Severe chronic kidney disease is associated with poor survival after initial CRT-defibrillator tachyarrhythmia
Evan C Adelstein1, Samir Saba2, Sandeep Jain2
1Division of Cardiology, Albany Medical College, Albany, New York.
Insights
Survival after cardiac resynchronization therapy (CRT)-defibrillator therapy declines significantly with lower glomerular filtration rate (GFR). Patients with GFR ≤30 have substantially reduced survival post-shock, questioning CRT-defibrillator benefit in chronic kidney disease.
Area of Science:
- Cardiology
- Nephrology
- Medical Devices
Background:
- Implantable cardioverter-defibrillator (ICD) recipients receiving appropriate therapies have limited survival.
- The survival benefit of ICDs in patients with chronic kidney disease (CKD) is uncertain.
- This study investigates CKD's impact on survival following cardiac resynchronization therapy (CRT)-defibrillator tachyarrhythmia therapies.
Purpose of the Study:
- To examine the association between chronic kidney disease (CKD) and survival in patients receiving CRT-defibrillator therapy.
- To compare survival rates across different stages of CKD (defined by glomerular filtration rate - GFR) after appropriate tachyarrhythmia therapies.
Main Methods:
- Compared overall survival in 439 CRT-defibrillator recipients (LVEF ≤35%, QRS duration >130ms) stratified by GFR at implant (≤30, 31-60, >60).
- Analyzed outcomes including appropriate shocks or anti-tachycardia pacing.
- Followed patients for a median of 64 months, assessing survival post-first therapy.
Main Results:
- Time to first therapy was similar across GFR groups.
- Survival after therapy declined significantly with decreasing GFR (P < .001).
- Median survival post-shock was 90 days (GFR ≤30), 612 days (GFR 31-60), and 1672 days (GFR >60).
- Lower GFR, ischemic heart disease, diabetes, and older age independently predicted increased post-shock mortality.
Conclusions:
- Survival after appropriate CRT-defibrillator tachyarrhythmia therapies, especially shocks, is significantly reduced in patients with severe CKD (GFR ≤30).
- These findings raise concerns about the survival benefit of CRT-defibrillators compared to CRT-pacemakers in patients with severe CKD.
- Further research is needed to optimize device therapy selection for CKD patients.
Background:
Implantable cardioverter-defibrillator (ICD) recipients who receive appropriate device therapies have limited survival, and survival benefit in chronic kidney disease (CKD) has been questioned. We examined the association between CKD and survival after cardiac resynchronization therapy (CRT)-defibrillator tachyarrhythmia therapies.
Methods:
We compared overall survival after appropriate shocks or anti-tachycardia pacing in 439 CRT-defibrillator recipients with left ventricular ejection fraction (LVEF) ≤35%, non-right bundle-branch block QRS pattern, and QRS duration >130 ms according to glomerular filtration rate (GFR) at implant, including 31 patients with GFR ≤30, 164 patients with GFR 31-60, and 244 patients with GFR >60. At least one shock occurred in 302 patients (24 with GFR ≤30, 102 with GFR 31-60, and 176 with GFR >60). Serial echocardiograms were also compared.
Results:
Patients were followed 64 months (interquartile range [IQR]: 29-94) after implant, including 32 months (IQR: 12-61) after first therapy. Time to first therapy or shock was similar across GFR groups. However, survival after first therapy declined directly with declining GFR (P < .001), with median postshock survival of 90 days for GFR ≤30 (95% confidence of interval [CI]: 0-233), 612 days (95% CI: 365-859) for GFR 31-60, and 1672 days (95% CI: 1396-1948) for GFR >60. Declining GFR category, ischemic heart disease, diabetes, and increasing age were independently associated with increased postshock mortality. Echocardiographic response was similar across GFR groups and was not associated with post-therapy survival.
Conclusions:
Survival after appropriate tachyarrhythmia therapies, particularly shocks, is attenuated in patients with GFR ≤30. This raises concern over potential lack of survival benefit conferred by CRT-defibrillators versus CRT-pacemakers in this population.
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