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Cardiac Resynchronization With or Without Defibrillator in Nonischemic Cardiomyopathy: A Nationwide Cohort Study
Padmini Selvaganesan1, Mohamad Karnib1,2, Irfan Helmy1,2
1Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH (P.S., M.K., I.H., I.R., M.N.O., R.A., A.I., J.S., V.S.).
Insights
Adding a defibrillator to cardiac resynchronization therapy (CRT) did not improve survival for nonischemic cardiomyopathy (NICM) patients. Further research is needed to clarify the benefits of CRT defibrillator (CRT-D) versus CRT pacemaker (CRT-P) in this population.
Area of Science:
- Cardiology
- Electrophysiology
- Heart Failure Management
Background:
- Evolving therapies for heart failure with reduced ejection fraction necessitate clarity on the role of defibrillators in patients undergoing cardiac resynchronization therapy (CRT).
- The specific benefit of adding a defibrillator to CRT in nonischemic cardiomyopathy (NICM) remains uncertain, prompting investigation into comparative survival outcomes.
Purpose of the Study:
- To evaluate the long-term survival differences between patients with NICM who received CRT defibrillator (CRT-D) versus CRT pacemaker (CRT-P).
- To assess secondary outcomes including generator replacement, device-related infections, heart failure hospitalizations, and ventricular arrhythmias in NICM patients undergoing CRT.
Main Methods:
- A multicenter cohort study (DECIDE-CRT) analyzed data from 170 US Veterans Affairs hospitals.
- Patients with NICM receiving primary-prevention CRT-P or CRT-D between 2006 and 2020 were identified.
- Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics, followed by an IPTW-weighted Cox model to estimate all-cause mortality hazards.
Main Results:
- Of 3965 NICM patients meeting criteria, 3158 received CRT-D and 807 received CRT-P.
- After a median follow-up of 5.2 years, no significant difference in all-cause mortality was observed between CRT-P and CRT-D groups (adjusted HR, 0.90; 95% CI, 0.71-1.13; P=0.34).
- The CRT-D group experienced higher rates of generator replacement and device-related infections, with no significant difference in heart failure hospitalization rates.
Conclusions:
- This nationwide observational study did not find a clear survival advantage for adding a defibrillator to CRT in patients with NICM.
- Residual confounding cannot be excluded, and the incremental benefit of CRT-D over CRT-P in NICM requires further investigation.
- A randomized trial is recommended to definitively test the incremental value of CRT-D versus CRT-P in the NICM population.
Background:
With evolving therapy for heart failure with reduced ejection fraction, the benefits of adding a defibrillator in patients undergoing cardiac resynchronization therapy (CRT) remain unclear, particularly for nonischemic cardiomyopathy (NICM). This study evaluates long-term survival among patients with NICM treated with CRT defibrillator (CRT-D) versus CRT pacemaker (CRT-P).
Methods:
DECIDE-CRT (Cardiac Resynchronization With or Without Defibrillator in Non-Ischemic Cardiomyopathy) is a multicenter cohort study across 170 US Veterans Affairs hospitals. We identified patients with NICM receiving primary-prevention CRT-P or CRT-D between January 1, 2006, and December 31, 2020. Using a propensity score approach, we applied inverse probability of treatment weighting to balance baseline characteristics between the CRT-P and CRT-D groups. An inverse probability of treatment weighting-weighted Cox model estimated hazards for all-cause mortality. Secondary outcomes included generator replacement, device-related infections, hospitalization for heart failure, and ventricular arrhythmias.
Results:
Of 16 609 CRT recipients, 3965 met NICM primary-prevention criteria (CRT-D=3158; CRT-P=807). At baseline, patients with NICM receiving CRT-P were much older, with more cardiovascular and noncardiovascular comorbidities compared with the CRT-D group. During the median follow-up of 5.2 years, the mortality rate for CRT-P versus CRT-D was 9.46 versus 9.21 per 100 person-years (RR, 0.97 [95% CI, 0.71-1.13]; P=0.66). The adjusted hazard ratio for all-cause mortality using the inverse probability of treatment weighting-Cox model was 0.90 (95% CI, 0.71-1.13; P=0.34). There was no difference in adjusted hazard for heart failure hospitalization (hazard ratio, 1.27 [95% CI, 0.86-1.87]), while the CRT-D group had higher rates of generator replacement and device-related infections.
Conclusions:
This nationwide observational study from the Veterans Affairs Health system did not demonstrate a clear survival advantage with the addition of a defibrillator among patients with NICM receiving CRT although residual confounding cannot be excluded. Given the uncertainty surrounding the incremental benefit of the defibrillator in this setting, a randomized trial is needed to test the incremental value of CRT-D over CRT-P in NICM.
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