Advanced Practice Provider-led Multidisciplinary Approach to Managing Cardiac Resynchronization Therapy

EP Lab Digest. 2022;22(12):1,10-11.

Cardiac resynchronization therapy (CRT) is a highly effective, underutilized treatment in specific patients with heart failure (HF) with reduced ejection fraction and ventricular dyssynchrony.¹ Outcomes following CRT device implantation are variable and ~30% of device recipients do not benefit from CRT therapy.¹ Determining response to CRT is challenging due to absence of consensus for a definition of ‘non-response’.

Medical guidelines exist for appropriate use of CRT; however, the guidelines stop at implant and do not provide guidance on postimplant management, further confounding assessment of how response to CRT is evaluated. Furthermore, postimplant management of these patients can be complex and require multidisciplinary expertise from both HF and electrophysiology (EP) services. Unfortunately, communication between specialties is not always cohesive, making care siloed and fragmented.

To tackle these challenges, some institutions have started CRT “non-responder” or “optimization” clinics.

The Heart Center for Excellence at OhioHealth Riverside Methodist Hospital has developed a specialized CRT Clinic. OhioHealth is a not-for-profit multidisciplinary health care system consisting of 12 hospitals, 200+ ambulatory sites, hospice, home health, and medical equipment, spanning 47 counties. Riverside Methodist Hospital is a 1059-bed teaching hospital and the largest hospital within the OhioHealth system. In August 2020, OhioHealth launched the Advanced Cardiac Therapies (ACT) Clinic at Riverside Methodist Hospital to standardize the follow-up of patients following CRT implant. All patients implanted with a cardiac resynchronization therapy defibrillator (CRT-D) at Riverside Methodist Hospital are automatically enrolled into a clinical pathway for follow-up. In addition to standard follow-up, this pathway provides additional, formal CRT-specific evaluation.

The ACT Clinic at OhioHealth is unique, because it is run by advanced practice providers (APPs). Specialty-trained HF APPs, as well as an EP APP who is a certified cardiac device specialist (CCDS), are the clinical providers in this clinic. Additionally, the clinic is staffed by a dedicated registered nurse who serves as a clinical coordinator and is the main point of contact for patients from the time of device implant to the ACT Clinic visit. The clinic has physician oversight from both HF and EP as well.

At the time of implant, each patient is enrolled into both the standard device clinic and ACT Clinic. Each patient follows the standard OhioHealth protocol for device follow-up, which includes a 7- to 10-day device incision check, remote interrogations every 3 months, and annual device clinic follow-up.

ACT Clinic evaluation starts at 1-month postimplant, at which time a remote device interrogation is scheduled and reviewed by the EP nurse practitioner. Lead, device parameters, and percent CRT pacing are reviewed. If CRT pacing is less than 98%, reasons for suboptimal CRT pacing are evaluated and addressed. This may require programming changes, arrhythmia management, and/or medication adjustments. Subsequent remote transmissions may then be scheduled to ensure improvement in CRT pacing. (Figure)

Approximately 6 months after device implant, the patient is seen for a formal in-person visit. During this visit, an echocardiogram is completed and compared to the preimplant echo. The patient also completes the Minnesota Living with Heart Failure Questionnaire (MLHFQ) (also compared to preimplant data) and performs a 6-minute walk test (6MWT) to assess functional status. A full device interrogation is performed as well. The patient is formally evaluated by both a HF and EP APP. When indicated, medication titration and device optimization is provided. The patient is then classified as either a responder or nonresponder. A responder has (1) subjective improvement in symptoms; (2) a left ventricular (LV) ejection fraction improvement of greater than or equal to 5%; and (3) a decrease in LV end systolic volume index of greater than or equal to 10%.

At the conclusion of the visit, each patient is provided with an individualized follow-up plan based on how they are doing post device implant and to ensure appropriate longitudinal HF and EP follow-up. From a HF standpoint, patients may (1) return back to his/her primary cardiology practice for ongoing care; (2) continue ongoing follow-up within the HF clinic for possible advanced therapies; or (3) continue ongoing follow-up with a HF clinic as an adjunct to their primary cardiology team. Based on any arrhythmia history or other related concerns, appropriate EP follow-up is arranged.

A significant component of the ACT Clinic protocol is education. From the time of device implant, the patient is educated about the ACT Clinic and what to expect for the initial 6-month follow-up appointment. After implant, the dedicated ACT Clinic nurse sends out an educational flyer that outlines the follow-up timeline and testing. At this visit, patients are provided with extensive education on HF, medications, cardiac device therapy, and the relationship between their HF and EP care. The importance of long-term follow-up is underscored for both HF and device management.

The ACT Clinic makes it a point to stay on top of emerging evidence in CRT care. Redefining CRT response is a hot topic right now after the recently published data from the 5-year outcome of the REVERSE Study.² We are currently working on revising the criteria of responder/nonresponder for the clinic based upon this data. The clinic’s current and conventional definition may be somewhat restrictive and may not accurately capture those patients who have clinically stabilized post device implant. We are leaning toward using new definitions such as “improved”, “stabilized”, and “worsened”, using a clinical composite score definition³ as well as reverse remodeling measures.² Using these definitions will better define patients’ response and better determine which patients are at high risk for adverse cardiovascular outcomes and may require further advanced HF therapies.

The ACT Clinic at Riverside Methodist Hospital was developed to provide standardized follow-up for patients after CRT implant, using a multidisciplinary APP model. Currently, there are no published guidelines available for post-CRT management. Using a standard care pathway, patients who undergo CRT device implant have consistent follow-up, ample opportunity for education, and may potentially improve response to CRT therapy. The collaboration between EP and HF services in this clinic serves to recognize patients who are at risk of further deterioration and offer ongoing arrhythmia management as well as assist in identifying candidates who may benefit from advanced HF therapies. 

Disclosures: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. They have no conflicts of interest to report regarding the content herein. Outside the published manuscript, Ms Swinning reports honoraria from Medtronic for lectures, presentations, speakers bureaus, manuscript writing, or educational events. Dr Amin reports consulting fees from Medtronic and Boston Scientific, and participation on an Advisory Board for Boston Scientific. Dr Billakanty reports payments from AtriCure and Biosense Webster for lectures, presentations, speakers bureaus, manuscript writing, or educational events.

References

1. Daubert C, Behar N, Martins RP, et al. Avoiding non-response to cardiac resynchronization therapy: a practical guide. Eur Heart J. 2017;38(19):1463-1472. doi:10.1093/eurheartj/ehw270

2. Gold MR, Rickard J, Daubert C, et al. Redefining the classifications of response to cardiac resynchronization therapy: results from the REVERSE study. JACC EP. 2021;7(7):871-880. doi:10.1016/j.jacep.2020.11.010

3. Packer M. Proposal for a new clinic end point to evaluate the efficacy of drugs and devices in the treatment of chronic heart failure. J Card Fail. 2001;7(2):176-182. doi:10.1054/jcaf.2001.25652