Participation of Cardiac Resynchronisation Therapy in Clinical Practice

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Participation of Cardiac Resynchronisation Therapy in Clinical Practice

Despite demonstrating substantial benefits, CRT is underutilised even in developed countries like US and Europe.²⁷ It was estimated that, between 2002–2013, 100,000–430,000 HF patients in the US were potential candidates for CRT but did not receive the implantation.²⁷ There are several reasons for the apparent gap between guidelines and realworld practice, the most important being risk and cost-related issues.

1. CRT is an expensive therapy, which is an obstacle in terms of reimbursement. Currently, the benefit of CRT outweighs the cost of HF within health systems and CRT is considered a cost-effective treatment compared with optimal medical therapy or implantable cardioverter-defibrillator (ICD). Data shows that the additional costeffectiveness ratio is $7,320 per quality-adjusted life year. A study conducted in Europe (Belgium) found that CRT in New York Heart Association (NYHA) class III and IV patients resulted in an incremental cost-effectiveness ratio of about €11,200 per quality-adjusted life year.²⁸ Though CRT is a worthwhile investment in severe HF, its high expense hinders its use in developing countries.
2. Another issue affecting the use of CRT in clinical practice is its relatively high complication rate due to the complicated anatomy of the coronary vein. Implantation requires greater experience, skill and training compared with ICD or RV pacing implantation. Risks associated with CRT implantation include implantation dissection, lead displacement and dislodgement as well as phrenic nerve stimulation.
3. During a 20-year history, it is unsurprising that the benefits of CRT have been challenged, and was doubted its long-term results. A large percentage of patients received ICD despite showing indications for CRT. In addition, around on quarter of HF patients were implanted with RV pacing with frequent ventricular pacing percentage. More education with guideline-directed medical therapy in both patients and physician groups is required to tackle the low participation rate.