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Contemporary use of devices in chronic heart failure in the Netherlands
Anne G Raafs1, Gerard C M Linssen2, Jasper J Brugts3
1Department of Cardiology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
Insights
Device implantation rates for heart failure (HF) patients with reduced ejection fraction (LVEF) vary significantly across Dutch centers. Less than half of eligible HF patients received implantable cardioverter defibrillators (ICDs) or cardiac resynchronization therapy (CRT), highlighting a need for practice uniformity.
Area of Science:
- Cardiology
- Medical Device Technology
- Clinical Research
Background:
- Real-world data on device implantation for heart failure (HF) management remains limited.
- Previous surveys did not fully capture the nuances of device use in HF patients with reduced left ventricular ejection fraction (LVEF).
Purpose of the Study:
- To investigate device implantation rates in HF patients with LVEF < 50% across 34 Dutch centers.
- To identify variations in device implantation practices among different healthcare facilities.
Main Methods:
- A cross-sectional outpatient registry of 6666 HF patients with LVEF < 50% was analyzed.
- Patients were categorized by device type: conventional pacemakers (PM), implantable cardioverter defibrillators (ICD), cardiac resynchronization therapy with defibrillator function (CRT-D), cardiac resynchronization therapy with pacemaker function (CRT-P), or no device.
- Centers were classified as ICD-implanting, CRT-implanting, or referral centers.
Main Results:
- Overall implantation rates were 17.5% for ICD, 13.3% for CRT-D, 3.7% for CRT-P, and 8.4% for PM.
- In patients with LVEF ≤ 30%, 42.5% received ICD or CRT-D therapy.
- Significant inter-center variation was observed, with implantation rates ranging widely for all device types.
- Implantation centers demonstrated higher rates of ICD, CRT-D, and CRT-P compared to referral centers (36% vs. 25% for defibrillators, 17% vs. 9% for CRT).
- Independent predictors for ICD/CRT-D use included LVEF < 40% and male sex, while older age was associated with less ICD/CRT-D and more CRT-P/PM use.
Conclusions:
- Less than half of eligible HF patients with reduced LVEF received ICD or CRT, even with LVEF ≤ 30%.
- A substantial variation in device implantation rates exists between Dutch centers.
- There is a need for greater uniformity in guideline-based device therapy application in clinical practice.
Aims:
Despite previous surveys regarding device implantation rates in heart failure (HF), insight into the real-world management with devices is scarce. Therefore, we investigated device implantation rates in HF with reduced left ventricular ejection fraction (LVEF) in 34 Dutch centres.
Methods And Results:
A cross-sectional outpatient registry was conducted in 6666 patients with LVEF < 50% and with information about device implantation available [74 (66-81) years of age; 64% male]. Patients were classified into conventional pacemakers (PM, n = 562), implantable cardioverter defibrillators (ICD, n = 1165), and cardiac resynchronization therapy with defibrillator function (CRT-D, n = 885) or pacemaker function only (CRT-P, n = 248), or no device (n = 3806). Centres were divided into ICD-implanting and CRT-implanting and referral centres. Overall, 17.5% had an ICD, 13.3% CRT-D, 3.7% CRT-P, and 8.4% PM. Of those with LVEF ≤ 30%, 42.5% had ICD or CRT-D therapy. A large variation in implantation rates existed between centres: 3-51% for ICD therapy, 0.3-44% for CRT-D therapy, 0-11% for CRT-P therapy, and 0-25% PM therapy. Implantation centres showed higher implantation rates of ICD, CRT-D, and CRT-P compared with referral centres [36% vs. 25% for defibrillators (ICD or CRT-D) and 17% vs. 9% for CRT devices (CRT-D or CRT-P), respectively, P < 0.001], independently of other factors. A large number of clinical factors were predictive for device usage. Among other, LVEF < 40% and male sex were independent positive predictors for ICD/CRT-D use [odds ratio (OR) = 3.33, P < 0.001; OR = 1.87, P = 0.019, respectively]. Older age was independently associated with less ICD/CRT-D (OR = 0.96 per year, P < 0.001) and more CRT-P/PM use (OR = 1.03 per year, P = 0.006).
Conclusions:
In this large Dutch HF registry, less than half of the patients with reduced LVEF received an ICD or CRT, even if LVEF was ≤30%, and a large variation between centres existed. Patients from implantation centres had more often ICD or CRT. More uniformity regarding guideline-based use of device therapy in clinical practice is needed.
