High compliance with CRT guidelines

In her PhD thesis, Camilla Normand compares and evaluates adherence to recommendations for cardiac resynchronization therapy (CRT).


  1. Most patients get cardiac resynchronization therapy in line with international guidelines.
  2. There are some differences in CRT recommendations across different guidelines in situations where the effect of the treatment is uncertain.
  3. Older and more symptomatic heart failure patients are more likely to receive a CRT pacemaker rather than a CRT defibrillator.


Thesis: Cardiac Resynchronization Therapy (CRT): Patient Selection and Guideline Adherence.
Candidate: Camilla Normand
Time: September 9, 2020 at 12:15
Place: Online-based solution, due to the covid-19 situation
Link to university website (in Norwegian)


(1/4) Only 2% of CRTs in Europe are implanted without support in European guidelines, and this number is below 1% in Norway. These results from the large international CRT Survey II indicate that therapists all over Europe comply well with the ESC guidelines. However, there is some variation in practice in the different countries.

The study includes data from 11088 patients with CRT pacemakers or CRT defibrillators in 42 European countries. Adherence data were available for 8021 patients, of which 67% had a Class I guideline indication for CRT. 26% had a a Class IIa recommendation, whereas 5% had a Class IIb indication.

(2) All the six analyzed international guidelines recommend cardiac resynchronization therapy strongly in patient groups where the effect is well documented. For patient groups with uncertain effects of the treatment – for example in patients with bundle branch morphology and atrial fibrillation – there are large variations in the recommendations between the various guidelines.

The study includes two European guidelines, as well as guidelines for the UK, North America, Canada and Australia/New Zealand. All were published between 2011 and 2017.

(3) 70% of 10 692 included patients received a CRT defibrillator, whereas 30% received and CRT pacemaker. Older females were more likely to get a CRT pacemaker, as well as patients with more symptomatic heart failure, heart failure of non-ischemic aetiology, atrial fibrillation and atrioventricular block.


(1) Dickstein, K., Normand, C., Auricchio, A., Bogale, N., Cleland, J. G., Gitt, A. K., Stellbrink, C., Anker, S. D., Filippatos, G., Gasparini, M., Hindricks, G., Lundqvist, C. B., Ponikowski, P., Ruschitzka, F., Botto, G. L., Bulava, A., Duray, G., Israel, C., Leclecq, C., Margitfalvi, P., Cano, Ó., Plummer, C., Sarigul, N. U., Sterlinski, M., & Linde, C. (2018). CRT Survey II: a European Society of Cardiology survey of cardiac resynchronisation therapy in 11 088 patients—who is doing what to whom and how?. European journal of heart failure20(6), 1039-1051.

(2) Normand, C., Linde, C., Singh, J., & Dickstein, K. (2018). Indications for cardiac resynchronization therapy: a comparison of the major international guidelinesJACC: Heart Failure6(4), 308-316.

(3) Normand, C., Linde, C., Bogale, N., Blomström-Lundqvist, C., Auricchio, A., Stellbrink, C., Witte, K. K., Mullens, W., Sticherling, C., Marinskis, G., Sciaraffia, E., Papiashvili, G., Iovev, S., & Dickstein, K. (2019). Cardiac resynchronization therapy pacemaker or cardiac resynchronization therapy defibrillator: what determines the choice?—findings from the ESC CRT Survey IIEP Europace21(6), 918-927.

(4) Normand, C., Linde, C., Blomström-Lundqvist, C., Stellbrink, C., Gasparini, M., Anker, S. D., Plummer, C., Sarigul, N. U., Papiashvili, G., Iovev, S., & Dickstein, K. (2020). Adherence to ESC cardiac resynchronization therapy guidelines: findings from the ESC CRT Survey IIEP Europace22(6), 932-938.

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