Clinical Characteristics and Outcomes of Older Cardiac Resynchronization Therapy Recipients Using a Pacemaker versus
Muhammad Bilal Munir1, Andrew D Althouse1, Shasank Rijal1
1Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
Insights
Cardiac resynchronization therapy (CRT) pacemakers (CRT-P) and defibrillators (CRT-D) show similar mortality in elderly patients when adjusted for baseline differences. Device selection in heart failure management needs clearer guidelines and further study.
Area of Science:
- Cardiology
- Medical Devices
- Geriatrics
Background:
- Cardiac resynchronization therapy (CRT) is vital for heart failure management.
- Current guidelines lack differentiation between CRT pacemakers (CRT-P) and CRT defibrillators (CRT-D).
- Significant disparities exist in device size, longevity, and cost between CRT-P and CRT-D.
Purpose of the Study:
- To compare clinical characteristics and outcomes of elderly CRT-P and CRT-D recipients.
- To investigate mortality differences in older adults receiving CRT-P versus CRT-D.
Main Methods:
- Retrospective analysis of 512 patients (≥75 years) with heart failure and QRS duration >120 ms.
- Comparison of baseline characteristics and all-cause mortality between CRT-P and CRT-D groups.
- Utilized Cox proportional hazards models and propensity matching for outcome validation.
Main Results:
- CRT-P recipients were older and had more comorbidities than CRT-D recipients.
- Unadjusted analysis showed higher mortality in CRT-P patients (HR 1.54).
- Adjusted analysis revealed no significant difference in mortality between CRT-P and CRT-D groups (HR 1.18).
Conclusions:
- Observed mortality differences in elderly CRT-P versus CRT-D patients are primarily due to baseline demographic and clinical factors.
- Ambiguity in current guidelines contributes to device selection disparities in clinical practice.
- Randomized controlled trials are necessary to establish optimal CRT device selection criteria.
Background:
Cardiac resynchronization therapy (CRT) is commonly used to manage heart failure, yet published guidelines do not distinguish between recommendations for pacemakers (CRT-P) and defibrillators (CRT-D) despite significant differences in size, longevity, and cost between these devices. The purpose of this study is to compare the clinical characteristics and outcomes between elderly recipients of CRT-P and CRT-D.
Methods And Results:
Data from 512 patients (405 CRT-D, 107 CRT-P) aged ≥75 years with LV ejection fraction ≤35% and QRS duration >120 milliseconds were retrospectively analyzed for baseline characteristics and followed to the primary outcome of all-cause mortality. Cox proportional hazards models were used to adjust for possible confounders. Results were further validated through propensity matching cohorts. Compared to CRT-D recipients, CRT-P patients were older (83 years vs. 81 years, P < 0.001) and had more comorbid conditions (Charlson index = 5 [3-6] vs. 4 [3-5], P = 0.007). During 40.8 months of follow-up, there were 280 deaths. Compared to CRT-D patients, CRT-P recipients had higher unadjusted mortality (HR 1.54, 95% CI 1.15-2.08, P = 0.004). However, this difference lost significance after adjusting for baseline differences between the groups (HR 1.18, 95% CI 0.78-1.77, P = 0.435).
Conclusion:
Higher all-cause mortality in older CRT-P versus CRT-D patients is largely explained by baseline clinical and demographic differences between the two groups, which are likely the drivers of device selection in real-world clinical practice, where the published guidelines remain ambiguous. There is a need for randomized studies to determine optimal CRT device selection.
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