National Trends in the Use of Cardiac Resynchronization Therapy With or Without Implantable Cardioverter-Defibrillator

Abstract

Background Candidates for cardiac resynchronization therapy (CRT) receive either a biventricular pacemaker (CRT-P) or a biventricular pacemaker with an implantable-cardioverter defibrillator (ICD; CRT-D). Optimal device selection remains challenging as the benefit of ICD therapy may not be uniform, particularly in patients at competing risk of non-sudden death. Methods and Results In this serial cross-sectional study using the National Inpatient Sample database, we identified 311,086 admissions associated with CRT implant between 2006-2012. CRT-D was the most common device-type (86.1%), including in patients ≥75 years old with 5 or more Elixhauser comorbidities (75.5%). Multivariate predictors of CRT-D implant included demographic, clinical, and geographic factors: prior ventricular arrhythmia (rate ratio [RR], 1.14; 95% CI, 1.13-1.14), ischemic heart disease (RR, 1.11; 95% CI, 1.10-1.11), male gender (RR, 1.10; 95% CI, 1.09-1.10), black race (RR, 1.06; 95% CI: 1.04-1.07), and Northeast geographic region (RR, 1.06; 95% CI, 1.04-1.09). There was significant inter-hospital variation in the use of CRT-D (10-90 percentile range, 72.9% to 98.0% CRT-D). Conclusions The majority of patients in this contemporary US cohort underwent implantation of CRT-D. Predictors of CRT-D implant included demographic, clinical, and geographic factors. In patient subgroups predicted to have an attenuated benefit from ICD therapy (older adults with multiple comorbidities), CRT-D remained the dominant device type. An improved understanding of the determinants of device selection may aid in decision-making and ultimately better align patient risk with device benefit at the time of CRT implantation.

Survival in Women Versus Men Following Implantation of Pacemakers, Defibrillators, and Cardiac Resynchronization Therapy Devices in a Large, Nationwide Cohort

“…Among defibrillators, the proportion of single‐chamber/dual‐chamber/resynchronization devices was 21%/37%/42%, respectively. Collectively, these characteristics are similar to those noted in national databases inclusive of all manufacturers' devices …”

“…The NCDR does not register these devices. In the National Implant Sample, CRT‐P accounted for 14% of implanted resynchronization devices in 2009, with 58% male proportion and age 75 years (ie, demographics identical to our cohort) . However, this registry lacks postimplant follow‐up data.…”

“…This is notable given that CRT‐P and CRT‐D recipients differ significantly in US practice. CRT‐P patients were more likely to be older, have atrial fibrillation, complete atrioventricular block, and have greater accompanying comorbidities in the National Implant Sample, and were reported to have better superior left ventricular function in the ADVANCE CRT Registry . That survival advantage in women receiving CRT‐P was of similar extent to CRT‐D, despite these baseline differences, may point to a primary sex‐specific difference in CRT effect.…”

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

“…Previous studies of geographic variation in treatment and spending have focused on traditional fee‐for‐service Medicare populations, but the Institute of Medicine has called for more understanding of variation in commercially insured populations, including Medicare Advantage 16. One recent study used the National Inpatient Sample to characterize CRT‐D versus CRT‐P and found significant variation among hospitals 17. We build on these efforts, examining both inpatient and outpatient procedures.…”

“…16 One recent study used the National Inpatient Sample to characterize CRT-D versus CRT-P and found significant variation among hospitals. 17 We build on these efforts, examining both inpatient and outpatient procedures. Thus, we sought to evaluate patients treated with implantable cardiac devices as measured in a large national commercial claims database, focusing on the overall, temporal, and geographic variation in the United States between 2008 and 2013.…”