Population-Level Impact of the Guidelines Update on Patient Selection and Outcomes After Cardiac Resynchronization
Ahmad B Allaw1, Suneet Mittal2, Faisal M Merchant3
1Center for Arrhythmia Care, Heart and Vascular Institute, The University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA.
Insights
The 2012 ACC/AHA/HRS guidelines increased cardiac resynchronization therapy with defibrillator (CRT-D) use in patients with left bundle branch block (LBBB). This led to reduced heart failure hospitalizations, even in sicker patients.
Area of Science:
- Cardiology
- Electrophysiology
- Health Services Research
Background:
- The 2012 ACC/AHA/HRS guidelines updated recommendations for cardiac resynchronization therapy with defibrillator (CRT-D).
- Left bundle branch block (LBBB) became a Class I indication for CRT-D, expanding patient eligibility.
Purpose of the Study:
- To evaluate the impact of the 2012 ACC/AHA/HRS guideline update on CRT-D utilization and efficacy.
- To assess changes in heart failure (HF) hospitalization rates and mortality following the guideline revision.
Main Methods:
- Analysis of the IBM Watson MarketScan Database from 2003-2018 for CRT-D implants/upgrades.
- Primary outcome: HF hospitalization post-left ventricular lead implant. Secondary outcomes: all-cause mortality, lead revisions.
- Comparison of patient characteristics and outcomes between pre- and post-guideline update cohorts.
Main Results:
- The proportion of patients with LBBB receiving CRT-D increased significantly post-update (29% to 55%).
- Post-update patients had higher comorbidity burden but experienced a significant decline in HF hospitalizations (HR: 0.89).
- Reduced HF hospitalization was associated with LBBB presence and ARNI prescription; all-cause mortality unchanged, lead revisions decreased.
Conclusions:
- The 2012 guideline revision successfully increased CRT-D utilization in LBBB patients.
- This expansion of therapy was associated with improved clinical outcomes, specifically reduced HF hospitalizations.
- The benefits were observed despite treating a population with increased comorbidities.
Objectives:
This study sought to analyze the impact of the American College of Cardiology, American Heart Association, and Heart Rhythm Society (ACC/AHA/HRS) guidelines for cardiac resynchronization therapy with defibrillator (CRT-D) update on utilization and efficacy of CRT-D.
Background:
In September 2012, the ACC/AHA/HRS guidelines for CRT-D were modified to include left bundle branch block (LBBB) as a Class I indication.
Methods:
The IBM Watson MarketScan Database was queried between January 1, 2003, and December 31, 2018, for CRT-D implants or upgrades. The primary outcome was heart failure (HF) hospitalization following left ventricular lead implant. Secondary outcomes included all-cause mortality and device-related lead revision.
Results:
A total of 27,238 patients were analyzed: 18,384 pre-update and 8,854 post-update. Mean age was 69 ± 11 years, 73% men, and 98% with history of HF hospitalization. The proportion of patients with LBBB increased from 29% to 55% (P < 0.001) after the update. Patients receiving CRT-D post-update demonstrated a greater prevalence of comorbidities, including atrial fibrillation (47% vs 40%; P < 0.001), diabetes mellitus (45% vs 39%; P < 0.001), chronic kidney disease (24% vs 15%; P < 0.001), and HF hospitalization in the year before CRT-D (40% vs 37%; P < 0.001). Despite greater baseline comorbidities, HF hospitalization significantly declined post-update (HR: 0.89; P < 0.001). Multivariate predictors of reduced HF hospitalization included angiotensin receptor neprilysin inhibitor prescription (HR: 0.48; P < 0.001) and presence of LBBB (HR: 0.71; P < 0.001). All-cause mortality was not significantly different between the 2 groups, and fewer lead revisions were noted post-update (0.6% vs 1.7%; P < 0.001).
Conclusions:
The revised 2012 guidelines led to an increased proportion of LBBB patients receiving CRT-D at the population-level. This change was associated with reduced HF hospitalization, despite broadening therapy to patients with more comorbid conditions.
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