Heart Failure Treatment – CRT-P or CRT-D

Heart Failure Treatment – CRT-P or CRT-D and the Medtronic Screenlink App for Healthcare Professionals.

https://itunes.apple.com/gb/app/screenlink-medtronic/id602846516?mt=8&uo=4&at=11lofC

We now know that, in advanced heart failure (NYHA III & IV) and cardiac dysynchrony, cardiac resynchronization (CRT) improves symptoms and the quality of life and reduces complications and the risk of death. (1)

Graph A makes it nice and clear for all to see…  

There are two main types of CRT device, CRT-P and CRT-D

CRT-P is a Biventricular Pacemaker that can control when the left side of the heart contracts in relation to the right heart and vice versa. This control over the timing of the hearts contraction allows us to improve the efficiency of a heart beat.
A CRT-D also has this control over the heart beat but with the addition of ICD capability. I.e. the device can treat dangerous cardiac arrhythmias (VT and VF) by shocking or overdrive pacing the tachycardias .

Graph A – Shows the Benefit of Device Treatment of Severe Heart Failure

With approximately 50% of heart failure deaths in this patient population accountable to Sudden Death (Cardiac Arrhythmias, VT and VF) (2) it is ESSENTIAL that we implant a CRT-D in patients that qualify for one otherwise they may be left defenceless to a fatal arrhythmia. 

So in summary of this evidence, IF a patient qualifies for a CRT-P then they should have be offered one!! and also if a patient requires the ICD functionality also they should be offered that too!
Is this the case? well the truth is I don’t know for sure. In an ideological world every person would have the appropriate device to maximise their quality of life and life longevity.

Here are some national and international stats (if you are into that kind of thing) taken from the National Device Survey 2011.
Looking at discrepancies in international and national statistics, there is the suggestion that there are patients out there that do not have the device that is most appropriate for them. Are people falling victim to a post code lottery?!
I would be very surprised if geographical socio-economic variations were solely responsible for these statistics. Instead I simply theorise that because the guidelines are quite complex and often inconstant, this leads to variations in treatment of heart failure when using implantable cardiac devices.
I am concerned people are slipping through the net and may be deprived from better healthcare.
How can we prevent this? well I do not know the perfect answer. There is however a very helpful and FREE App by Medtronic (a Pacing Company) that uses all the latest regional guidance to indicate which device is best for your patient. You input patient statistics such as NYHA Class and Ejection Fraction, it will then use all the latest clinical guidance to suggest the appropriate device classification. Used properly this app will certainly help.
What is more impressive is that it does not promote any Medtronic devices and is simply a tool provided by them. Why? well probably because they will benefit financially if more devices and more complex devices are implanted and because at the same time more people will be getting the appropriate healthcare. Which is ultimately what we should all be striving to achieve!!!!! Its one of those instances where everyone will benefit!
DOWNLOAD it and test it out! Its totally free and if you don’t like it then delete it. I reckon at least half my readers will end up using it!

Further explanation around these topics and more is available in the book Pacemakers Made Easy by Carl Robinson.

Thanks for Reading Cardiac Technician
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Share if you know someone who will be interested in the APP.
1) John G.F. Cleland, M.D., Jean-Claude Daubert, M.D., Erland Erdmann, M.D., Nick Freemantle, Ph.D., Daniel Gras, M.D., Lukas Kappenberger, M.D., and Luigi Tavazzi, M.D. for the Cardiac Resynchronization — Heart Failure (CARE-HF) Study Investigators N Engl J Med 2005; 352:1539-1549April 14, 2005


2) Fadi G. Akar PhD, FHRS, Gordon F. Tomaselli MD., Electrophysiological Remodeling in Heart Failure – Electrical Diseases of the Heart 2013, pp 369-386

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