Pacemaker Versus Defibrillator Therapy in Patients Eligible for Cardiac Resynchronisation Therapy: Evidence from the
Philipp S Lange1,2, Gerrit Frommeyer1, Thomas Kleemann2
1Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, D-48149 Münster, Germany.
Insights
Most patients receive cardiac resynchronization therapy with a defibrillator (CRT-D). CRT-P selection is linked to non-ischemic cardiomyopathy, but CRT-P shows higher mortality in ischemic cases compared to CRT-D.
Area of Science:
- Cardiology
- Medical Devices
- Clinical Research
Background:
- Cardiac resynchronization therapy (CRT) is guideline-recommended for heart failure patients with reduced ejection fraction and left bundle branch block.
- The choice between CRT with a pacemaker (CRT-P) and CRT with a defibrillator (CRT-D) is debated, with registry data suggesting higher mortality with CRT-P.
- This study investigates the clinical factors influencing CRT-P vs. CRT-D selection and their comparative outcomes in a real-world setting.
Purpose of the Study:
- To identify clinical determinants for selecting CRT-P versus CRT-D in patients eligible for CRT.
- To compare the one-year clinical outcomes of CRT-P and CRT-D therapies using large, multi-center registry data.
Main Methods:
- Analysis of the German Device Registry (DEVICE), a prospective, nationwide registry of 5451 patients with device implantations.
- Focus on 1603 patients who received cardiac resynchronization therapy, comparing CRT-P (n=67) and CRT-D (n=1536) groups.
- One-year follow-up data were used to assess mortality and clinical characteristics.
Main Results:
- The majority of CRT patients (95.8%) received CRT-D. CRT-P patients had better baseline left ventricular systolic function and less history of myocardial infarction.
- Preexisting pacemakers and history of stroke/peripheral embolism were key determinants for CRT-P selection.
- Overall one-year mortality was 8.0%. In ischemic cardiomyopathy, CRT-P was associated with significantly higher mortality (21.2%) than CRT-D (8.9%). No significant difference was observed in non-ischemic cardiomyopathy.
Conclusions:
- Most patients undergoing CRT receive a CRT-D system.
- CRT-P is more frequently selected for patients with non-ischemic cardiomyopathy and those with a prior pacemaker.
- Treatment outcomes differ significantly between CRT-P and CRT-D, particularly in patients with ischemic cardiomyopathy, where CRT-D appears superior.
Abstract:
Background: According to current guidelines, cardiac resynchronisation therapy (CRT) is recommended in patients with significantly impaired left ventricular systolic function and left bundle branch block. However, the decision between pacemaker (CRT-P) and defibrillator (CRT-D) in patients eligible for CRT remains a matter of debate. Register data have shown a higher all-cause mortality in CRT-P in comparison to patients with a CRT-D. Here, we investigated clinical determinants of the selection of CRT-P vs. CRT-D and clinical outcome in large registry data from a multi-centre 'real-life' registry on patients with CRT defibrillator or pacemaker therapy. Methods: The German Device Registry (DEVICE) is a nationwide, prospective registry with one-year follow-up investigating 5451 patients receiving device implantations in 50 German centres. The present analysis of DEVICE focused on all patients from the register receiving cardiac resynchronization therapy. Results: Out of 1603 patients receiving cardiac resynchronisation therapy, 1536 (95.8%) received a CRT defibrillator system and 67 (4.2%) a CRT pacemaker system. Patients in the CRT-P group had a significantly better left ventricular systolic function compared to the CRT-D group (median 35% vs. 25%), and significantly less often had a history of myocardial infarction (9.0% vs. 25.2%). A preexisting pacemaker and a history of stroke/peripheral embolism were identified as determinants for the selection of CRT-P vs. CRT-D. Overall mortality after one-year follow-up was 8.0%. Patients with ischemic cardiomyopathy receiving CRT-P therapy had a higher one-year mortality than patients receiving CRT-D (21.2% vs. 8.9%, p = 0.020). On the other hand, patients with non-ischemic cardiomyopathy did not display differences between these two treatment groups (CRT-P 8.1%, CRT-D 6.6%, p = 0.72). Conclusions: Data from the German device registry show that most patients receiving cardiac synchronization therapy have an implanted CRT-D system. In comparison to patients with CRT-D, those with CRT-P more often had a non-ischemic cardiomyopathy and a preexisting pacemaker system. The outcomes between these two treatment groups were different as regards ischemic cardiomyopathy only.
