Comparative effectiveness of cardiac resynchronization therapy with an implantable cardioverter-defibrillator versus
Insights
Cardiac resynchronization therapy with a defibrillator (CRT-D) reduces mortality and readmission risks compared to implantable cardioverter-defibrillators (ICD) in older patients. However, CRT-D is linked to a higher risk of device-related infection.
Area of Science:
- Cardiology
- Medical Devices
- Clinical Trials
Background:
- Limited trials compare implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy with a defibrillator (CRT-D) in selected patient groups.
- Contemporary practice data is needed to evaluate these therapies.
Purpose of the Study:
- To compare outcomes between CRT-D and ICD therapy in a large, real-world patient population.
- To assess risks for mortality, readmission, and device complications over three years.
Main Methods:
- Retrospective cohort study utilizing the National Cardiovascular Data Registry's ICD Registry linked with Medicare claims.
- Included 7090 propensity-matched patients over 65 years with reduced ejection fraction and prolonged QRS duration.
- Analyzed risks for death, readmission, and device-related complications over 3 years.
Main Results:
- CRT-D was associated with significantly lower risks for mortality (25.7% vs. 29.8%), all-cause readmission (68.6% vs. 72.8%), cardiovascular readmission (45.0% vs. 52.4%), and heart failure readmission (24.3% vs. 29.4%) compared to ICD therapy.
- CRT-D showed a higher risk for device-related infection (1.9% vs. 1.0%).
- Benefits of CRT-D for heart failure readmission were most pronounced in patients with left bundle branch block, QRS duration ≥150 ms, and in women.
Conclusions:
- In older patients with reduced ejection fraction and prolonged QRS duration, CRT-D demonstrated superior outcomes regarding mortality and readmission compared to ICD therapy alone.
- Limitations include non-randomized assignment and potential limited generalizability to younger patients or those outside fee-for-service Medicare.
Background:
Trials comparing implantable cardioverter-defibrillator (ICD) therapy with cardiac resynchronization therapy with a defibrillator (CRT-D) are limited to selected patients treated at centers with extensive experience.
Objective:
To compare outcomes after CRT-D versus ICD therapy in contemporary practice.
Design:
Retrospective cohort study using the National Cardiovascular Data Registry's ICD Registry linked with Medicare claims.
Setting:
780 U.S. hospitals implanting both CRT-D and ICD devices.
Patients:
7090 propensity-matched patients older than 65 years with reduced left ventricular ejection fraction (<0.35) and prolonged QRS duration on electrocardiography (≥120 ms) having CRT-D or ICD implantation between 1 April 2006 and 31 December 2009.
Measurements:
Risks for death, readmission, and device-related complications over 3 years.
Results:
Compared with ICD therapy, CRT-D was associated with lower risks for mortality (cumulative incidence, 25.7% vs. 29.8%; adjusted hazard ratio [HR], 0.82 [99% CI, 0.73 to 0.93]), all-cause readmission (cumulative incidence, 68.6% vs. 72.8%; adjusted HR, 0.86 [CI, 0.81 to 0.93]), cardiovascular readmission (cumulative incidence, 45.0% vs. 52.4%; adjusted HR, 0.80 [CI, 0.73 to 0.88]), and heart failure readmission (cumulative incidence, 24.3% vs. 29.4%; adjusted HR, 0.78 [CI, 0.69 to 0.88]). It was also associated with greater risks for device-related infection (cumulative incidence, 1.9% vs. 1.0%; adjusted HR, 1.90 [CI, 1.07 to 3.37]). The lower risks for heart failure readmission associated with CRT-D compared with ICD therapy were most pronounced among patients with left bundle branch block or a QRS duration at least 150 ms and in women.
Limitations:
Patients were not randomly assigned to treatment groups, and few patients could be propensity-matched. The findings may not extend to younger patients or those outside of fee-for-service Medicare.
Conclusion:
In older patients with reduced left ventricular ejection fraction and prolonged QRS duration, CRT-D was associated with lower risks for death and readmission than ICD therapy alone.
Primary Funding Source:
Agency for Healthcare Research and Quality.
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