Key result
In heart failure patients with a narrow QRS complex, CRT=ON vs CRT=OFF showed a signal for less harm in those with diabetes (HR 0.86; 95% CI 0.58-1.27) compared to those without (HR 1.58; P-int=0.041).
Why the study?
Does cardiac resynchronization therapy affect outcomes differently in heart failure patients with narrow QRS and dyssynchrony based on the presence of diabetes?
RCT
Does cardiac resynchronization therapy affect outcomes differently in heart failure patients with narrow QRS and dyssynchrony based on the presence of diabetes?
Hazard Ratio: 0.86 (95% CI 0.58–1.27)
Absolute Event Rate: 31.4% vs 34%
p-value: p=0.041 for interaction
In heart failure patients with narrow QRS and dyssynchrony, the harm associated with cardiac resynchronization therapy appears attenuated in those with concomitant diabetes compared to those without.
CRT decisions in narrow-QRS HF should remain diabetes-independent; this observational interaction is hypothesis-generating and needs prospective confirmation.
AIMS: As patients with heart failure (HF) and concomitant diabetes carry a poor prognosis, this post-hoc subgroup analysis aimed to compare the outcomes of patients with and without diabetes randomized in the Echocardiography Guided Cardiac Resynchronization Therapy (EchoCRT) study. METHODS AND RESULTS: EchoCRT randomized patients with a QRS duration <130 ms and echocardiographic evidence of left ventricular dyssynchrony to CRT turned on (CRT=ON) vs. off (CRT=OFF) following device implantation. At study entry, 328 patients (40.5%) had diabetes. The primary outcome (all-cause death or first hospitalization for worsening HF) occurred more frequently in patients with than without diabetes (32.6% vs. 23%, P = 0.003). A significant treatment interaction was observed for the primary outcome indicating a higher risk for CRT=ON vs. CRT-OFF in patients without [26.5% vs. 19.8%, hazard ratio (HR) 1.58, 95% confidence interval (CI) 1.08-2.31] vs. with diabetes (31.4% vs. 34%; HR 0.86, 95% CI 0.58-1.27; P for interaction 0.041). This effect was mainly driven by a lower rate in HF hospitalizations, but was only of borderline significance after multivariate adjustment (P = 0.063). The most pronounced effect was observed in patients with non-ischaemic cardiomyopathy, where a significantly reduced risk of reaching the primary endpoint for CRT=ON vs. CRT-OFF was observed in patients with (HR 0.27, P = 0.003) vs. patients without diabetes (HR 1.79, P = 0.038; P for interaction 0.005). No treatment interaction by diabetes diagnosis was found for mortality endpoints. CONCLUSION: In EchoCRT, HF patients with a narrow QRS complex and coexisting diabetes demonstrated a signal for less harm caused by CRT compared with patients without diabetes, which was driven by differences in hospitalizations owing to HF.
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Nägele et al. (2016) conducted an RCT in Heart failure with concomitant diabetes. Cardiac Resynchronization Therapy (CRT=ON) vs. CRT turned off (CRT=OFF) was evaluated on All-cause death or first hospitalization for worsening HF (HR 0.86, 95% CI 0.58-1.27, p=0.041 for interaction). In heart failure patients with a narrow QRS complex, CRT=ON vs CRT=OFF showed a signal for less harm in those with diabetes (HR 0.86; 95% CI 0.58-1.27) compared to those without (HR 1.58; P-int=0.041).
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