art & science cardiology

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Cardiac resynchronisation therapy for patients with heart failure

Frodsham R (2005) Cardiac resynchronisation therapy for patients with heart failure. Nursing Standard. 19, 45, 46-50. Date of acceptance: May 4 2005.

Summary
Cardiac resynchronisation therapy (CRT) is a non-pharmacological treatment for heart failure. The method resynchronises the contraction of the right and left ventricles, resulting in better cardiac output, thus improving symptoms. This article discusses symptoms, morbidity and mortality of heart failure; potential benefits of CRT to patients quality of life; and the implications of CRT for nursing practice.

Author
Robert Frodsham is senior staff nurse, coronary care unit, Whiston Hospital, Prescot, Liverpool. Email: robert.frodsham@sthkhealth.nhs.uk

Keywords
Cardiovascular system and disorders; Heart disorders: nursing These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit our online archive at www.nursing-standard.co.uk and search using the keywords.

HISTORICALLY, DESCRIPTIONS of heart failure exist from ancient Egypt, Greece and India. Ancient Greeks and Romans used the juice of the foxglove (Digitalis purpurea) for sprains and bruises. In the 1700s a tea was brewed from foxglove leaves and used to heal dropsy, a disease in which water accumulates in the body and causes swelling. Modern treatment for heart failure continues to include digoxin. Only a limited understanding of the function of the heart existed until William Harvey described the circulatory system in 1628. Roentgens discovery of X-rays and Einthovens development of electrocardiography in the 1890s led to improvements in the investigation of heart failure (Davis et al 2000). Echocardiography, cardiac catheterisation and nuclear medicine have since improved the diagnosis and investigation of patients with heart failure. This article discusses the symptoms of heart failure and highlights the potential improvements in patients conditions following cardiac resynchronisation therapy (CRT). The implications of CRT for nursing practice are also identified. 46 july 20 :: vol 19 no 45 :: 2005

Heart failure is a major cause of morbidity and mortality in the Western world. In the UK, it is estimated to account for 5 per cent of all hospital admissions: approximately 100,000 each year (National Institute for Health and Clinical Excellence (NICE) 2003). Heart failure affects three to 20 people per 1,000, although this number exceeds 100 per 1,000 in those aged 65 or over (NICE 2003). Heart failure is estimated to occur in 900,000 people per year in the UK and the average age is 76 years (NICE 2003). The incidence of heart failure is increasing because of the ageing population. Advancement in treatments of acute myocardial infarction, such as thrombolysis and emergency angioplasty, leads to survival in patients with impaired left ventricular function. Heart failure population The underlying abnormality for the majority of patients with heart failure in the Western world is impaired left ventricular systolic function secondary to ischaemic cardiomyopathy (Cowie et al 2000). The New York Heart Association (NYHA) classification ranges from class I: no symptoms although left ventricular systolic impairment is evident on echocardiogram to class IV: severe symptoms of breathlessness at rest (Box 1) (Criteria Committee of the New York Heart Association (CCNYHA) 1994). Despite maximal drug treatment with angiotensin-converting enzyme (ACE) inhibitors, diuretics and beta-blockers, many patients still experience symptoms of breathlessness on minimal exertion or rest (NYHA classes III and IV). This limitation has a marked impact on quality of life (NICE 2003). Patients with these symptoms will probably experience recurrent and prolonged hospital admissions for episodes of decompensation (acute episodes of worsening symptoms) because of failure of the heart to compensate for the disease and increased loss of independence. Death is most commonly due to ventricular arrhythmia or progressive pump failure as demonstrated in clinical trials. Studies report a mortality of close to 40 per cent within one year of diagnosis and around 10 per cent each year NURSING STANDARD

thereafter (Cowie et al 2000). However, some earlier studies, such as the Hillingdon Heart Study (Cowie et al 1999) were carried out before the widespread introduction of beta-blockers and specialist heart failure nurses. Ventricular dyssynchrony It is estimated that 30 per cent of patients with chronic heart failure have evidence of abnormal interventricular conduction as shown on a 12-lead electrocardiogram (ECG), that is, the QRS complex is greater than 120 milliseconds (Cowie et al 2000); often in the form of left bundle branch block: a type of abnormal interventricular conduction. This abnormal interventricular conduction results in an abnormal activation of the ventricular myocardium, thus causing deranged ventricular contraction, commonly called ventricular dyssynchrony. Typically, the interventricular septum contracts earlier than the delayed contraction of the lateral wall of the left ventricle. In severe cases, dyssynchrony can result in contraction of the septum while the lateral wall is relaxing, and vice versa. If opposing ventricular walls fail to contract together, a sizable proportion of blood is shifted around the left ventricle and is not ejected into the circulation, thereby reducing cardiac output, the amount of blood ejected from the left ventricle in one minute. Dyssynchrony also reduces left ventricular filling time, further reducing the already poor cardiac output. There is also an added risk of intracardiac thrombi. In patients with chronic heart failure and poor systolic function, ventricular dyssychrony further compromises performance and will exacerbate symptoms of heart failure.

FIGURE 1 Dual chamber right-sided cardiac resynchronisation therapy Cardiac resynchronisation therapy leads

Superior vena cava

Right atrium

Coronary sinus Epicardial vein

Left ventricle

Atrioventricular valve Right ventricle Cardiac resynchronisation therapy (CRT) lead positions used in transvenous CRT. The endocardial leads are positioned in the right atrium and right ventricle, and the left ventricle is paced via a lead, which is passed through the coronary sinus into an epicardial vein on the free wall of the left ventricle

Cardiac resynchronisation therapy

Dual chamber, right sided cardiac resynchronisation therapy In the 1980s, CRT for heart failure set out to improve any atrioventricular delay thought to reduce cardiac output. This was carried out by implanting dual chamber right atrial and right ventricular leads. It appeared to benefit patients with first-degree atrioventricular block. However, in patients with NYHA class III and IV heart failure, little or no symptomatic relief was obtained (Gold et al 1995, Linde et al 1995). Multisite cardiac resynchronisation therapy Daubert et al (1998) suggested that the left ventricular wall could also be paced on a longterm basis in conjunction with right ventricular CRT by using a transvenous technique. Resynchronisation of the ventricles was addressed by introducing a lead via the coronary sinus and positioning the tip in an epicardial vein on the lateral wall of the left ventricle as part of a permanent CRT system (Figure 1). The aim was to eradicate dyssynchrony between the NURSING STANDARD

BOX 1 New York Heart Association (NYHA) Scale NYHA I Patients have no limitation on activities and experience no symptoms from ordinary activities, however, there is evidence of left ventricular impairment on echocardiography. Patients experience mild limitation of activity; they are comfortable at rest or with mild exertion. Evidence of mild to moderate left ventricular impairment on echocardiography. Patients experience marked limitation of activity; they are comfortable only at rest. Evidence of moderate to severe left ventricular impairment on echocardiography. Patients confined to bed or chair; even minimal activity causes discomfort and symptoms occur at rest. Evidence of severe left ventricular impairment on echocardiography.

NYHA II

NYHA III

NYHA IV

(Criteria Committee of the New York Heart Association 1994)

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ventricular septum and the left lateral ventricular wall, and to increase cardiac output and reduce symptoms of heart failure. This treatment was also known as biventricular pacing.

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Clinical trials
Several clinical trials have compared CRT with medical treatment alone, such as diuretic and ACE inhibitor therapy. The Multisite Stimulation in Cardiomyopathies (MUSTIC) study (Cazeau et al 2001) and the Multicenter InSync Randomized Clinical Evaluation (MIRACLE) study (Abraham et al 2002), showed improvements in quality of life, exercise tolerance, NYHA class scores, and left ventricle ejection fraction with CRT. The MIRACLE study (Abraham et al 2002) also showed a reduction in hospital admissions for worsening heart failure. At six months the risk of admission due to decompensated heart failure reduced by 50 per cent. A 77 per cent reduction in total hospital days saved for treating heart failure was observed in the CRT group compared with the control group. The COMPANION study (Bristow et al 2000) randomised more than 1,600 patients to medical treatment only, to CRT and to CRT with implantable cardiac defibrillators. This study had to be stopped part-way through because of a 20 per cent reduction in mortality and admission rates in the group with CRT. The group with the most notable benefit, receiving CRT with implantable cardiac defibrillators, showed a 40 per cent reduction in all cause mortality. These preliminary data indicate the benefits CRT may have on mortality. Possible limitations within this research have to be acknowledged. Many trials have a small sample size, which may undermine the external validity of the findings. Trial populations differ from those in clinical practice, for example, older patients and patients with co-morbidities are not well represented, leaving a gap in the evidence. There also appears to be limited follow-up to most trials. However, with the ongoing increase in CRT systems being fitted each year, future studies may be able to provide more answers and guidance for practice.

Effects of cardiac resynchronisation therapy on cardiac output

Systolic mitral regurgitation Mitral regurgitation occurs when the hearts mitral valve does not close properly, causing blood to leak (back-flow) into the left atrium from the left ventricle during cardiac contractions. Reports show that mitral regurgitation, as observed on echocardiography, was significantly reduced in patients with CRT: from 7cm2 in the mitral regurgitation jet before CRT to 4cm2 in the mitral regurgitation jet after the procedure (Etienne et al 2001). The explanation for this improvement in mitral regurgitation may be the change in the electrical activation of the left ventricle. Contraction normally occurs from apex to base, but when CRT is initiated in the coronary venous system the pattern is reversed and the base contracts before the apical myocardium, thus reducing mitral regurgitation. Improved systolic function Due to the delay in activation time between the ventricular septum and the depolarisation of the left ventricular wall, contractile patterns arise where the septal muscle is relaxing as the left free wall enters systole at the time at which ventricular contraction occurs, resulting in reduced contractile efficiency. Magnetic resonance angiography has confirmed the wobbling motion of the left ventricle in severely dilated cardiomyopathy and left ventricle dilation (Curry et al 2000). Correction of dyssynchrony resulting in simultaneous activation of the septal and free wall muscle leads to improved ejection fraction, which in turn increases cardiac output and therefore increases arterial pressure. Previous treatments to increase systolic function (that is, inotropic support) have been associated with increased myocardial oxygen demand, however, in CRT this is not the case. Effects of diastolic ventricular activity Patients with heart failure and left bundle branch block tend to have left ventricular diastole starting later than right ventricular diastole. Therefore, the right ventricle will fill first, causing an expansion in the pericardial sac and resulting in decreased left ventricle filling. CRT of the left ventricle before the right reverses this so that the left ventricle enters diastole first. This increases left ventricle filling time which aids cardiac output. 48 july 20 :: vol 19 no 45 :: 2005

Psychological considerations
Many patients do not receive adequate psychological support before implantation of implantable cardioverter defibrillators (ICD) (Tagney 2004). The absence of support is compounded in patients with heart failure who already require a great deal of psychological support from nursing and medical teams within a hospital setting and in primary care due to the poor long-term prognosis of the disease. NICE (2000) acknowledges that implantation and activation of an ICD can cause adverse psychological impact, and calls for psychological preparation for patients living with an ICD. However, it does not suggest how NURSING STANDARD

this preparation should be conducted, or how healthcare professionals should be trained to provide such a service.

Nursing patients with cardiac implants

Studies exploring patients experiences of living with an ICD suggest that a wide range of psychological, physical and socioeconomic considerations need to be addressed (Dougherty et al 2000, Tagney et al 2003). A recent study indicates that nurses are ill-equipped to provide the information and support needed for patients to come to terms with this life-changing event (Tagney 2004). In Tagneys (2004) study, more than 50 per cent of nurse respondents who were trained in cardiology wards and coronary care units, stated that they have cared for patients with ICDs. However, nurses were unable to list any lifestyle changes that a patient with an ICD may have to make when at home, or what support was available to them and their families on discharge from hospital. Safety aspects of living with the device seem to be poorly understood, with more than one third of respondents in this study not citing any hazards to avoid. These problems seem to be more apparent in referring hospitals compared with specialist cardiology centres where there are facilities to implant CRT devices and ICDs. With an increase in funding in the UK, improved techniques in lead placement, stronger evidence through clinical trials and ongoing expertise of pacing teams, an increasing number of patients are being offered CRT. It is essential that nurses recognise possible psychological and emotional effects of CRT, such as altered body image at insertion site, worries of failure to function and anxieties of ICDs misfiring, to ensure that patients and their families have confidence in the care provided. There are many considerations that need to be addressed by nurses caring for patients with heart failure who may be treated with a CRT system. These include preparing patients and relatives for the implantation of the system. Technical information and explanation will be required and an understanding of the success rate of CRT is essential to give patients and families a realistic view of possible outcomes. When CRT is unsuccessful in providing symptom relief, emotions will be high and feelings of anger and disappointment may need to be addressed with sensitivity. Caring for patients after CRT implantation also requires considerable knowledge of the technical aspects of device function and the psychological effects on patients and family members. Experience, educational preparation and area of work may all affect a nurses ability to NURSING STANDARD

care for patients treated with CRT. However, Tagney et al (2003) suggest that nurses abilities to provide skilled, evidence-based information and care have been assumed, not assured by training, highlighting relevant educational needs within this field. Good communication skills are essential to assist patients in coming to terms with their situation. Further nursing research is required in this field so that nurses can improve their knowledge. Approaches to improving patient care could include study days, development of information packs and closer collaboration with specialist centres. This will enable nursing staff to inform patients and provide better understanding and support.

Limitations
Suitability and symptoms There are many factors to consider when a patient is referred for CRT, such as systolic heart failure, non-reversible cause, NYHA class III or IV, and optimal drug therapy. Echocardiography is the main tool used for predicting ventricular dyssynchrony and hence suitability for CRT. Up to 20 per cent of patients with heart failure who fulfil the criteria for CRT show little or no clinical benefit from resychronisation (Reuter et al 2002). With this in mind, medical staff may need more sensitive screening tools when assessing patients suitability for CRT. This could include tissue Doppler echocardiography, which allows quantification of dyssynchrony and provides a more accurate prediction of how patients would respond to resynchronisation therapy. It is important to acknowledge that patients, nurses and even medical staff are often unsure of the mechanisms of dyspnoea and there are likely to be many contributing factors to dyspnoea, many of which are not completely understood at present. Some conditions related to heart failure will almost certainly be irreversible, for example, pulmonary hypertension. Therefore, it is not surprising that CRT may not provide symptom improvement for all patients with heart failure. Left ventricular lead placement It is widely acknowledged that there are technical and anatomical problems when placing the left ventricular lead (Daubert et al 1998, Cazeau et al 2001). Eight per cent of procedures result in implant failures (Abraham et al 2002). Nearly all of these failures are caused by the inability to deploy the left ventricular lead (Abraham et al 2002), including the inability to intubate the coronary sinus, dissection of the coronary sinus, displacement of the left ventricular lead, and diaphragmatic stimulation. Most of the problems are reduced by the operators july 20 :: vol 19 no 45 :: 2005 49

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experience, technique, testing at implantation and programming of the pacemaker.

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Conclusion
The subject of CRT is discussed at cardiology conferences worldwide. Research trials and the money currently being invested in providing this treatment, mean that CRT will be a major treatment for patients with heart failure in the future. Although the device in the UK is about twice as expensive as a standard dual chamber system, repeated trials highlight the reduction in hospital admissions due to decompensating episodes of heart failure (Bristow et al 2000, Cazeau et al 2001, Abraham et al 2002). Growth in this technology will have economic implications for those planning and delivering health care. Research on the treatment of heart failure shows that medication, such as beta-blockers and ACE inhibitors (CONSENSUS Trial Study Group 1987, MERIT-HF Study Group 1999, Segev and Mekori 1999), and certain systems of care, such

as the introduction of heart failure nurse specialists (NICE 2003), reduce hospital admissions and are therefore cost effective. It could also be argued that, as CRT is a relatively new treatment for heart failure, this analysis of true cost effectiveness has not been proven. Furthermore, it is uncertain whether CRT is equally cost effective for all patients. Future research needs to determine whether CRT is less, equal or more effective than medication and/or care provision by specialist nurses. If there are 900,000 patients in the UK with heart failure, and up to 30 per cent have wide QRS complexes on ECG, then up to 300,000 patients may need to be considered for CRT. The resources needed to meet those demands are immense and the demographics of heart failure should also be considered. CRT techniques are becoming more effective with advancements in equipment, facilities and expertise. However, effects on mortality will not be fully determined until further trials are completed. Nurses need to develop their skills and knowledge to provide adequate patient support during informed decision-making regarding CRT and when providing care following resynchronisation NS

References
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