How to choose between a pacemaker or defibrillator for resynchronization therapy?
Insights
The study found that while cardiac resynchronization therapy with a defibrillator (CRT-D) showed lower mortality in simple analyses, this survival benefit for CRT-D versus CRT-P diminished in complex models, suggesting it is marginal.
Area of Science:
- Cardiology
- Medical Devices
- Clinical Outcomes
Background:
- Cardiac resynchronization therapy (CRT) is used for heart failure management.
- The choice between CRT with a defibrillator (CRT-D) and CRT with a pacemaker (CRT-P) remains debated.
- ESC guidelines suggest patient selection based on comorbidities and age.
Purpose of the Study:
- To investigate if CRT-D offers a long-term survival benefit over CRT-P when patients are selected according to ESC guidelines.
- To evaluate the impact of comorbidities and age on the survival outcomes of CRT-P versus CRT-D.
Main Methods:
- Retrospective analysis of 144 patients who received CRT devices between 2001 and 2007.
- Uni- and multivariate Cox regression analyses were performed to assess predictors of outcome.
- Three distinct multivariate models were applied to analyze survival differences.
Main Results:
- Patients receiving CRT-P were older with more comorbidities.
- CRT-D recipients initially showed significantly lower mortality.
- Multivariable analyses indicated that the survival benefit of CRT-D over CRT-P disappeared with increasing model complexity.
- Amiodarone use and COPD/renal insufficiency were associated with higher mortality; beta-blockers were protective.
Conclusions:
- The apparent survival benefit of CRT-D over CRT-P was dependent on the number of covariates in the analysis.
- The survival advantage of CRT-D, if present, is likely marginal when accounting for patient characteristics.
- Comorbidities like COPD and renal insufficiency significantly impact mortality risk in CRT patients.
Objective:
The choice between a resynchronization pacemaker (CRT-P) or defibrillator (CRT-D) is still a matter of debate. We hypothesised that when selecting patients based on co-morbidities and age as proposed by the ESC-guidelines, there would be no long-term survival benefit of CRT-D compared to CRT-P.
Methods:
We performed a retrospective analysis of patients who received a CRT device at the University Hospitals Leuven between 2001 and 2007. For the analysis of the association between predictors and outcome, uni- and multivariate Cox regression analyses were performed. We present data from three multivariate models.
Results:
A total of 144 CRT devices were implanted (CRT-D n=98, CRT-P n=46). Patients who received a CRT-P were older and had a higher prevalence of co-morbidities. Patients who received a CRT-D had a significant lower mortality. When applying incremental multivariate analysis using 1st variables with a P < 0.05 in univariate analysis, 2nd variables with a P < 0.10 and 3rd adding on top all the baseline variables that were significantly different between the two groups, the significance of a possible survival benefit for CRT-D over CRT-P disappeared: risk model 1, hazard ratio 2.21 (P = 0.008), risk model 2, HR 1.81 (P = 0.069), and risk model 3, HR 1.85 (P = 0.091). The use of amiodarone and the presence of COPD or renal insufficiency remained associated with a significant, higher mortality risk, while the use of beta blockers was protective in all three models.
Conclusion:
The choice of a CRT-D seemed a predictor of improved survival in simple but not in more complex multivariable analyses. The fact that the survival benefit strongly depended on the number of co-variables suggests that it is at most marginal.
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