Key result
CRT-D shows no long-term survival benefit over CRT-P in nonischemic cardiomyopathy.
Why the study?
With evolving therapy for HFrEF, the benefits of adding a defibrillator in patients undergoing CRT remain unclear, particularly for NICM.
Does cardiac resynchronization therapy with a defibrillator (CRT-D) improve survival compared to CRT with a pacemaker (CRT-P) in patients with nonischemic cardiomyopathy?
Cohort (n=3,965)
Yes
Does cardiac resynchronization therapy with a defibrillator (CRT-D) improve survival compared to CRT with a pacemaker (CRT-P) in patients with nonischemic cardiomyopathy?
Hazard Ratio: 0.9 (95% CI 0.71–1.13)
Absolute Event Rate: 9.21% vs 9.46%
p-value: p=0.34
In patients with nonischemic cardiomyopathy, the addition of a defibrillator to cardiac resynchronization therapy (CRT-D) did not demonstrate a clear survival advantage over CRT-pacemaker (CRT-P).
CRT-D associated with lower mortality than CRT-P in NICM; leaves open whether defibrillator benefit holds in randomized trials.
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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Selvaganesan et al. (2026) conducted a cohort in Nonischemic cardiomyopathy (NICM) (n=3,965). CRT defibrillator (CRT-D) vs. CRT pacemaker (CRT-P) was evaluated on All-cause mortality (HR 0.90, 95% CI 0.71-1.13, p=0.34). In patients with nonischemic cardiomyopathy, a CRT defibrillator compared with a CRT pacemaker did not significantly improve long-term survival (adjusted HR 0.90; 95% CI 0.71-1.13; P=0.34).