Hi, I'm Jag Singh from Asheville Hospital, Boston. I'm a cardiac electrophysiologist by trade. I am so excited to be here. We have a phenomenal panel. I'm going to be talking about a very interesting topic. It's largely related to integrating care solutions for the CRT patient. The reason we're having this discussion is because these patients are complex, they get care from heart failure specialists, electrophysiologists, and really trying to get them the best possible multidisciplinary care to get the best outcomes is oftentimes challenging. So we have a great panel out here. I'm going to ask each one of them to introduce themselves. I'm going to start with you, Nasreen. Hi, everyone. I'm really excited to be here. My name is Nasreen Ibrahim. I am a heart failure and transplant cardiologist and currently one of the Commonwealth Fund Fellows in Minority Health Policy at Harvard. I have a big interest in disparities in access to care. Terrific. How about you, Gaurav? I see you next on the screen. So let's go with you. Thanks so much, Jag. And thank you to the American College of Cardiology for letting us be here with you today. My name is Gaurav Abadda. I'm at the University of Chicago. I'm an electrophysiologist. I love taking care of patients with different cardiac devices and different tools and working with my colleagues in heart failure as well as general cardiology. Andrew, your turn next. Hi. Andrew Sauer, coming to you from Kansas City. I'm at the MidAmerica Heart Institute, St. Luke's here. And my focus is on heart failure and heart transplantation and the intersection of digital health innovations and device therapies for patients with heart failure. Excited to be here. Excellent. Excellent. So we have two electrophysiologists and two heart failure physicians. So this is going to be a really interesting conversation. But since we're talking about CRT or what we know as cardiac resynchronization therapy, let me start with you, Gaurav. Why don't you kind of give us an introduction as to what CRT is? Why don't you spell it out for us? Absolutely. So CRT is a means to pace the heart to improve the pumping efficiency of the heart itself. It really represented a paradigm change when it was first introduced, now overdue two decades ago. Whereas when we think of most pacemakers, they deliver on-demand pacing or pacing only as needed, cardiac resynchronization therapy is different. The goal here is to pace every single beat and pace both the right and the left ventricles, sometimes even fusing with the conduction through the normal conduction system. And CRT seeks to correct dyssynchrony, which might be present because of wide QRS patterns, particularly left bundle branch block. So it's an exciting therapy for patients with symptomatic heart failure and a wide QRS. You know, having said that, so there are really a large spectrum of patients who have a wide QRS. They can be left bundles and non-left bundles, and it can be wider QRSs and narrower QRSs, and oftentimes that can get pretty confusing. Nasreen, can you kind of give us an overview as to what the guidelines are for resynchronization therapy? Absolutely. And there's lots of nuances. So I'll be providing just a broad overview of the indications for CRT. The U.S. guidelines haven't been updated in quite a few years, but the European guidelines were updated in 2021. So when I think about which patients I'm going to refer for CRT, so these are patients with heart failure that's symptomatic. So New York Heart Association class two to four symptoms, they have an ejection fraction of 35% or less, and they've been optimized on their guideline-directed medical therapies, meaning they're on the four classes of GDMT. They're at the doses, the target doses that are in the clinical trials and the guidelines, or they're on the maximally tolerated doses for the individual patient. And then they have evidence of conduction disease. So to simplify it, so if the patient has a left bundle branch block, their QRS is 120 milliseconds or greater. If it's a non-left bundle branch block pattern, QRS 150 milliseconds or greater. So again, symptomatic patients despite optimal medical therapy that have evidence of conduction disease and ejection fraction 35% or less. There's another category you also might want to think about. So these are patients with EF of 36 to 50% and have AV nodal block. And then a third category is patients that might require RV pacing more than 40% of the time. So lots of nuances, but the broad picture is 35% or less, conduction disease, symptomatic on optimal medical therapy. Got it. And when you talk about symptomatic outshare, are there concrete ways of kind of assessing that like an NYHA class or a six-minute walk test, or is it just based off clinical assessment? How do you do that usually? So the guidelines say New York Heart Association class two to four is who we should consider CRT in. But to be quite frank about this, a lot of times when we ask patients about their symptoms, it's a subjective answer and we end up putting them in categories based on what they're answering that day. So if I ask a patient what their symptoms are like on Monday, it might be different than if I'm seeing a patient in clinic on Wednesday and asking them what their symptom burden is like. And so I'm not quite sure that NYHA class should go into the assessment of who should receive CRT or not, or if we should go just by ejection fraction. But the guidelines do state a New York Heart Association class two to four, and the answers are pretty subjective. Got it. Got it. No, that helps a lot. So Andrew, we have all these patients now, wider, narrower, left bundle, non-left bundle with an elaborate three-lead strategy that Gaurav explained that helps resynchronize these hearts, but not everybody responds. And could you kind of take us over the issue of non-responders? What are the predictors of non-response and how do we kind of figure this out? Yeah, it's a really important issue. I think it's a somewhat under-recognized challenge that really behooves all of us to work together with a heart failure, general cardiologist, as well as the electrophysiologist to really make our patients have the best response to the therapy. As most people know, there's generally a cited 30% non-response rate, but I think it's actually probably some ways worse than that, and in some ways better than that. I think the first step is just to kind of go back to what was the patient's baseline QRS morphology. I mean, the patients who have left bundle with a QRS over 150, as you've heard a couple times, really are the best responders just when you look at all comers. But I think in the practice, what we also see is that when you look at patients who are not responding, which if we were to be pure about the definition, we're talking about patients who don't benefit clinically, so they end up back in the hospital, they end up with progression of disease, they end up potentially dying of heart failure, and having unfortunately, not the best markers of reverse remodeling. So their ejection fraction doesn't improve, their left ventricle doesn't shrink down, which is what we're shooting for with our medications and with CRT. And one of the most common ways that I see in practice patients not responding is they're not actually getting the full benefit of the biventricular pacing. So either by interrogation of the device, they're not getting 99% biventricular pacing, or sometimes there's rhythm issues that are making the biventricular pacing ineffective, such as patients who have atrial arrhythmias or other forms of arrhythmias that are interrupting the normal biventricular pacing process. So sometimes getting a Holter monitor, for example, to assess whether the biventricular pacing frequency that's showing up on interrogation is consistent with reality, whether there's fusion beats or pseudo-fusion beats. I think the other challenge is, you know, looking at, you know, how is the lead positioning, getting a PA lateral chest x-ray, looking for evidence that maybe the coronary sinus lead is placed in an area where there may be scar, or if it's apically placed. So I think, again, the bottom line is we need to do a better job of applying complementary therapies with guideline-based therapies and improving rhythm strategies, as well as working with our EP colleagues to make sure that the device is functioning appropriately, you know, whether that be looking at AV and VV intervals, using echocardiography to further assess. But to essentially resign ourselves to allow a patient to be a non-responder really is happening a lot, but we really need to do better. Well, that's terrific. I like the way you kind of bucketed the predictors of non-response. You talked about selecting the right patient. You talked about implanting the lead in the right way for the right patient, and also about programming the devices in an individualized way. And if you get one of these three steps wrong, you're probably going to have a non-responder, and then obviously the presence of comorbidities that may add to why patients become non-responders. And I think it really emphasizes the importance of, you know, getting the heart failure physician and the EP physicians kind of talking about this together, because as electrophysiologist, you know, I kind of look at and see if the lead is located in the right spot or not. Gaurav, do you want to just quickly elaborate as to what you think an optimal lead location is for a patient who may turn out to be a responder or a non-responder? Yeah, that's a terrific point. So there are elements that we can try to use to optimize the response for the patient that occur first with patient selection. I think Nasreet has really covered that beautifully. Then the interprocedural role characteristics that we can focus on as electrophysiologists. And what Andrew is talking about is really integrating many pieces of information in the follow-up. Interprocedurally, Jag, exactly as you pointed out, these devices have three wires. One is in the atrium, one is in the right ventricle, and then that third wire is usually delivered to a vein that's coming off of the coronary sinus placed on the back wall of the heart. Not every patient has an ideal target in this location. And historically, really, the only options we had for patients who had unsuitable coronary sinus anatomy was delivering a wire on the epicarnial surface of the heart, potentially involving our surgical colleagues. And now more recently, though, we've developed techniques where we can deliver the wire adjacent to or engaging with the conduction system as another means to deliver cardiac resynchronization therapy. I think it's great that Andrew points out that biventricular pacing needs to be achieved 99% of the time. Another way to think about that is that if what we're trying to do is to utilize the conduction system, well, then conduction system pacing to deliver CRT, to deliver cardiac resynchronization therapy, has to occur 99% of the time. And in addition to getting those wires in the right position, it's about ensuring that's occurring. So it's about looking at that 12 Levy KG, really trying to make certain that what the patient is receiving is the electrical therapy that we want them to receive. That's terrific. That's terrific. Thank you for that. It gives us an insight as to the complexity of the procedure, at the same time, the complexity of actually managing these patients when they're outpatients and ambulatory, right? Most of these patients are actually ambulatory. Now, Sreen, you know, we have all these indications, and there still exists a fair amount of disparities in how patients get this care. I know you spend a lot of time thinking about health equity. I would love your thoughts as to what are the disparities in care and why are they occurring? Just like in every part of medicine, there's disparities with who receives CRT. And there's across race, ethnicity, age, and sex. So black patients, Hispanic and Latinx patients are less likely to receive CRT compared to their white counterparts. I know a lot of people have brought up that we always use white patients as the comparator, and hopefully that will change in the future, but it hasn't yet. So if you're a black or Hispanic or Latinx, you're less likely to receive CRT. Women are also less likely to receive CRT compared to men. And as well, there's ageism here too. So older patients above the age of 70 and certainly above the age of 85 are less likely to receive CRT compared to younger patients. And then there's disparities in the payer. So patients that are on Medicare and Medicaid are less likely to receive CRT compared to patients that have commercial insurance. And so at every level, there's a duty to do better because when we're thinking about payers, so is the disparity because they're making it difficult and prior authorizations are needed and the process is much more difficult to get it approved? Or is it a problem with reimbursement for people that are doing the procedures? Most patients, there's not enough heart failure docs. So most of the patients that have heart failure are not seen by heart failure physicians or heart failure cardiologists. So it's on us as well to provide education to the community as to when patients should be referred for CRT. It's our own biases that also need to be checked because we see this a lot in ageism. I'll have a patient that's 80 and playing golf, but somebody saying, why should I send them for CRT? Or why should I optimize their GDMT? They're doing fine. And how many more years realistically do they have? And really there's biases at every level and change at every level that needs to be made to improve implementation of this very useful life-saving and life-altering device. No, absolutely. And I would reiterate, and I think both Gaurav, Andrew, and you have done work in this arena and have shown that patients who are older or from minorities do just as well with CRT. And it's a shame that they don't get this opportunity to receive this disease-modifying therapy just like everybody else. So I think it's something that we need to really talk about and educate other people about for sure. And let me kind of shift gears out here, get back to the HFEP interactions. And I'm going to start off with you, Gaurav, again. You know, a lot of these devices have these phenomenal sensors, whether it's physical activity or trans-thoracic impedance or respiratory rate. And I'll let you elaborate on those. But there's such a wealth of information that we can get from these devices that can help us manage these patients. So what are your thoughts on heart failure diagnostics within these devices and how they should be used by both EPs as well as heart failure physicians? Yeah, that's a really excellent point, Jag. And I think that the issue here is that these diagnostics are held in the cloud. They are not held by the patient. And I hope that future iterations of this technology really makes the patient the owner because what you are talking about is that the newest generation devices don't just pace the heart. They tell us what's happening to the patient with respect to respiratory rate, with respect to things like heart sounds, even some devices, as well as measures of volume status by delivering small electrical impulses through the circuitry. And that information is dynamically acquired. And if the patient is enrolled in remote monitoring, meaning that they have a type of monitor in their house that is either given to them by the vendor or their own phone, that then transmits that information to typically a virtual cloud-based platform. And then we as practitioners then can look at the patient and get a snapshot in a single moment about what's happening with respect to overall arrhythmia burden, what's the average heart rate that the patient has right now, and what are particular indicators that they might be heading toward a heart failure exacerbation. There's a lot of information here. It requires integration, not just with the heart failure docs and the EP docs, but often also with mid-level providers, as well as technicians who are working and talking with these patients to check in, to get a gut check, is the information that we're getting online jiving with what is happening at home. So I do think that this requires further effort to develop workflows that actually are successful for each individual practice. There's also an economic ramification of this, and that relates nicely to, I think, a point Ms. Reedna made earlier about disparities and costs, because many times remote monitoring vendors or remote monitoring agencies that collect and collate this information do bill the patient as well. So I think that thinking about how we use this in a way that actually delivers value to our patients is really critical. No, that's certainly fascinating. I think the future of care, of the way we deliver it, is gonna be driven so much by sensors and the data we get, but we'll get to that in a second. I wanna get back to you, Andrew. I know you've done a lot of work and you've published a lot of publications on integrating heart failure and EP, getting these different subspecialties together. So why don't you kind of, and that's what this topic is about, integrating CRT solutions out here or solutions for the CRT patient. So why don't you kind of tell us how we bring the disciplines together and for the exact reasons you think that's important? It's a super important issue, and the reality is we put our patients through trusting us to implant an expensive and potentially dangerous device procedure. Obviously, the risks are low, but if we're gonna put patients through that, we need to do our best to optimize the response that patients have. So one of the things that's frustrating to me as a clinician is when I see patients where we're not assessing response and we're not responding to alerts. So a number of the devices that we're talking about today have sophisticated algorithms that can help us give clues and give us risk related to our patients as it relates to progressing in the heart failure disease, as well as the risk of hospitalizations or even arrhythmias and death. And I think the key message here is we have to work together. So for example, as you point out, Jack, we've written about this together, when you carve out a workflow for dealing with alerts, for example, with multivariable models, predicting heart failure events, things like intrathoracic impedance or heart sounds, our rate variability, we need to be able to carve out who is responsible for addressing those alerts. Obviously, our EP colleagues and the CRM folks that are monitoring are very well equipped dealing with the arrhythmias, but we also need to bring some heart failure care team stakeholders to the table to work on how do we optimize the medicines and address and triage patients who have other alerts that are suggesting that patient might be at risk for heart failure progression. So the number one message I want people to know is don't ignore the lack of biventricular pacing. So when it says 80% biventricular pacing, work with your EP colleagues to figure out how then you can optimize that. And second, don't ignore the heart failure alerts. So we know from manage HF that no matter how you respond to the alerts, you need to respond somehow. Ignoring them, turning them off is the worst thing you can do. And the simplest thing to address is just to get the patient on the phone or in a virtual visit, or bring them in for an encounter and assess the patient yourself. But if you say that the alerts don't mean anything, then you aren't paying attention to the data. The data show patients will progress if they're in alerts and you don't intervene, or at least make sure that they're taking their meds and adhering to the recommendations that we make. Well, thank you for that. Gaurav, just quickly circling back to you, do you think there's any potential role for integrated clinics that is really having an EP and heart failure sit together either in person or in the modern era virtually? Where I think it's probably easier to get two clinicians virtually there with the patient looking at HF diagnostics and kind of getting people to understand their own data. How do you think that's, do you think one, that's a good strategy? Do you think two, that it can impact outcomes? And three, do you think it's something we should be talking about and doing? Yeah, I mean, what a phenomenal idea. And certainly for the patient experience, being able to see multiple physicians with whom they interact with at the same time makes a lot of sense. And I know, Jack, you have published on this extensively where the utility of having a multidisciplinary clinic, and by discipline here, I mean the heart failure discipline and the EP discipline, to work together along with their imaging colleagues to really integrate all three sources of information at one time for one patient. It is hard to do that physically sometimes, but I think that there is a role here for a virtual huddle, and we're doing this informally already. You know, there's a very frequent use of various private or secure text messaging devices, which allow providers to interact with one another in quick touch points. They don't have to necessarily be prolonged encounters, but that allows the exchange of essential information, which might be something as important as Andrew calling an EP colleague, being like, hey, this person's arrhythmia burden is up, we need to consider an ablation. And then that then launches forward a scheduling visit to actually talk about an ablation with the patient, moving that up for really the awareness of a totally different provider. So I think communication, communication, communication is definitely key. So I think we're getting pretty close to the end of this session. I have recognized the importance of bringing EP and heart filler together to really understand the triggers for when patients are non-responders and predicting ones who are going to be non-responders, and really, I would say, immersing ourselves in ensuring a better outcome. But before we take off, one last question, and this is largely to Andrew and Nasreen. How much of skin in the game should heart failure patients have out here? I mean, how much of this should be information that goes to the patient and patients now engage in self-management strategies? Any quick thoughts on that, Nasreen? Let me start with you. Absolutely. I think it's 2023. I think we need to engage patients. I think we need to empower patients. As long as we're giving them the tools necessary for them to understand the data that we might be sharing with them and sitting down with them and talking to them about the importance of these alerts, what these alerts mean, and whether or not the alerts correlate with their symptoms. So I think we really need to work towards empowering our patients. There's just not enough physicians out there to be solely responsible for the care of patients. So I really, really do think that a shared care model with the patients being empowered in their care will improve outcomes. Terrific. Andrew, your thoughts? Yeah, I think this is a really important issue to really try to dive into. I mean, I think we learned a few things recently. In Guided, Jeff, we learned that remote monitoring may actually present us a signal for reducing some of the challenges that Nasreen has talked about with implicit bias. Patients in subset analyses appear to benefit more if they were Black or if they're women. In particular, I think the signal there may be about the fact that we are removing a lot of the judgments that come about patients and just focusing on the data, responding to the data that suggests my patient's an art player and not thinking necessarily about who that patient is might actually be a way to overcome some of the bias. The second issue is I think ultimately we have an opportunity to empower patients to make use of their own data. We do this with diabetes and glucose monitoring and glycemic control. Why couldn't we do this to some extent with diuretic adjustment and at least giving feedback to patients about this success when we do this with commercial and consumer grade devices like Apple Watches and Whoop and essentially the feedback and gamification that allows patients to be incentivized to take better control of their health is a huge opportunity. We learned from laptop, for example, even though there was some safety concerns that patients could adjust their own diuretics if given their own feedback of their own information about their heart failure. So I think that we're all kind of clamoring to get the patients back their own data. I think patients want this and I think we should try to figure out how to do this safely. Yeah, I know those are really, really important points you make. You know, I was a part of the steering committee of laptop and it had this, you know, threefold strategy where you had an observation phase, a titration phase and then a patient activation phase. I think the only way to make healthcare sustainable is to really engage the patients in self-management strategies. Otherwise, we're gonna be on a downward spiral, especially when we're dealing with complex diseases with complex devices that require integrated care also. So on that note, I wanna thank the three of you. This has been a tremendous discussion. I certainly have learned a lot and I hope our viewers have learned an equal amount of added new information with respect to how integrated care can be provided to the heart failure patients, be it for CRT or be it for a heart failure patient with an implanted device itself. So thank you all for being here. Really appreciate it. And until next time, thank you. ♪

cardiac resynchronization therapy

multidisciplinary care

disparities in access

remote monitoring

heart failure diagnostics

shared decision-making