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Optimizing heart failure treatment following cardiac resynchronization therapy

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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.

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Abbreviations

ACE-I:

Angiotensin-converting enzyme inhibitors

ARB:

Aldosterone receptor blocker

ARNI:

Angiotensin receptor neprilysin inhibitor

BNP:

Brain natriuretic peptide

CRT:

Cardiac resynchronization therapy

ICD:

Implantable cardioverter-defibrillator

LVEF:

Left-ventricular ejection fraction

MRA:

Mineralocorticoid antagonist

NT-proBNP:

N-terminal pro-brain natriuretic peptide

NYHA:

New York Heart Association

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Funding

The ImagingCRT study was funded by Aarhus University, the Danish Heart Foundation (11-04-R84-A3234-22641), the Danish Council for Independent Research (11-107461), Central Denmark Region (1-45-72-4-09), Eva and Henry Frænkels Foundation, and Fabrikant Karl G. Andersens Foundation. Sponsors were not involved in the design of the study, recruitment or patient investigations, nor in analysis, interpretation of data, and writing of the report.

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Author notes

  1. Anders Jorsal and Kasper Pryds have contributed equally to the study.

Authors and Affiliations

  1. Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark

    Anders Jorsal, Kasper Pryds, Henrik Wiggers, Anders Sommer, Jens Cosedis Nielsen & Roni Ranghøj Nielsen

  2. Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark

    Kasper Pryds

  3. Diagnostic Center, Silkeborg Regional Hospital, Falkevej 1A, 8600, Silkeborg, Denmark

    Kasper Pryds

  4. BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK

    John J. V. McMurray

  5. Queen Elizabeth University Hospital, 1345 Govan Road, Govan, Glasgow, G51 4TF, UK

    John J. V. McMurray

Authors
  1. Anders Jorsal
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  2. Kasper Pryds
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  3. John J. V. McMurray
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  4. Henrik Wiggers
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  5. Anders Sommer
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  6. Jens Cosedis Nielsen
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  7. Roni Ranghøj Nielsen
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Contributions

AJ, KP, and RRN were responsible for the conception and design of the study, analysis and interpretation of data, and drafting of the manuscript. AS and JCN were responsible for data acquisition. All authors have critically revised the manuscript for important intellectual content and approved the final version.

Corresponding author

Correspondence to Kasper Pryds.

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Conflict of interest

Professor John J. V. McMurray’s employer, Glasgow University, has been paid by Novartis for his time spent as Principal Investigator/Executive/Steering Committee member for a number of clinical trials using sacubitril/valsartan and meetings and lectures related to sacubitril/valsartan. The Novo Nordisk Foundation (NNF16OC0018658) financially supports Professor Jens Cosedis Nielsen. The other authors report no conflicts of interest.

Data sharing statement

Raw data and statistical coding are available from the corresponding author at kpryds@clin.au.dk

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Jorsal, A., Pryds, K., McMurray, J.J.V. et al. Optimizing heart failure treatment following cardiac resynchronization therapy. Clin Res Cardiol 109, 638–645 (2020). https://doi.org/10.1007/s00392-019-01553-4

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  • DOI: https://doi.org/10.1007/s00392-019-01553-4

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