatment improves prognosis in a subset of patients with heart failure and reduced ejection fraction. However, some patients remain symptomatic or their heart failure even progresses despite cardiac resynchronization therapy (CRT). The aim of the study was to evaluate the proportion of patients who could benefit from optimization of medical therapy using sacubitril/valsartan, ivabradine, or both following CRT implantation.

Methods: We conducted a post hoc analysis of a single-centre, patient and outcome-assessor blinded, randomized-controlled trial, in which patients scheduled for CRT were randomized to empiric (n = 93) or imaging-guided left-ventricular lead placement (n = 89). All patients underwent clinical evaluation and blood sampling at baseline and 6 months following CRT implantation. The proportion of patients meeting the indication for sacubitril/valsartan (irrespective of angiotensin-converting enzyme inhibitor or angiotensin 2 receptor blocker dosage) and/or ivabradine according to current guidelines was evaluated at baseline and after 6 months.

Results: Of 182 patients with an indication for CRT, 146 (80%) also had an indication for optimization of medical therapy at baseline by adding sacubitril/valsartan, ivabradine, or both. Of the 179 survivors at 6 months, 136 (76%) were still symptomatic after device implantation; of these, 51 (38%) patients had an indication for optimization of medical therapy: sacubitril/valsartan in 37 (27%), ivabradine in 7 (5%), and both drugs in 7 (5%) patients. Seven (18%) patients without indication at baseline developed an indication for medical optimization 6 months after CRT implantation.

Conclusion: In the present study, 38% of those who remained symptomatic 6 months after CRT implantation were eligible for optimization of medical therapy with sacubitril/valsartan, ivabradine, or both. Patients with CRT may benefit from systematic follow-up including evaluation of medical treatment.

Keywords: Angiotensin receptor neprilysin inhibitor; Cardiac resynchronization therapy; Heart failure; Ivabradine.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aminobutyrates / therapeutic use*
  • Angiotensin Receptor Antagonists / therapeutic use*
  • Biphenyl Compounds
  • Cardiac Resynchronization Therapy*
  • Cardiovascular Agents / therapeutic use*
  • Drug Combinations
  • Female
  • Heart Failure / complications
  • Heart Failure / physiopathology
  • Heart Failure / therapy*
  • Humans
  • Ivabradine / therapeutic use*
  • Male
  • Middle Aged
  • Stroke Volume
  • Tetrazoles / therapeutic use*
  • Treatment Outcome
  • Valsartan

Substances

  • Aminobutyrates
  • Angiotensin Receptor Antagonists
  • Biphenyl Compounds
  • Cardiovascular Agents
  • Drug Combinations
  • Tetrazoles
  • Ivabradine
  • Valsartan
  • sacubitril and valsartan sodium hydrate drug combination