Key result
A clinical decision tool identified a subgroup of CRT patients with 0-1 risk factors for appropriate therapy and ≥3 risk factors for HF hospitalization who were more likely to die prior to receiving appropriate ICD therapy.
Observational (n=305)
Yes
Hazard Ratio: 2.2 (95% CI 1.3–3.6)
p-value: p=0.002
Clinical and biomarker data can risk-stratify primary prevention CRT-D recipients to identify subgroups at high risk for HF progression but low risk for ventricular arrhythmias, who may benefit more from CRT-P rather than CRT-D.
May support CRT-P preference in low-arrhythmia-risk CRT patients; hypothesis-generating and requires randomized confirmation.
BACKGROUND: Cardiac resynchronization therapy (CRT) devices reduce mortality through pacing-induced cardiac resynchronization and implantable cardioverter defibrillator (ICD) therapy for ventricular arrhythmias (VAs). Whether certain factors can predict if patients will benefit more from implantation of CRT pacemakers (CRT-P) or CRT defibrillators (CRT-D) remains unclear. METHODS AND RESULTS: We followed 305 primary prevention CRT-D recipients for the two primary outcomes of HF hospitalization and ICD therapy for VAs. Serum biomarkers, electrocardiographic and clinical variables were collected prior to implant. Multivariable analysis using Cox-proportional hazards model was used to fit the final models. Among 282 patients with follow-up outcome data, 75 (26.6%) were hospitalized for HF and 31 (11%) received appropriate ICD therapy. Independent predictors of HF hospitalization were atrial fibrillation (HR = 1.8 (1.1,2.9)), NYHA class III/IV (HR = 2.2 (1.3,3.6)), ejection fraction <20% (HR = 1.7 (1.1,2.7)), HS-IL6 >4.03pg/ml (HR = 1.7 (1.1,2.9)) and hemoglobin (<12g/dl) (HR = 2.2 (1.3,3.6)). Independent predictors of appropriate therapy included BUN >20mg/dL (HR = 3.0 (1.3,7.1)), HS-CRP >9.42mg/L (HR = 2.3 (1.1,4.7)), no beta blocker therapy (HR = 3.2 (1.4,7.1)) and hematocrit ≥38% (HR = 2.7 (1.03,7.0)). Patients with 0-1 risk factors for appropriate therapy (IR 1 per 100 person-years) and ≥3 risk factors for HF hospitalization (IR 23 per 100-person-years) were more likely to die prior to receiving an appropriate ICD therapy. CONCLUSIONS: Clinical and biomarker data can risk stratify CRT patients for HF progression and VAs. These findings may help characterize subgroups of patients that may benefit more from the use of CRT-P vs. CRT-D systems. TRIAL REGISTRATION: ClinicalTrials.gov NCT00733590.
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Nauffal et al. (2017) conducted an observational in Heart failure with depressed ejection fraction (n=305). NYHA class III/IV vs. NYHA class I/II was evaluated on Heart failure hospitalization (HR 2.2, 95% CI 1.3-3.6, p=0.002). A clinical decision tool identified a subgroup of CRT patients with 0-1 risk factors for appropriate therapy and ≥3 risk factors for HF hospitalization who were more likely to die prior to receiving appropriate ICD therapy.
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