{"id":8756,"date":"2011-06-14T13:56:45","date_gmt":"2011-06-14T17:56:45","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?p=8756"},"modified":"2011-07-19T17:44:22","modified_gmt":"2011-07-19T21:44:22","slug":"crt-for-hf-patients-with-moderately-prolonged-qrs-interval-unethical","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2011\/06\/14\/crt-for-hf-patients-with-moderately-prolonged-qrs-interval-unethical\/","title":{"rendered":"CRT for HF Patients with Moderately Prolonged QRS Interval: Unethical?"},"content":{"rendered":"

Approximately 40% of cardiac resynchronization therapy (CRT) devices are implanted in patients with QRS intervals below 150 msecs, but a meta-analysis published in Archives in Internal Medicine<\/em><\/a> finds that these patients may not benefit from the device.<\/p>\n

Ilke Sipahi and colleagues performed a meta-analysis that included five CRT clinical trials (COMPANION, CARE-HF, REVERSE, MADIT-CRT, RAFT) with designs that enabled them to examine the effect of QRS duration on outcome. Although patients with severely prolonged QRS had a 40% reduction in risk associated with CRT therapy (CI 0.53-0.67, p<0.001), no benefit at all was observed in the patients with only moderately prolonged QRS. The same finding was observed in patients with class 1 and 2 heart failure as in patients with class 3 and 4 heart failure. The presence or absence of an ICD did not alter the pattern.<\/p>\n

The authors point out that between one third and one half of patients who receive CRT don’t benefit from the therapy and then suggest “that a predominant reason for CRT non-response is a suboptimal patient selection criterion for QRS duration.” They recommend an individual patient level analysis of current trials to more precisely identify which patients enjoy the benefits of CRT.<\/p>\n

“It may now be unethical…”<\/strong><\/p>\n

In an accompanying commentary<\/a>, Lynne Warner Stevenson addresses the issue of subgroup analysis, agreeing that skepticism is warranted in trials with negative findings, but asking: “What about those with positive results?” In this instance, she argues, “the results of this meta-analysis are robust enough to anchor a growing suspicion that the patients with QRS in the 120- to 150- millisecond range do not improve after CRT. The trials are remarkably congruent, regardless of clinical class or etiology.” She then writes:<\/p>\n

To continue to perform this procedure when benefit is unlikely will undermine enthusiasm for a remarkably effective therapy in appropriate patients. It may have been optimistic to recommend and reward this procedure in patients for whom there was no evidence of benefit; it may now be unethical to recommend and reward this procedure in patients for whom we now have evidence of no benefit.<\/p>\n","protected":false},"excerpt":{"rendered":"

Approximately 40% of cardiac resynchronization therapy (CRT) devices are implanted in patients with QRS intervals below 150 msecs, but a meta-analysis published in Archives in Internal Medicine finds that these patients may not benefit from the device. Ilke Sipahi and colleagues performed a meta-analysis that included five CRT clinical trials (COMPANION, CARE-HF, REVERSE, MADIT-CRT, RAFT) […]<\/p>\n","protected":false},"author":196,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[13,14],"tags":[542,411,876],"class_list":["post-8756","post","type-post","status-publish","format-standard","hentry","category-electrophysiology","category-heart-failure","tag-crt","tag-crt-d","tag-qrs"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/8756","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\/196"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=8756"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/8756\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=8756"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=8756"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=8756"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}