What determines who gets cardiac resynchronization therapy in Europe? A comparison between ESC-HF-LT registry,
Paolo Gatti1, Cecilia Linde1,2, Lina Benson1
1Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
Insights
Cardiac resynchronization therapy (CRT) is underutilized in heart failure with reduced ejection fraction (HFrEF) patients. This study identified factors influencing CRT implantation, revealing significant underuse in eligible populations across registries.
Area of Science:
- Cardiology
- Heart Failure Management
- Medical Device Therapy
Background:
- Cardiac resynchronization therapy (CRT) is a proven treatment for heart failure with reduced ejection fraction (HFrEF) and dyssynchrony.
- Despite its efficacy, CRT remains underutilized in clinical practice.
- Identifying barriers to CRT implantation is crucial for improving patient outcomes.
Purpose of the Study:
- To investigate clinical, organizational, and healthcare system factors associated with CRT implantation in HFrEF patients.
- To quantify the extent of CRT underutilization among eligible patients.
- To compare CRT utilization rates and influencing factors across different patient cohorts and healthcare settings.
Main Methods:
- Analysis of data from three large registries: ESC-HF-Long Term Registry (ESC-HF-LT), Swedish Heart Failure Registry (SwedeHF), and ESC-CRT Survey II.
- Inclusion of patients with HFrEF meeting specific criteria for CRT eligibility.
- Statistical analysis to identify independent predictors of CRT implantation, including demographic, clinical, and healthcare access variables.
Main Results:
- A significant proportion of eligible HFrEF patients did not receive CRT across the studied registries.
- CRT utilization rates varied between the ESC-HF-LT (47% of eligible) and SwedeHF (25% of eligible) registries.
- Predictors for CRT implantation included guideline-directed medical therapy, atrial fibrillation, prior HF hospitalization, NYHA class, hospital type, and socioeconomic factors.
Conclusions:
- Cardiac resynchronization therapy is underused in a substantial minority of eligible heart failure patients.
- Factors such as guideline adherence, patient comorbidities, and healthcare system characteristics influence CRT implantation rates.
- Further efforts are needed to optimize CRT utilization and improve outcomes for HFrEF patients.
Aims:
Cardiac resynchronization therapy (CRT) is effective in heart failure with reduced ejection fraction (HFrEF) and dyssynchrony but is underutilized. In a cohort study, we identified clinical, organizational, and level of care factors linked to CRT implantation.
Methods And Results:
We included HFrEF patients fulfilling study criteria in the ESC-HF-Long Term Registry (ESC-HF-LT, n = 1031), the Swedish Heart Failure Registry (SwedeHF) (n = 5008), and the ESC-CRT Survey II (n = 11 088). In ESC-HF-LT, 36% had a CRT indication of which 47% had CRT, 53% had indication but no CRT, and the remaining 54% had no indication and no CRT. In SwedeHF, these percentages were 30, 25, 75, and 70%. Median age of patients with CRT indication and CRT present vs. absent was 68 vs. 65 years with 24% vs. 22% women in ESC-HF-LT, 76 vs. 74 years with 26% vs. 26% women in SwedeHF, and 70 years with 24% women in CRT Survey II (all had CRT). For ESC-HF-LT, independent predictors of having CRT were guideline-directed medical therapy (GDMT), atrial fibrillation (AF), prior HF hospitalization, and NYHA class. For SwedeHF, they were GDMT, age, AF, previous myocardial infarction, lower NYHA class, enrolment at university hospital, and follow-up at HF centre/Hospital. In SwedeHF, above median income and higher education level were also independently associated with having CRT. In the ESC-CRT Survey II (n = 11 088), all patients received CRT but with differences in the clinical characteristics between countries.
Conclusion:
CRT was used in a minority of eligible patients and more used in ESC-HF-LT than in SwedeHF.
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