Improved prognosis after cardiac resynchronization therapy over a decade

Q: What are the key findings of this study?

CRT implantation in contemporary practice (2018-2019) was associated with a significantly reduced risk of total mortality compared to earlier practice (2010-2011) (HR 0.72, 95% CI 0.69-0.76), despite an increasing comorbidity burden.

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Heart failure requiring cardiac resynchronization therapy (n=64968). Intervention: CRT implantation in contemporary practice (2018-2019) vs. CRT implantation in earlier practice (2010-2011). Primary outcome: Total mortality (HR 0.72, 95% CI 0.69-0.76, p=<0.001).

Q: What does this research mean for the field?

Patients undergoing cardiac resynchronization therapy (CRT) in 2018-2019 had a significantly lower risk of 2-year mortality and heart failure hospitalization compared to those in 2010-2011, despite an increasing burden of patient comorbidities. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Francisco Leyva; Abbasin Zegard; Peysh Patel; Berthold Stegemann; Howard Marshall; Peter Ludman; Joseph de Bono; Giuseppe Boriani; Tian Qiu

doi:10.1093/europace/euad141

June 1, 2023EP EuropaceOpen Access

Improved prognosis after cardiac resynchronization therapy over a decade

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Key result

Contemporary CRT implantation is linked to ~28% lower total mortality versus earlier practice.

HR 0.72
95% CI 0.69-0.76
P<0.001
n=64,968

Why the study?

With increased delivery of cardiac resynchronization therapy for heart failure over the past decade, it was unknown whether clinical outcomes after implantation have changed across an entire public healthcare system.

Does contemporary CRT implantation (2018-2019) improve total mortality compared to earlier era CRT implantation (2010-2011) in patients with heart failure?

Study Design

Type

Observational (n=64,968)

Multicenter

Yes

Structured PICO

Does contemporary CRT implantation (2018-2019) improve total mortality compared to earlier era CRT implantation (2010-2011) in patients with heart failure?

P

Population

64,968 consecutive adults with heart failure undergoing CRT implantation in England, mean age 71.4 years, followed for a median of 4.54 years.

E

Exposure

Cardiac resynchronization therapy (CRT) implantation in the later era (2018-2019 cohort)

C

Comparator

Cardiac resynchronization therapy (CRT) implantation in the earlier era (2010-2011 cohort)

O

Outcome

Total mortalityhard clinical

Main Result

Hazard Ratio: 0.72 (95% CI 0.69–0.76)

Absolute Event Rate: 14.2% vs 18.4%

p-value: p=<0.001

Clinical outcomes after CRT implantation have significantly improved over the last decade at a national healthcare system level, despite a sicker and more comorbid patient population.

Limitations

Retrospective, observational study based on administrative datasets
Limited clinical details (no data on left ventricular function, ECG variables, or medications)
Assumption of ischemic etiology of heart failure based on previous coronary artery disease coding
Inability to exclude the possibility that improved treatment of comorbidities or HF medications contributed to the improved outcomes
Retrospective observational design based on administrative data
Lack of granular clinical data (LVEF, ECG variables, medications)
Cannot definitively establish causality vs secular trends in HF management
Relies on ICD coding for comorbidities and etiology

Implication

Contemporary CRT was associated with lower mortality despite rising comorbidities; extends prior data but leaves open drivers of improvement.

Abstract

AIMS: The past decade has seen an increased delivery of cardiac resynchronization therapy (CRT) for patients with heart failure (HF). We explored whether clinical outcomes after CRT have changed from the perspective of an entire public healthcare system. METHODS AND RESULTS: A national database covering the population of England (56.3 million in 2019) was used to explore clinical outcomes after CRT from 2010 to 2019. A total of 64 698 consecutive patients (age 71.4 ± 11.7 years; 74.8% male) underwent CRT-defibrillation [n = 32 313 (49.7%)] or CRT-pacing [n = 32 655 (50.3%)] implantation. From 2010-2011 to 2018-2019, there was a 76% increase in CRT implantations. During the same period, the proportion of patients with hypertension (59.6-73.4%), diabetes (26.5-30.8%), and chronic kidney disease (8.62-22.5%) increased, as did the Charlson comorbidity index (CCI ≥ 3 from 20.0% to 25.1%) (all P < 0.001). Total mortality decreased at 30 days (1.43-1.09%) and 1 year (9.51-8.13%) after implantation (both P < 0.001). At 2 years, total mortality [hazard ratio (HR): 0.72; 95% confidence interval (CI) 0.69-0.76] and total mortality or HF hospitalization (HR: 0.59; 95% CI 0.57-0.62) decreased from 2010-2011 to 2018-2019, after correction for age, race, sex, device type (CRT-defibrillation or pacing), comorbidities (hypertension, diabetes, chronic kidney disease, and myocardial infarction), or the CCI (HR: 0.81; 95% CI 0.77-0.85). CONCLUSIONS: From the perspective of an entire public health system, survival has improved and HF hospitalizations have decreased after CRT implantation over the past decade. This prognostic improvement has occurred despite an increasing comorbidity burden.

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Published by EP Europace · CC BY-NC

Cite This Study

Leyva et al. (2023) conducted an observational in Heart failure requiring cardiac resynchronization therapy (n=64,968). CRT implantation in contemporary practice (2018-2019) vs. CRT implantation in earlier practice (2010-2011) was evaluated on Total mortality (HR 0.72, 95% CI 0.69-0.76, p=<0.001). CRT implantation in contemporary practice (2018-2019) was associated with a significantly reduced risk of total mortality compared to earlier practice (2010-2011) (HR 0.72, 95% CI 0.69-0.76), despite an increasing comorbidity burden.

synapsesocial.com/papers/6a208dde6832c8bccb4d1a25 https://doi.org/10.1093/europace/euad141