What is the level of evidence for combined cardiac resynchronization and defibrillation therapy in heart failure? reply
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In the letter, Doctors Lam and Owen offer some very relevant comments on the recommendations for cardiac resynchronization combined with defibrillation therapy (CRT-D) in the ESC guidelines.1 In regard to point 3.2.1, the authors provide further evidence from a network meta-analysis2 grouping randomized controlled trials on device therapy in heart failure (HF) and its effects on death from any cause. This meta-analysis observed a significant reduction in deaths of any cause (Odds ratio 0.57, 95% confidence interval 0.40–0.80) conferred by CRT-D compared with medical therapy. This recent contribution was not available at the time of publication of these guidelines and it strengthens further the indication for CRT-D.
In relation to the second point, the recommendation of section 3.2.3, is addressed to patients fulfilling the conventional indication for CRT and who present a concomitant Class I indication for the implantation of an ICD. This includes not only primary prevention, but also secondary prevention such as cardiac arrest survivors or patients with documented sustained ventricular tachycardia: it is clear that, in these cases, a CRT-P device is not adequate, and a CRT-D device is compulsory. Even considering primary prevention of SCD,3 the current recommendations indicate (class I) the use of an ICD in HF patients with LV impairment. This statement could not be neglected by the CRT guidelines. For these reasons, the consensus was that a class I recommendation should be given.
References
- Vardas PE, Auricchio A, Blanc JJ, Daubert JC, Drexler H, Ector H, Gasparini M, Linde C, Morgado FB, Oto A, Sutton R, Trusz-Gluza M. European Society of Cardiology; European Heart Rhythm Association. Guidelines for cardiac pacing and cardiac resynchronization therapy: the task force for cardiac pacing and cardiac resynchronization therapy of the European Society of Cardiology. Developed in collaboration with the European Heart Rhythm Association. Eur Heart J (2007) 28:2256–2295.
[Free Full Text] - Lam SKH, Owen A. Combined resynchronization and defibrillation therapy in left ventricular dysfunction: Bayesian network meta-analysis of randomized controlled trials. BMJ (2007) 335:925–928.
[Abstract/Free Full Text] - Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC Jr, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee For Practice Guidelines. EHRA, HRS. J Am Coll Cardiol (2006) 48:e247–e346.
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