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Patients with heart failure who require an implantable defibrillator should have cardiac resynchronisation routinely
  1. John G F Cleland,
  2. Ahmed Tageldien,
  3. Nidal Maarouf,
  4. Neil Hobson
  1. Department of Cardiology, Castle Hill Hospital, Hull Royal Infirmary and University of Hull, Kingston-upon-Hull, UK
  1. Professor John G F Cleland, Department of Cardiology, University of Hull, Castle Hill Hospital, Kingston-upon-Hull, HU16 5JQ, UK; j.g.cleland{at}

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Should patients with heart failure who require an implantable cardiac defibrillator (ICD) get a device capable of delivering cardiac resynchronisation therapy (CRT-D) routinely? For those that like to read the conclusions first, the answer is “yes”. It is difficult to justify implanting only a defibrillator in anyone who has heart failure and an indication for an ICD. Most of these patients should get a CRT-D device.

This conclusion might seem odd at first but the arguments are quite straightforward. National Institute for Health and Clinical Excellence (NICE) guidelines1 suggest that patients with heart failure as a result of ischaemic heart disease (IHD) should get an ICD if their left ventricular ejection fraction (LVEF) is <35% and they also have non-sustained ventricular tachycardia (NSVT) on ambulatory electrocardiographic monitoring and inducible ventricular tachycardia (VT) on electrophysiological monitoring, provided that the patient is not in end-stage heart failure and is not within one month of a myocardial infarction. Alternatively, in patients with an LVEF, less than 30% patients without end-stage heart failure who have a QRS interval >120 ms, should receive an ICD. NICE has not yet issued guidance on defibrillators for patients with heart failure from causes other than IHD. The LVEF criteria are based on evidence from clinical trials in patients receiving contemporary pharmacological therapy (fig 1).24

Figure 1 Two-year mortality in contemporary clinical trials in patients with heart failure and a reduced left-ventricular ejection fraction. Trials marked with an asterisk are trials of devices. SOLVDp, Studies of Left Ventricular Dysfunction Prevention Trial (comparing placebo and enalapril 10 mg twice daily). SCD-HeFT, Sudden Cardiac Death in Heart Failure Trial (comparing placebo, amiodarone and ICD. Outcome on amiodarone and placebo were similar). MADIT, Multicenter Automatic Defibrillator Implantation Trial (comparing ICD or not). MERIT, Metoprolol Extended-Release Randomized Intervention Trial (comparing placebo and metoprolol succinate modified-release 200 mg/day). SOLVDt, Studies of Left Ventricular Dysfunction Trial (comparing placebo and enalapril 10 mg twice daily). CIBIS, Cardiac Insufficiency Bisoprolol Study (comparing placebo and bisoprolol 10 mg/day). CARE-HF, Cardiac Resynchronization in Heart Failure (comparing CRT or not). COMPANION, Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (comparing CRT, CRT-D or neither. Outcome with CRT and CRT-D were similar). COPERNICUS, Carvedilol Prospective Randomized Cumulative Survival (comparing placebo and carvedilol 25 mg twice daily). RALES, Randomized Aldactone Evaluation Study (comparing placebo and spironolactone mainly at 25 mg/day). TEN-HMS, Trans-European Network-Home-Care Management System (comparing usual care with nurse support or telemonitoring. Outcome with nurse support and telemonitoring was similar). CONSENSUS, Cooperative North Scandinavian Enalapril Survival Study (comparing placebo and enalapril 20 mg twice daily).

The NSVT criterion is based on a moderate amount of evidence acquired in the era before widespread use of β-blockers that suggested a higher mortality in such patients, although not necessarily from arrhythmias.5 6 The prevalence of NSVT will vary according to the extent of ventricular disease, the duration of monitoring and the quality of heart failure management, but it may be present in the majority of patients.5 Amino-terminal pro-brain natriuretic peptide is a much more robust, …

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  • Competing interests: JGFC was principal investigator for the CARE-HF study funded by Medtronic and has received speaker’s honoraria and grants from them and from Biotronik and Boston Scientific. NH has received funding for travel from Medtronic.