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

Abstract

BackgroundCardiac implantable electric devices are commonly used to treat heart failure. Little is known about temporal and geographic variation in use of cardiac resynchronization therapy (CRT) devices in usual care settings.Methods and ResultsWe identified new CRT with pacemaker (CRT‐P) or defibrillator generators (CRT‐D) implanted between 2008 and 2013 in the United States from a commercial claims database. For each implant, we characterized prior medication use, comorbidities, and geography. Among 17 780 patients with CRT devices (median age 69, 31% women), CRT‐Ps were a small and increasing share of CRT devices, growing from 12% to 20% in this study period. Compared to CRT‐D recipients, CRT‐P recipients were older (median age 76 versus 67), and more likely to be female (40% versus 30%). Pre‐implant use of β‐blockers and angiotensin‐converting enzyme inhibitors or angiotensin II receptor blockers was low in both CRT‐D (46%) and CRT‐P (31%) patients. The fraction of CRT‐P devices among all new implants varied widely across states. Compared to the increasing national trend, the share of CRT‐P implants was relatively increasing in Kansas and relatively decreasing in Minnesota and Oregon.ConclusionsIn this large, contemporary heart failure population, CRT‐D use dwarfed CRT‐P, though the latter nearly doubled over 6 years. Practice patterns vary substantially across states and over time. Medical therapy appears suboptimal in real‐world practice.

Cardiac Resynchronization Therapy in Older Patients: Age Is Just a Number, and Yet …

“…As the authors note, CRT-D implantation dominates in the United States (US): One recent study of contemporary US CRT utilization based on claims (N = 17,780) found that only 15% of implants were CRT-P, though an increase from 12% to 20% was seen from 2008 to 2013. 16,17 This contrasts to the current study (79% CRT-P in octogenarians) and other reports from Europe illustrating more judicious use of CRT-D systems. 18,19 These observations collectively raise several questions: What matters most to older patients with heart failure?…”

New‐onset left bundle branch block‐associated idiopathic nonischemic cardiomyopathy and time from diagnosis to cardiac resynchronization therapy: The NEOLITH II study

“…Stable GDMT was therefore mandated as background therapy prior to enrollment in device trials. Third, most CRT devices in the United States are implanted with cardioverter‐defibrillator capability . The efficacy of ICD implantation <9 months from initial diagnosis of NICM is not well studied in clinical trials .…”

“…Third, most CRT devices in the United States are implanted with cardioverter-defibrillator capability. 4 The efficacy of ICD implantation <9 months from initial diagnosis of NICM is not well studied in clinical trials. 3 Fourth, data supporting the concept of LBBB-induced cardiomyopathy are recent and limited.…”

“…3 In a study of real-world CRT use in the United States, 85% were CRT-Ds and 15% were CRT-pacemakers (CRT-P). 4 However, shorter times from symptom onset and HF diagnosis to CRT were associated with echocardiographic super-response in two studies that included subjects with both nonischemic and ischemic etiologies and a variety of intraventricular dyssynchrony measurements. 5,6 Timing of CRT is of particular interest in those with idiopathic NICM and left bundle branch block (LBBB), given the possible causative role played by LBBB.…”

“…For nonischemic cardiomyopathy (NICM), one reason for delay may be the underrepresentation of subjects diagnosed <9 months in implantable cardioverter‐defibrillator (ICD) trials . In a study of real‐world CRT use in the United States, 85% were CRT‐Ds and 15% were CRT‐pacemakers (CRT‐P) . However, shorter times from symptom onset and HF diagnosis to CRT were associated with echocardiographic super‐response in two studies that included subjects with both nonischemic and ischemic etiologies and a variety of intraventricular dyssynchrony measurements .…”