Page 141 - Simplicity is Key in CRT

For the intensive follow-up, a full device check-up is performed and patient complaints are evaluated. Physical examination and, if needed, additional resources i.e. ECG, echocardiogram, chest X-ray, laboratory investigations and an exercise test are used to exclude device-related complications and verify adequate device functioning. The “Mullens-checklist” is used to systematically evaluate possible reasons for suboptimal benefit from CRT.
If indicated, the patient is evaluated on an ad hoc basis, until a stable condition has returned. Once intensive follow- up is no longer applicable, the patient will return to the regular (non-intensive) follow-up plan.
Discussion
CRT is a proven, evidence-based therapy for HF. With continued extensive research, the indications are tending to expand and the health care burden will likely increase. Apart from HF being a comprehensive and complex disease, CRT remains a complex treatment for HF, the mechanisms of which we still do not fully understand. In addition, a substantial portion of patients treated in large trials and registries have limited benefit of CRT. Therefore it is essential for CRT care, in combination with general HF care, to be structured and above all multidisciplinary, with specialised nurses, electrophysiologists, HF-specialists and imaging-specialist working as part of a single care pathway, to optimize delivered care and minimize healthcare burden.
Even though guidelines and expert consensus papers extensively describe what to do in terms of CRT indications, implantation, follow-up and optimization, they do not provide a comprehensive protocol for routine clinical practice. With this paper, we propose a protocol-based, best practice, CRT care-pathway. This model allows for adjustments due to local practices and resources, while still providing uniform care for all CRT recipients by making use of standardized forms and algorithms.
Although guidelines provide clear recommendations for the indications for CRT, multiple studies have shown considerable heterogeneity in utilisation of this therapy, with both under- utilisation in appropriate patients and over-utilization in inappropriate patients [49, 62]. To address heterogeneity issues and suboptimal care in HF, recent studies have investigated the role of structured checklists and other aids in clinical practice. The IMPROVE HF study, as the OPTIMIZE HF study earlier, showed that structured CRT care (with the help of structured aids) helped in guideline adherence for an outpatient population [17, 18].
The best practice CRT care pathway described in this manuscript does not prescribe the indication for CRT as that may change with time. However, through the use of the checklists for screening of referrals, we expect referring physicians to feel more confident about referring appropriate patients for CRT. By using this care pathway implanters acquire more insight into the completeness of the indications and contra-indications for CRT in the referred case. One of the major issues in CRT is uncoordinated care and fragmentation of care across different specialities. While most studies on CRT have been focused on inclusion criteria and implantation techniques for CRT, little attention has been paid to follow-up care.
A few studies have focused on a structured, multidisciplinary approach to optimize outcomes in CRT. Mullens et al. [49] was the first to show that an algorithm with standard equipment and testing, reproducible in any outpatient cardiology clinic, could identify suboptimal medical treatment, LV lead position, and uncontrolled arrhythmias that were associated with a suboptimal response to CRT. Furthermore, they showed that if this protocol-driven CRT approach was started immediately after implantation it was associated with improved response to CRT. Importantly, these favourable effects appeared to be driven not only by appropriate device and arrhythmia management but also by improved HF care, by HF education and optimization of HF medication [50]. More recently, a larger
141