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Complications and Mortality Following CRT-D Versus ICD Implants in Older Medicare Beneficiaries With Heart Failure
Emily P Zeitler1, Andrea M Austin2, Christopher G Leggett2
1Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.
Insights
Cardiac resynchronization therapy with defibrillator (CRT-D) reduced mortality in older heart failure patients (≥74 years). CRT-D also lowered heart failure hospitalizations in the oldest group (≥85 years), supporting its use in eligible seniors.
Area of Science:
- Cardiology
- Geriatric Medicine
- Medical Device Technology
Background:
- Heart failure with reduced ejection fraction (HFrEF) affects a growing number of older adults.
- The specific benefits of cardiac resynchronization therapy (CRT) in elderly populations with HFrEF remain largely uncharacterized.
- Understanding device effectiveness in older Medicare beneficiaries is crucial for optimizing heart failure management.
Purpose of the Study:
- To compare the effectiveness of cardiac resynchronization therapy with a defibrillator (CRT-D) versus an implantable cardioverter-defibrillator (ICD) alone.
- To evaluate outcomes in older Medicare patients (≥65 years) diagnosed with heart failure with reduced ejection fraction (HFrEF).
- To stratify effectiveness by age groups (65-74, 75-84, and 85+ years).
Main Methods:
- A cohort study identified fee-for-service Medicare beneficiaries aged 65 years and older with HFrEF who received either CRT-D or ICD implantation between January 2008 and August 2015.
- Patients were stratified into three age groups: 65-74, 75-84, and 85+ years.
- Inverse probability weighting was employed to compare outcomes between the CRT-D and ICD groups, adjusting for baseline characteristics.
Main Results:
- The CRT-D group was generally older and exhibited higher rates of White race, female sex, and left bundle branch block compared to the ICD group.
- Overall complications were substantial (14%-20%) and 1-year mortality rates were high across all age and device groups.
- In the two oldest age strata (75-84 and 85+ years), CRT-D was associated with a significantly lower hazard of mortality (HR 0.90 and 0.81, respectively).
- The hazard of heart failure hospitalization was also reduced with CRT-D compared to ICD alone in the 85+ years age group (HR 0.82).
Conclusions:
- Complications and 1-year mortality remain high in older Medicare beneficiaries receiving ICDs with or without CRT.
- Cardiac resynchronization therapy with a defibrillator (CRT-D) demonstrated a reduced hazard of mortality in patients aged 74 years and older compared to ICD alone.
- CRT-D was associated with a lower hazard of heart failure hospitalization in the oldest cohort (≥85 years), suggesting clinical benefit in this population.
Objectives:
This study sought to assess the comparative effectiveness of cardiac resynchronization therapy with defibrillator (CRT-D) over implantable cardioverter-defibrillator (ICD) alone in older Medicare patients with heart failure with reduced ejection fraction (HFrEF).
Background:
Despite growing numbers of older patients with HFrEF, the benefits of cardiac resynchronization therapy (CRT) in this group are largely unknown.
Methods:
A cohort of fee-for-service Medicare beneficiaries ≥65 years of age with HFrEF and enrolled in Medicare Part D who underwent CRT-D or ICD implantation from January 2008 to August 2015 was identified. Beneficiaries were divided by age (65-74, 75-84, and 85+ years), and outcomes were compared between the CRT-D and ICD groups after inverse probability weighting.
Results:
Compared with the ICD group, the CRT-D group was older and more likely to be White, be female, and have left bundle branch block. After weighting, overall complications were high across age and device groups (14%-20%). The 1-year mortality was high across all groups. In the 2 oldest age strata, the hazard of death was lower in the CRT-D group (HR: 0.90; 95% CI: 0.86-0.95 and HR: 0.81; 95% CI: 0.72-0.90, respectively; P < 0.001); the hazard of heart failure hospitalization was lower for CRT-D vs ICD in the 85+ years age group (HR: 0.82; 95% CI: 0.74-0.92; P < 0.001).
Conclusions:
In older Medicare beneficiaries undergoing ICD with or without CRT, complications and 1-year mortality were high. Compared with ICD alone, CRT-D was associated with a lower hazard of mortality in patients ≥74 years of age and lower hazard of HF hospitalization in those ≥85 years of age. These findings support the use of CRT in eligible older patients undergoing ICD implantation.
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