Extending the Boundaries of Cardiac Resynchronization Therapy: Efficacy in Atrial Fibrillation, New York Heart Association Class II, and Narrow QRS Heart Failure Patients

Abstract 

Background

Large-scale clinical trials have demonstrated the benefits of cardiac resynchronization therapy (CRT) in patients with New York Heart Association (NYHA) Class III/IV heart failure, systolic left ventricular dysfunction, and a wide QRS. However, additional patient groups may also benefit from CRT.

Methodsand Results

We meta-analyzed clinical benefits of CRT in heart failure patients with narrow QRS, atrial fibrillation (AF) and NYHA Class II symptoms. Thirteen trials of 2882 patients contributed to this meta-analysis. In the narrow versus wide QRS group comparison, no difference in benefit was observed for change in left ventricular ejection fraction (standardized mean difference [SMD] 0.30, 95% confidence interval [CI] −0.37 to 0.97) or left ventricular end systolic volume (SMD 0.30, 95% CI −1.14 to 1.74). The benefit was greater in the wide QRS group for the 6-minute walk test (SMD 1.27, 95% CI 0.59 to 1.96) and NYHA class improvement (SMD 1.24, 95% CI 0.72 to 1.75). In the atrial fibrillation (AF) versus sinus rhythm (SR) group comparison, no difference in benefit was observed for change in left ventricular ejection fraction (SMD −0.38, 95% CI −1.28 to 0.53) or NYHA improvement (SMD 0.32, 95% CI −0.77 to 1.40). In the NYHA II versus NYHA III/IV group comparison, no difference in benefit was observed for change in left ventricular end diastolic diameter (SMD 0.05, 95% CI -0.94 to 1.05) or left ventricular end systolic diameter (SMD 0.74, 95% CI −1.98 to 3.46).

Conclusions

Large-scale clinical outcome trials of CRT are warranted in heart failure patients with narrow QRS, AF, and NYHA II, given the similar benefits observed to those with wide QRS, SR, and NYHA III/IV for many parameters.

Key Words: Cardiac resynchronization therapy, atrial fibrillation, New York Heart Association II, narrow QRS