Comparative Effectiveness of CRT-D Versus Defibrillator Alone in HF Patients With Moderate-to-Severe Chronic Kidney
Daniel J Friedman1, Jagmeet P Singh2, Jeptha P Curtis3
1Division of Cardiology, Duke University Hospital, Durham, North Carolina.
Insights
Cardiac resynchronization therapy with a defibrillator (CRT-D) significantly reduces heart failure hospitalization or death in patients with moderate-to-severe chronic kidney disease (CKD). This real-world study found CRT-D effective and safe across CKD stages.
Area of Science:
- Cardiology
- Nephrology
- Medical Devices
Background:
- Moderate-to-severe chronic kidney disease (CKD) patients are underrepresented in cardiac resynchronization therapy (CRT) clinical trials.
- Understanding CRT effectiveness in CKD is crucial for managing heart failure (HF) in this population.
Purpose of the Study:
- To compare the real-world effectiveness of CRT with a defibrillator (CRT-D) versus an implantable cardioverter-defibrillator (ICD) alone.
- To evaluate outcomes in CRT-eligible patients with moderate-to-severe CKD.
Main Methods:
- An inverse probability-weighted analysis of 10,946 CRT-eligible patients with stage 3-5 CKD from the NCDR ICD Registry.
- Comparison of CRT-D (n=9,525) versus ICD alone (n=1,421) using Medicare claims data up to 3 years.
- Primary endpoint: HF hospitalization or death. Secondary endpoint: death. Assessed using Cox and Fine-Gray models.
Main Results:
- CRT-D use was associated with a significant reduction in HF hospitalization or death (HR: 0.84) and all-cause death (HR: 0.85).
- CRT-D also reduced HF hospitalizations alone (subdistribution HR: 0.84).
- Benefits were observed across all CKD stages, with no significant difference in device-related complications.
Conclusions:
- CRT-D is associated with significantly lower risks of HF hospitalization or death in moderate-to-severe CKD patients.
- CRT-D demonstrates effectiveness and acceptable complication rates in this understudied population.
Background:
Patients with moderate-to-severe chronic kidney disease (CKD) are poorly represented in clinical trials of cardiac resynchronization therapy (CRT).
Objectives:
This study sought to assess the real-world comparative effectiveness of CRT with defibrillator (CRT-D) versus implantable cardioverter-defibrillator (ICD) alone in CRT-eligible patients with moderate-to-severe CKD.
Methods:
We conducted an inverse probability-weighted analysis of 10,946 CRT-eligible patients (ejection fraction <35%, QRS >120 ms, New York Heart Association functional class III/IV) with stage 3 to 5 CKD in the National Cardiovascular Data Registry (NCDR) ICD Registry, comparing outcomes between patients who received CRT-D (n = 9,525) versus ICD only (n = 1,421). Outcomes were obtained via Medicare claims and censored at 3 years. The primary endpoint of heart failure (HF) hospitalization or death and the secondary endpoint of death were assessed with Cox proportional hazards models. HF hospitalization, device explant, and progression to end-stage renal disease were assessed using Fine-Gray models.
Results:
After risk adjustment, CRT-D use was associated with a reduction in HF hospitalization or death (hazard ratio [HR]: 0.84; 95% confidence interval [CI]: 0.78 to 0.91; p < 0.0001), death (HR: 0.85; 95% CI: 0.77 to 0.93; p < 0.0004), and HF hospitalization alone (subdistribution HR: 0.84; 95% CI: 0.76 to 0.93; p < 0.009). Subgroup analyses suggested that CRT was associated with a reduced risk of HF hospitalization and death across CKD classes. The incidence of in-hospital, short-term, and mid-term device-related complications did not vary across CKD stages.
Conclusions:
In a nationally representative population of HF and CRT-eligible patients, use of CRT-D was associated with a significantly lower risk of the composite endpoint of HF hospitalization or death among patients with moderate-to-severe CKD in the setting of acceptable complication rates.
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