Immediate pharmacotherapy intensification after cardiac resynchronization therapy: incidence, characteristics, and impact

• Published in: ESC Heart Failure Vol. 11; no. 4; pp. 1888 - 1899
• Main Authors: Ogawa, Kojiro, Yamasaki, Hiro, Aonuma, Kazutaka, Otani, Masafumi, Hattori, Ai, Baba, Masako, Yoshida, Kentaro, Igarashi, Miyako, Nishina, Hidetaka, Suzuki, Kou, Nogami, Akihiko, Ieda, Masaki
• Format: Journal Article
• Language: English
• Published: England John Wiley & Sons, Inc 01-08-2024; John Wiley and Sons Inc; Wiley
• Subjects: Adrenergic beta-Antagonists - administration & dosage; Adrenergic beta-Antagonists - therapeutic use; Aged; Angiotensin Receptor Antagonists - administration & dosage; Angiotensin Receptor Antagonists - therapeutic use; Angiotensin-Converting Enzyme Inhibitors - therapeutic use; Beta blockers; Bundle-Branch Block - epidemiology; Bundle-Branch Block - physiopathology; Bundle-Branch Block - therapy; Cardiac arrhythmia; Cardiac resynchronization therapy; Cardiac Resynchronization Therapy - methods; Cardiomyopathy; Drug dosages; Drug therapy; Ejection fraction; Enzymes; Female; Follow-Up Studies; Heart failure; Heart Failure - epidemiology; Heart Failure - physiopathology; Heart Failure - therapy; Hemodynamics; Hospitalization; Humans; Hypotension; Immediate pharmacotherapy intensification; Incidence; Ischemia; Left bundle branch block; Male; Middle Aged; Mineralocorticoid Receptor Antagonists - administration & dosage; Mineralocorticoid Receptor Antagonists - therapeutic use; Mortality; Optimization; Original; Pacemakers; Patients; Prognosis; Retrospective Studies; Stroke Volume - physiology; Time Factors; Treatment Outcome; Ventricular Function, Left - physiology; New York; United States > US; Heart failure; Left bundle branch block; Prognosis; Cardiac resynchronization therapy; Immediate pharmacotherapy intensification
• ISSN: 2055-5822; 2055-5822
• DOI: 10.1002/ehf2.14737

Aims
Cardiac resynchronization therapy (CRT) is an established treatment for drug‐refractory heart failure (HF) in patients with left bundle branch block (LBBB). Acute haemodynamic improvement after CRT implantation may enable the intensification of HF medication soon thereafter. Immediate pharmacotherapy intensification (IPI) after CRT implantation achieves a synergetic effect, possibly leading to a better prognosis. This study aimed to explore the incidence, characteristics, and impact of IPI on real‐world outcomes among CRT recipients with a history of hospitalization for acute HF.
Methods and results
This multicentre retrospective study enrolled CRT recipients with LBBB morphology, a QRS width ≥120 ms, a left ventricular ejection fraction ≤35%, and New York Heart Association II–IV HF symptoms. All patients had previous HF hospitalizations within the previous year and received guideline‐directed medical therapy before CRT implantation. Patient baseline characteristics, including HF medication, were collected. IPI was defined as the intensification of beta‐blockers, angiotensin‐converting enzyme inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor antagonists within 30 days of CRT implantation. The primary endpoint was all‐cause death or first hospitalization for HF; the secondary endpoint was all‐cause death. We enrolled 194 patients (75% male; mean age, 65 ± 13 years; 78% with non‐ischaemic cardiomyopathy). One hundred five (54%) patients received IPI. Patients who received IPI exhibited a significantly shorter QRS duration (159 ± 26 vs. 171 ± 32 ms; P = 0.004), higher estimated glomerular filtration rate (55.2 ± 20.0 vs. 47.8 ± 24.7 mL/min/1.73 m2; P = 0.022), and more dilated cardiomyopathy. During a median follow‐up period of 29 months, 70 (36%) patients reached the primary endpoint and 42 (22%) patients died. Patients with IPI showed significantly better outcomes for the primary and secondary endpoints than patients without IPI. The volumetric responder ratio at 6 months after implantation was not significantly different between patients with and without IPI; however, patients who received IPI had reduced mortality even at 6 months after implantation. In the multivariate analysis, IPI was an independent predictor of the primary endpoint (hazard ratio, 0.51; 95% confidence interval, 0.27–0.97; P = 0.043).
Conclusions
Immediate intensification of HF medication was achieved in 54% of CRT recipients and was significantly higher in patients without excessive QRS prolongation, preserved renal function, and dilated cardiomyopathy than others. In patients with LBBB morphology and QRS ≥ 120 ms, IPI was associated with a significantly better prognosis and fewer HF hospitalizations after CRT implantation than others.