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Reduced appropriate implantable cardioverter-defibrillator therapy after cardiac resynchronization therapy-induced
Neal A Chatterjee1, Attila Roka1, Steven A Lubitz1
1Department of Medicine and the Cardiac Arrhythmia Service, GRB 109, Massachusetts General Hospital Heart Center, 55 Fruit Street, Boston, MA 02411, USA.
Insights
Improved left ventricular ejection fraction (LVEF) after cardiac resynchronization therapy (CRT) significantly reduces appropriate implantable cardioverter-defibrillator (ICD) therapy. Patients with LVEF recovery, especially ≥45%, or primary prevention ICD indication face the lowest risk.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Cardiac resynchronization therapy (CRT) with an implantable cardioverter-defibrillator (ICD) is a common treatment for heart failure.
- Assessing the impact of CRT-induced left ventricular ejection fraction (LVEF) improvement on ICD therapy is crucial for patient management.
Purpose of the Study:
- To evaluate the association between LVEF recovery following CRT and the incidence of appropriate ICD therapy.
- To identify patient subgroups at lower risk for ICD therapy after CRT.
Main Methods:
- A meta-analysis was performed on data from 6 retrospective cohort studies, including 1740 patients.
- Pooled incidence rates of appropriate ICD therapy were compared between patients with and without LVEF recovery post-CRT, using various LVEF thresholds (≥35% and ≥45%).
Main Results:
- Significant reductions in appropriate ICD therapy were observed in patients with LVEF recovery (≥35% or ≥45%) compared to those without.
- Patients achieving LVEF ≥45% had an estimated ICD therapy rate of 2.3/100 person-years.
- Patients with a primary prevention ICD indication had very low rates of ICD therapy (0.4-0.8/100 person-years), irrespective of LVEF recovery.
Conclusions:
- Recovery of LVEF after CRT is linked to a substantially lower incidence of appropriate ICD therapy.
- Patients demonstrating significant LVEF improvement (≥45%) or those with a primary prevention ICD indication are associated with the lowest risk of appropriate ICD therapy.
Aims:
For patients undergoing cardiac resynchronization therapy (CRT) with implantable cardioverter-defibrillator (ICD; CRT-D), the effect of an improvement in left ventricular ejection fraction (LVEF) on appropriate ICD therapy may have significant implications regarding management at the time of ICD generator replacement.
Methods And Results:
We conducted a meta-analysis to determine the effect of LVEF recovery following CRT on the incidence of appropriate ICD therapy. A search of multiple electronic databases identified 709 reports, of which 6 retrospective cohort studies were included (n = 1740). In patients with post-CRT LVEF ≥35% (study n = 4), the pooled estimated rate of ICD therapy (5.5/100 person-years) was significantly lower than patients with post-CRT LVEF <35% [incidence rate difference (IRD): -6.5/100 person-years, 95% confidence interval (95% CI): -8.8 to -4.2, P < 0.001]. Similarly, patients with post-CRT LVEF ≥45% (study n = 4) demonstrated lower estimated rates of ICD therapy (2.3/100 person-years) compared with patients without such recovery (IRD: -5.8/100 person-years, 95% CI: -7.6 to -4.0, P < 0.001). Restricting analysis to studies discounting ICD therapies during LVEF recovery (study n = 3), patients with LVEF recovery (≥35 or ≥45%) had significantly lower rates of ICD therapy compared with patients without such recovery (P for both <0.001). Patients with primary prevention indication for ICD, regardless of LVEF recovery definition, had very low rates of ICD therapy (0.4 to 0.8/100-person years).
Conclusion:
Recovery of LVEF post-CRT is associated with significantly reduced appropriate ICD therapy. Patients with improvement of LVEF ≥45% and those with primary prevention indication for ICD appear to be at lowest risk.
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