Key result
In patients with non-ischemic heart failure, adding a defibrillator to cardiac resynchronization therapy provided a long-term mortality benefit in those with a low Goldenberg risk score (HR 0.68), but not in high-risk patients.
Why the study?
Primary prevention of SCD in non-ischemic HF patients remains debated at CRT implantation, requiring individual risk assessment to determine who benefits from adding an ICD.
Does CRT-D improve survival compared to CRT-P in non-ischemic heart failure patients when stratified by the Goldenberg risk score?
Cohort (n=667)
No
Does CRT-D improve survival compared to CRT-P in non-ischemic heart failure patients when stratified by the Goldenberg risk score?
In non-ischemic heart failure patients, adding an ICD to CRT provides a long-term mortality benefit primarily in those with a low Goldenberg risk score (<3).
Answers are grounded in this paper and cite their sources.
Low Goldenberg score may identify non-ischemic CRT patients for added ICD benefit; leaves open need for randomized confirmation before practice change.
Aims Primary prevention of sudden cardiac death (SCD) in non-ischemic heart failure (HF) patients remains a topic of debate at cardiac resynchronization therapy (CRT) implantation requiring individual risk assessment. Using the Goldenberg SCD risk score, we aimed to predict, which non-ischemic HF patients will benefit from the addition of an implantable cardioverter defibrillator (ICD) to CRT at long-term. Methods Between 2000 and 2018 non-ischemic HF patients undergoing CRT implantation were collected into our retrospective registry. The Goldenberg risk score (GRS) was calculated by the presence of atrial fibrillation, New York Heat Association (NYHA) class > 2, age > 70 years, blood urea nitrogen > 26 mg/dl and QRS > 120 ms. The primary endpoint was all-cause mortality, heart transplantation or left ventricular assist device implantation. Results From 667 patients, 347 (52%) underwent cardiac resynchronization therapy-pacemaker (CRT-P), 320 (48%) cardiac resynchronization therapy-defibrillator (CRT-D) implantations. During the median follow up time of 4.3 years, 306 (46%) patients reached the primary endpoint (CRT-D 37% vs. CRT-P 63%; p < 0.001). CRT-D patients were younger (64 vs. 69 years; p < 0.001), infrequently females (26 vs. 39%; p < 0.001), and had a lower ejection fraction (27 vs. 29%; p < 0.01) compared to CRT-P patients. After GRS calculation, patients were dichotomized by low (< 3) and high (≥ 3) scores. CRT-D patients with low GRS showed a mortality benefit compared to CRT-P (HR 0.68; 95% CI 0.48–0.96; p = 0.03), high-risk patients did not (HR 0.84; 95% CI 0.62–1.13; p = 0.26). Conclusion In our non-ischemic cohort, patients with low GRS showed a clear long-term mortality benefit by adding ICD to CRT, however, in high-risk patients no further benefit could be observed.
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Merkel et al. (2023) conducted a cohort in Non-ischemic heart failure (n=667). Cardiac resynchronization therapy-defibrillator (CRT-D) vs. Cardiac resynchronization therapy-pacemaker (CRT-P) was evaluated on Composite of all-cause mortality, heart transplantation, or left ventricular assist device implantation (HR 0.73, 95% CI 0.58-0.92, p=0.01). In patients with non-ischemic heart failure, adding a defibrillator to cardiac resynchronization therapy provided a long-term mortality benefit in those with a low Goldenberg risk score (HR 0.68), but not in high-risk patients.
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