European Heart Journal Advance Access originally published online on November 22, 2006
European Heart Journal 2006 27(24):3074-3075; doi:10.1093/eurheartj/ehl386
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QRS duration alone to select patients for cardiac resynchronization therapy: flying in the face of the evidence?
Department of Cardiology
Stobhill Hospital
Balornock Road
Springburn
Glasgow G21 3UW
UK
Tel: +44 1412013064
Fax: +44 1415585693
Email address: nathawkins{at}hotmail.com
Department of Cardiology
Royal Infirmary
Glasgow G31 2ER
UK
Department of Cardiology
Royal Infirmary
Glasgow G31 2ER
UK
Department of Cardiology
Stobhill Hospital
Glasgow G21 3UW
UK
Department of Cardiology
Western Infirmary
Glasgow G11 6NT
UK
We were surprised by Sanderson's view that patients should be selected for cardiac resynchronization therapy (CRT) according to some measurement of mechanical dyssynchrony and not on the basis of internationally accepted QRS duration criteria.1,2 At least 20 measurements of mechanical dyssynchrony have been proposed, derived largely from retrospective analyses in small, single centre, non-randomized studies.2 Most adopt surrogate volumetric endpoints, despite limited correlations with clinical response.3 Complete agreement between measures is unlikely, given the marked variation in techniques and arbitrary definitions of dyssynchrony. Despite this, the proponents never indicate exactly how we are to use these measures to deny patients potentially life-saving therapy. Are we to use just one parameter, or a combination? What level of synchrony would preclude implantation in a patient otherwise meeting the accepted QRS criteria?
Landmark clinical trials have randomized over 4000 patients based on QRS duration, typically greater than 120 or 130 ms.4 CARE-HF included only 92 patients with mechanical dyssynchrony, in conjunction with a borderline QRS duration. No echocardiographic study has prospectively randomized patients, or demonstrated improvements in hard clinical endpoints—death or hospital admissions. Progress is always desirable, but the validity of new selection criteria must be demonstrated in clinical trials, especially when the therapy that could be denied is life-saving. Until then we must select patients based upon proven criteria i.e. QRS duration. To do otherwise not only ‘flies in the face of the available evidence’, but also flies in the face of the guidelines of the European Society of Cardiology, American College of Cardiology/American Heart Association, Heart Failure Society of America, and Canadian Cardiovascular Society.4–7
References
- Sanderson JE. (2006) Assessment of ventricular dyssynchrony: global or regional function? Eur Heart J 27:2380–2381.
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- Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda M, Tavazzi L, Smiseth OA, Gavazzi A, Haverich A, Hoes A, Jaarsma T, Korewicki J, Levy S, Linde C, Lopez-Sendon JL, Nieminen MS, Pierard L, Remme WJ. (2005) Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Eur Heart J 26:1115–1140.
[Free Full Text] - . Heart Failure Society Of America Executive summary:. (2006) HFSA 2006 Comprehensive Heart Failure Practice Guideline. J Card Fail 12:10–38.[CrossRef][Web of Science][Medline]
- Arnold JM, Liu P, Demers C, Dorian P, Giannetti N, Haddad H, Heckman GA, Howlett JG, Ignaszewski A, Johnstone DE, Jong P, McKelvie RS, Moe GW, Parker JD, Rao V, Ross HJ, Sequeira EJ, Svendsen AM, Teo K, Tsuyuki RT, White M. (2006) Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: diagnosis and management. Can J Cardiol 22:23–45.[Web of Science][Medline]
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