In Silico Trials for Sex-Specific patient Inclusion Criteria in Cardiac Resynchronization Therapy: Advancing Precision in Heart Failure Treatment

TL;DR

This study uses in silico simulations to evaluate sex-specific differences in QRS duration criteria for cardiac resynchronization therapy, aiming to improve equitable patient selection.

Contribution

It introduces a population-based modeling approach to assess and optimize QRS duration criteria, accounting for sex and heart size differences in CRT patient selection.

Findings

Indexing QRSd by LVEDV and LV mass reduces sex disparities.

Height-indexed QRSd effectively resolves sex differences.

Proposed criteria maintain low non-LBBB over-selection rates.

Abstract

Cardiac resynchronization therapy (CRT) guidelines are based on clinical trials with limited female representation and inconsistent left bundle branch block (LBBB) definitions. Conventional QRS duration (QRSd) criteria show variable diagnostic accuracy between sexes, partly due to differences in heart size and remodeling. We evaluated the influence of sex, heart size, LBBB, and conduction delay on QRSd and assessed the diagnostic performance of conventional and indexed QRSd criteria using a population-based modelling approach. Simulated QRSd were derived from electrophysiological simulations conducted in 2627 UK Biobank healthy participants and 359 patients with ischemic heart disease, by modelling LBBB and normal activation combined with/without conduction delay. QRSd criteria under-selected LBBB females and over-selected non-LBBB patients. Indexing by LVEDV and LV mass reduced sex disparities but increased the over-selection in non-LBBB patients. Height-indexed QRSd effectively resolved sex differences and maintained low non-LBBB selection rates, demonstrating superior performance and potential for more equitable CRT selection.