Primary prevention implantable cardioverter defibrillator in cardiac resynchronization therapy recipients with
Ido Goldenberg1,2, Valentina Kutyifa1, Wojciech Zareba1
1University of Rochester Medical Center, Rochester, NY, United States.
Insights
Patients with advanced chronic kidney disease (CKD) receiving cardiac resynchronization therapy with a defibrillator (CRT-D) have a lower risk of arrhythmias but a higher risk of death. The benefit of CRT-D may be reduced in these patients.
Area of Science:
- Cardiology
- Nephrology
- Medical Devices
Background:
- Implantable cardioverter defibrillators (ICDs) are crucial for preventing sudden cardiac death (SCD) in heart failure with reduced ejection fraction (HFrEF) patients.
- The efficacy of ICDs in patients with advanced chronic kidney disease (CKD) remains uncertain.
- The benefit of ICDs may be diminished in HFrEF patients with advanced CKD who also receive cardiac resynchronization therapy (CRT).
Purpose of the Study:
- To investigate the hypothesis that patients with CKD who are CRT recipients may experience attenuated benefits from ICD therapy.
- To explore the role of competing risks, specifically death prior to arrhythmia, in this patient population.
Main Methods:
- A cohort of 1,015 patients receiving CRT with a defibrillator (CRT-D) for primary SCD prevention was analyzed.
- Patients were stratified into two groups based on CKD stage: Stage 1-3a (S1-S3a)KD and Stage 3b-5 (S3b-S5)KD.
- The primary endpoint was the occurrence of any ventricular tachycardia (VT) or ventricular fibrillation (VF); competing risk of death without VT/VF was also assessed.
Main Results:
- Patients with (S3b-S5)KD had a significantly lower incidence of VT/VF (12.6%) compared to (S1-S3a)KD (23.5%).
- Conversely, patients with (S3b-S5)KD exhibited a higher incidence of death without VT/VF (21.6%) compared to (S1-S3a)KD (6.6%).
- A competing risk model revealed that (S3b-S5)KD patients had a 43% lower risk of VT/VF and a nearly 5-fold increased risk of death without VT/VF.
Conclusions:
- The benefit of ICD therapy may be attenuated in CRT recipients with advanced CKD due to a lower incidence of arrhythmias and a higher competing risk of death.
- Future research should consider whether CRT alone, without a defibrillator, might be a more appropriate strategy for these patients.
Introduction:
The implantable cardioverter defibrillator (ICD) is effective for the prevention of sudden cardiac death (SCD) in patients with heart failure and a reduced ejection fraction (HFrEF). The benefit of the ICD in patients with advanced CKD, remains elusive. Moreover, the benefit of the ICD in patients with advanced chronic kidney disease (CKD) and HFrEF who are cardiac resynchronization therapy (CRT) recipients may be attenuated.
Hypothesis:
We hypothesized that patients with CKD who are CRT recipients may derive less benefit from the ICD due to the competing risk of dying prior to experiencing an arrhythmia.
Methods:
The study population included 1,015 patients receiving CRT with defibrillator (CRT-D) device for primary prevention of SCD who were enrolled in either (Multicenter Automated Defibrillator Implantation Trial) MADIT-CRT trial or the Ranolazine in High-Risk Patients with Implanted Cardioverter Defibrillator (RAID) trial. The cohort was divided into two groups based on the stage of CKD: those with Stage 1 to 3a KD, labeled as (S1-S3a)KD. The second group included patients with Stage 3b to stage 5 kidney disease, labeled as (S3b-S5)KD. The primary endpoint was any ventricular tachycardia (VT) or ventricular fibrillation (VF) (Any VT/VF).
Results:
The cumulative incidence of Any VT/VF was 23.5% in patients with (S1-S3a)KD and 12.6% in those with (S3b-S5)KD (p < 0.001) The incidence of Death without Any VT/VF was 6.6% in patients with (S1-S3a)KD and 21.6% in patients with (S3b-S5)KD (p < 0.001). A Fine and Gray multivariate competing risk regression model showed that Patients with (S3b-S5)KD had a 43% less risk of experiencing Any VT/VF when compared to those with (S1-S3a)KD (HR = 0.56, 95% CI [0.33-0.94] p = 0.03. After two years of follow up, there was almost a 5-fold increased risk of Death without Any VT/VF among patients with (S3b-S5)KD when compared to those with (S1-S3a)KD [HR = 4.63, 95% CI (2.46-8.72), p for interaction with time = 0.012].
Conclusion:
Due to their lower incidence of arrhythmias and higher risk of dying prior to experiencing an arrhythmia, the benefit of the ICD may be attenuated in CRT recipients with advanced CKD. Future prospective trials should evaluate whether CRT without a defibrillator may be more appropriate for these patients.
Related Concept Videos
01:30Continuous Renal Replacement Therapy
01:25Chronic Kidney Disease I: Introduction
01:22Heart Failure VI: Adjunct Therapies
01:29Cardiomyopathy V: Interprofessional Care
01:30Cardiomyopathy II: Dilated Cardiomyopathy
01:28Chronic Kidney Disease III: Interprofessional Care