{"id":38508,"date":"2013-09-03T04:35:48","date_gmt":"2013-09-03T08:35:48","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=38508"},"modified":"2013-09-03T04:49:06","modified_gmt":"2013-09-03T08:49:06","slug":"for-crt-let-ecg-not-echo-be-your-guide","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2013\/09\/03\/for-crt-let-ecg-not-echo-be-your-guide\/","title":{"rendered":"For CRT, Let ECG \u2014 Not Echo \u2014 Be Your Guide"},"content":{"rendered":"

CardioExchange\u2019s John Ryan<\/b> interviews Clyde Yancy<\/b>, who co-wrote the NEJM editorial<\/a> about the EchoCRT Study Group\u2019s randomized trial<\/a> of echocardiography-guided CRT for patients with NYHA class III\u2013IV heart failure and a narrow QRS complex. The trial was presented at the European Society of Cardiology conference in Amsterdam.<\/i>\u00a0<\/b><\/p>\n

THE STUDY<\/b><\/p>\n

Ruschitzka and colleagues evaluated the effect of cardiac resynchronization therapy (CRT) in patients with NYHA class III or IV heart failure, an LV ejection fraction \u226435%, a QRS duration <130 msec, and echocardiographic evidence of LV dyssynchrony. Participants from 115 centers underwent device implantation and were randomly assigned to have CRT capability turned on or off. In March 2013, with 809 patients randomized (mean follow-up, 19.4 months), the study was stopped. Incidence of the primary endpoint \u2014 a composite of death from any cause or first hospitalization for worsening heart failure \u2014 was 28.7% in the CRT group and 25.2% in the control group, a nonsignificant difference. The mortality rate was significantly greater in the CRT group (11.1% vs. 6.4% in the control group).\u00a0<\/b><\/p>\n

INTERVIEW WITH THE EDITORIALIST<\/b><\/p>\n

Ryan: What should a busy practitioner take from this study? Is this just reinforcing existing guidelines, or is anything new?<\/i><\/b><\/p>\n

Yancy:<\/i><\/b> The findings offer several takeaways for the practitioner:<\/p>\n

1. We need to focus on the sweet spot of efficacy for CRT, making every effort to optimize device therapy in those with the strongest indications — i.e., wide QRS, LBBB pattern already on optimal guideline directed care.<\/p>\n

2. As with so many other proven therapies in heart failure, we remain uncertain about the true markers of benefit for CRT. Arguably, it isn\u2019t truly\u00a0necessary to discover mechanical dyssynchrony, whereas it is imperative to identify a wide QRS.<\/p>\n

3. We are once again reminded of the perils of \u201cindication creep.\u201d Pushing indications for proven therapies into categories that are heuristically reasonable but substantively unproven might be a major therapeutic misstep.<\/p>\n

4. Most important, our guidelines and the process used to generate them really work.\u00a0As we enter an increasingly transparent era of clinical practice with greater practitioner accountability and much more financial risk, having trusted practice templates will serve our community well.<\/p>\n

Ryan: Was there anything less than straightforward about the trial \u2014 something fellows should notice about how it was done?<\/i><\/b><\/p>\n

Yancy: <\/i><\/b>Clinical trials remain challenging. Those of us who define our skill set as that of \u201cclinical trialists\u201d should beware. An excellent investigatory group conducted this study, yet a substantial number of patients withdrew, were lost to follow-up, or couldn\u2019t be contacted. That\u2019s not sloppy\u2014it\u2019s the reality of the process. All readers, especially fellows, need to appreciate the incredible number of potential permutations and perturbations that can surface when designing and implementing a clinical trial.\u00a0This isn\u2019t an easy business.<\/p>\n

JOIN THE DISCUSSION<\/b><\/p>\n

What lessons do you take away from the EchoCRT trial? Do you agree with Dr. Yancy?<\/b><\/p>\n

Journal Watch Cardiology<\/em>‘s coverage of this study<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

Clyde Yancy, coauthor of the NEJM editorial about the EchoCRT Study Group\u2019s randomized trial of echocardiography-guided CRT, provides further insights about the findings.<\/p>\n","protected":false},"author":316,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[13,14],"tags":[696,1216,498,287,1928],"class_list":["post-38508","post","type-post","status-publish","format-standard","hentry","category-electrophysiology","category-heart-failure","tag-cardiac-resynchronization-therapy","tag-ecg","tag-echocardiography","tag-heart-failure-2","tag-qrs-duration"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/38508","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/316"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=38508"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/38508\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=38508"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=38508"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=38508"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}