Suboptimal medical therapy in patients with systolic heart failure is associated with less improvement by cardiac resynchronization therapy

Background: Proven medical therapy is under-prescribed in heart failure (HF) for various reasons. Cardiac resynchronization therapy (CRT) is of proven value in selected patients with HF; however, the degree of benefit in those without the optimal therapy is not clear. Methods: This is a retrospective study comparing the effect of CRT in 30 patients without optimal combination therapy (group 1; 10 (33%) without ACEi or equivalent and 25 (83%) without beta-blockers) to an age, sex, ejection fraction (EF) and New York Heart Association (NYHA) class matched control but with the combination (group 2; n=30) at baseline. All patients were in NYHA class III or IV with EF <= 35% and QRS interval >= 120 ms. Echocardiographic examination and N-terminal pro-brain natriuretic peptide (NT pro-BNP) levels before and 3 months after CRT were compared between the two groups. The composite endpoints of HF hospitalization or death during follow-up were compared by Kaplan-Meier analysis. Results: There were significantly less improvement in EF (+4.0 +/- 2.5% vs +10.1 +/- 3.2%; p < 0.05) and degree of reverse remodeling in group I after 3 months. Patients in group I had significantly higher level of NT pro-BNP levels at 3 months (2221 +/- 2001 pg/mL vs 1038 905 pg/mL; p < 0.001) and higher rates of HF hospitalization or death (53.3% vs 23.3%; Log rank chi(2) 5.52; p=0.019). Conclusion: Patients receiving CRT but without optimal medical therapy were associated with less echocardiographic and clinical improvement. Optimal medical therapy, if tolerated, before CRT is necessary. (c) 2006 Elsevier Ireland Ltd. All rights reserved.