Clinical and Economic Implications of Cardiac Resynchronization Timing and Longitudinal Medication Titration: A
Eson Ekpo1, Brett Atwater2, Steven Zweibel3
1Stanford University Division of Cardiovascular Medicine, Stanford, California.
Insights
Early cardiac resynchronization therapy (CRT) in heart failure patients significantly reduces mortality and hospitalizations. This study suggests earlier CRT implantation may improve outcomes compared to delayed treatment alongside guideline-directed medical therapy (GDMT).
Area of Science:
- Cardiology
- Heart Failure Management
- Medical Device Therapy
Background:
- Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction faces challenges in optimal up-titration.
- Cardiac resynchronization therapy (CRT) improves HF outcomes, but its optimal timing relative to GDMT is unclear.
- Understanding GDMT titration patterns and CRT sequencing is crucial for improving patient care.
Purpose of the Study:
- To analyze longitudinal GDMT titration in heart failure patients.
- To evaluate the impact of early versus late CRT implantation on clinical outcomes.
- To assess the association between CRT timing and healthcare utilization and costs.
Main Methods:
- Retrospective cohort study of 6,334 Medicare beneficiaries with incident HF receiving CRT (2018-2022).
- Early CRT defined as implantation within 1 year of HF diagnosis.
- Propensity score overlap-weighted models used to compare outcomes between early and late CRT groups.
Main Results:
- GDMT uptake increased post-diagnosis but quickly plateaued at low utilization levels.
- Early CRT was linked to significantly lower risks of all-cause death or HF exacerbation (HR=0.80), death alone (HR=0.79), and fewer HF exacerbations (IRR=0.66).
- Early CRT also correlated with reduced inpatient/ED visits, lower Medicare expenditures, and decreased HF-related out-of-pocket costs.
Conclusions:
- Early CRT implantation demonstrates significant benefits, including reduced mortality and HF exacerbations.
- The findings support reconsidering the optimal sequencing of GDMT and CRT in heart failure management.
- Early CRT is associated with improved healthcare utilization and cost-effectiveness.
Background:
Despite advances in guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction, challenges with uptitration may delay optimal treatment. Cardiac resynchronization therapy (CRT) improves clinical outcomes, yet optimal sequencing of CRT and GDMT remains uncertain. We sought to characterize longitudinal GDMT titration and evaluate associations between CRT timing and outcomes among US patients.
Methods:
A retrospective cohort study of 6334 Medicare beneficiaries with an identifiable incident HF diagnosis who will receive CRT between 2018 and 2022. Early CRT was defined as implantation within 1 year of diagnosis. Medication use was assessed by medication possession ratios of ≥0.8 in quarterly intervals. Outcomes were compared using propensity score overlap-weighted models.
Results:
GDMT uptake increased sharply after the incident HF diagnosis but plateaued quickly with consistent medication use remaining low. Early CRT (n = 3777) was associated with lower adjusted risk of composite all-cause death or HF exacerbation (hazard ratio 0.80, 95% confidence interval [CI] 0.72-0.89), all-cause death alone (hazard ratio 0.79, 95% CI 0.69-0.90), and fewer HF exacerbations (incident rate ratio 0.66, 95% CI 0.58-0.75) vs late CRT (n = 2557). Early CRT was also associated with lower inpatient and emergency department use, Medicare expenditures, and HF-related out-of-pocket costs after CRT implant.
Conclusions:
Early CRT was associated with lower mortality, fewer HF exacerbations, and lower health care use, supporting reconsideration of GDMT and CRT treatment sequencing.
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