Causes-of-death analysis of patients with cardiac resynchronization therapy: an analysis of the CeRtiTuDe cohort study

Abstract

AimsThe choice of resynchronization therapy between with (CRT-D) and without (CRT-P) a defibrillator remains a contentious issue. Cause-of-death analysis among CRT-P, compared with CRT-D, patients could help evaluate the extent to which CRT-P patients would have additionally benefited from a defibrillator in a daily clinical practice.Methods and resultsA total of 1705 consecutive patients implanted with a CRT (CRT-P: 535 and CRT-D: 1170) between 2008 and 2010 were enrolled in CeRtiTuDe, a multicentric prospective follow-up cohort study, with specific adjudication for causes of death at 2 years. Patients with CRT-P compared with CRT-D were older (P < 0.0001), less often male (P < 0.0001), more symptomatic (P = 0.0005), with less coronary artery disease (P = 0.003), wider QRS (P = 0.002), more atrial fibrillation (P < 0.0001), and more co-morbidities (P = 0.04). At 2-year follow-up, the annual overall mortality rate was 83.80 [95% confidence interval (CI) 73.41–94.19] per 1000 person-years. The crude mortality rate among CRT-P patients was double compared with CRT-D (relative risk 2.01, 95% CI 1.56–2.58). In a Cox proportional hazards regression analysis, CRT-P remained associated with increased mortality (hazard ratio 1.54, 95% CI 1.07–2.21, P = 0.0209), although other potential confounders may persist. By cause-of-death analysis, 95% of the excess mortality among CRT-P subjects was related to an increase in non-sudden death.ConclusionWhen compared with CRT-D patients, excess mortality in CRT-P recipients was mainly due to non-sudden death. Our findings suggest that CRT-P patients, as currently selected in routine clinical practice, would not potentially benefit with the addition of a defibrillator.

Cause-of-death analysis in patients with cardiac resynchronization therapy with or without a defibrillator: a systematic review and proportional meta-analysis

“…Patients receiving CRT-D had a mean age in their 60s in all studies, while the mean age of CRT-P patients was in their 70s in eight studies 3,14,27,30,33,37,38,50 . Overall, those receiving CRT-D were younger (65 years vs. 68.2) , more often males (80.3% vs. 72%), had lower NYHA class (60% in NYHA class 2 vs. 88.6%), lower prevalence of atrial fibrillation (21% vs.…”

“…Two-hundred and thirtyseven were retrieved for analysis of titles and abstracts and 49 of these were selected for further analysis of the full-length article. Eighteen were considered eligible for inclusion 3,[9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] .…”

“…Patients receiving CRT-P are in general older, more often of female sex, have more advanced heart failure and comorbidity and are less often on beta-blockers and class III antiarrhythmic drugs. In the CeRtiTuDe cohort study, the higher all-cause mortality rate in CRT-P patients (mean age 75 years) was almost entirely due to much higher number of progressive heart failure related-or non-cardiac deaths, while SCD was only slightly more frequent 3 . The CeRtiTuDe findings illustrate that the benefit of the ICD may dramatically decrease with increasing number of comorbidities to a point where patients may cease to benefit from it 63,64 .…”

“…The CeRtiTuDe cohort study has recently shown that only a very small proportion of the increased mortality seen in CRT-P patients, compared with CRT-D, was actually related to SCD 3 . CRT-D patients have lower all-cause mortality rates, which could be related to differences in patient characteristics and/or the presence of the ICD 4 .…”

Geographic and Temporal Variation in Cardiac Implanted Electric Devices to Treat Heart Failure

“…While some argue that any patient treated with CRT should also receive defibrillator backup,7 others counsel restraint in adding additional device functions 8, 9. A recent cohort study adjudicated cause of death for patients with CRT‐P versus CRT‐D and found that the vast majority of excess mortality in CRT‐P patients was non‐sudden death, weakening the argument for default defibrillator backup 10. Preventing sudden cardiac death with an implantable cardioverter‐defibrillator (ICD) is distinct from improving heart failure symptoms, and not every patient views these as necessarily linked 11.…”