Cardiac Resynchronization Therapy in Seniors: When are we Too Old to Deserve a Device that Makes us Feel Better and Improves Clinical Outcomes?

This editorial refers to ‘Response to cardiac resynchronization therapy in elderly patients (≥70 years) and octogenarians’, by F.H. Verbrugge et al., published in this issue on pages 203–210. We should tip our hats in gratitude to Verbrugge et al. for providing welcome data that support what most of us knew we knew; CRT also improves symptoms and reduces adverse clinical events in patients over 75 years of age.1 It comes as no surprise. One's biology does not undergo a metamorphosis on one's 75th birthday. Part of the reason why these patients are frequently denied therapy stems from the fact that the evidence provided by the large randomized controlled trials demonstrating efficacy excluded these patients; as though advanced age itself is a co-morbidity. However, clinicians are wise, and >30% of the patients implanted in Europe today are indeed over 75 years of age.2 We certainly do not deny these patients adequate pharmacological therapy or conventional pacemakers. Verbrugge et al. report an open, retrospective analysis of 220 consecutive patients who received a CRT device at a single tertiary care centre during 2008–2011. All patients had conventional 1A guideline recommendation and had their device program optimized at a dedicated CRT clinic. Patients were divided into three age categories: <70, 70–79, and ≥80. The improvement in functional class and evidence of reverse remodelling was similar across the age groups. During a mean follow-up of 20 months, apart from a slightly higher annualized mortality rate in the elderly patients, there were no significant differences with regard to clinical outcomes; time to death or first heart failure admission. The demographics of the groups were similar, although the youngest group were more likely to receive a CRT-D, and the older groups had a wider QRS duration, most probably due to more stringent implantation criteria. The current European Society of Cardiology (ESC) guidelines include the statement that patients should be ‘ambulatory and expected to survive >1 year with good functional status’.3 Verbrugge concludes, ‘carefully selected patients with heart failure, irrespective of advanced age, benefit from CRT’. These data would certainly support this conclusion and should encourage investigators to include elderly patients in prospective, randomized clinical trials. It is unlikely that we will ever see a prospective trial, designed to demonstrate non-inferiority in the older patient population, but a rigorous subgroup analysis with an adequate sample size would promote the use of CRT in this large population. An experienced physician evaluates a patient's biological age and estimates their life expectancy based on their history, current health status, and extent of co-morbidity. In making a decision concerning implantation of a CRT, there are two important questions that need to be addressed. The first is does CRT work in the elderly? Unfortunately, we have sparse trial evidence. Only CARE-HF actually included some patients >75 years. However, there were too few patients for any rigorous subset analyses. This is where the study of Verbrugge et al. comes in. Albeit in a rather small, open, retrospective analysis, the findings are consistent and make biological sense. Yes, elderly patients feel better and seem to improve clinically following CRT implantation just as much as a younger cohort. The paper makes good reading and the findings are interpreted both clearly and appropriately. The second question is trickier; is CRT an effective use of resources in the elderly population? We all have limited resources, even in Norway. However, we know that well over 50% of the costs involved in managing the large population with heart failure are related to costs in connection with hospitalization. Also the prevalence of heart failure as well as the incidence of LBBB increases with age.4 A treatment that represents an efficient use of healthcare resources must reduce hospital admissions and shorten hospital stays. In addition, few interventions do that as effectively as CRT, with very low ‘numbers needed to treat’ in order to postpone an adverse clinical event.5 So what do we have to put in the calculation? Devices are expensive; not just the original purchase, but we must also consider the implantation and follow-up costs. However, the substantial, one-off investment must be seen in the context of the potential long-term savings. If the patient's functional status can be improved by CRT, they will remain active and productive longer, may require less intensive outpatient care, need less intensive chronic pharmacological therapy, and should spend less time in hospital. In contrast, denying device treatment in well-selected patients has consequences and may lead to a substantial annual financial burden; with increasing costs for drugs, outpatient care, and more frequent hospitalization. We have to evaluate costs during long-term chronic therapy. It is estimated that a patient needs to live for ∼4 years after CRT implantation to break even in costs.6 Now that is both good medicine and sensible economics. Another issue that deserves attention concerns the choice of device in elderly patients with heart failure. Perhaps the Swedes have got it right. In a recent report, the ratio of CRT-P vs. CRT-D implantation in Sweden was 1.8, whereas in Germany it was 0.2.7 This might be especially appropriate in the elderly population in that the defibrillator component is expensive and the indication may well be weaker in a population with a shorter long-term prognosis. In the report of Verbrugge et al., we see that the younger patients more often received a CRT-D. Interestingly, there were only two documented arrhythmia deaths in the entire cohort during follow-up. Over half the patients died due to progressive pump failure. However, ultimately, it comes down to a clinical decision in designing a treatment strategy in elderly patients. Usually there is little disagreement concerning the indication for the device. If one is restrictive, and only evaluates symptomatic patients with a typical left bundle branch pattern, a wide QRS complex, without major co-morbidity (i.e. a strong likelihood of a favourable response), then the indication is strong. However, it is the contraindications that dominate the decision-making in elderly patients. Certainly the prevalence of major co-morbidity increases with age and the aetiology is more frequently ischaemic. Renal and pulmonary function must be carefully evaluated. Imaging studies to detect extensive scar should be performed. Patients' functional status should be assessed thoroughly and compliance issues should be addressed. However, the bottom line is not rocket science and we must distinguish between chronology and biology. Your life expectancy is determined by the time from the present until the time of your death; not the time from your birth to the present. There are plenty of vigorous octogenarians out there with heart failure, LBBB, and a longer life expectancy than many much younger patients. We must provide equal opportunity to elderly patients with great expectations when we consider the potential benefit of implanting a device. Conflict of interest: none declared.