Prescription of Guideline-Recommended Implantable Cardioverter Defibrillator and Cardiac Resynchronization Therapy Among Patients Hospitalized With Heart Failure and Varying Degrees of Renal Function

Abstract

Implantable cardioverter defibrillators(ICD) and cardiac resynchronization therapy (CRT) reduce mortality in many patients with heart failure(HF), but the current use and effectiveness of ICD/CRT in patients with chronic kidney disease(CKD) are uncertain. We examined associations between kidney function and guideline-recommended prescription of ICD/CRT in the Get With The Guidelines-Heart Failure registry, a performance improvement program for hospitalized HF patients. We compared differences in ICD and CRT prescription between the following categories of estimated glomerular filtration rate(eGFR) (mL/min/1.73 m2): ≥60, 59–30, <30, and dialysis-dependent. From 2008 through 2014, 26,286 patients were eligible for ICD or CRT, and 16,123(61%) had an eGFR<60. De novo ICD and CRT prescription in this group was low at 45% and 30.5%, respectively. Compared to patients with eGFR≥60, patients with eGFR30–59 were more likely to receive an ICD (adjusted odds ratio[aOR]=1.08, 95% confidence intervals[CI]1.01–1.14), while dialysis patients were less likely (aOR=0.61, 95%CI 0.5–0.76). Worse kidney function was associated with a decreased likelihood of CRT prescription (aOR=0.97 per 10 mL/min eGFR decrease, p=0.03). During the study period, the likelihood of both ICD and CRT prescription increased over time among CKD patients (ICD aOR=1.12(95%CI 1.07–1.18), CRT aOR=1.14(95%CI 1.06–1.23) per year). Prescription of an ICT/CRT was associated with greater one-year survival in all eGFR groups. In conclusion, there are significant CKD-based differences in prescription of ICD and CRT in HF. However, given the current state of evidence, it is unclear whether or not improved prescription of ICD and CRT in the CKD population will result in improvement in outcomes.

A brief overview of cardiac resynchronization therapy and its current use in clinical practice

“…Contemporary data have also come from the US Get With The Guidelines HF registry, a recent reported analysis mainly focusing on device implantation rates with respect to renal function, which included 310 468 patients with HF hospitalized from 2008 to 2014 . After exclusion of patients with no indication for a device or lack of all the data necessary to establish an indication, logistic or other reasons for not implanting, 26 286 patients were eligible for an ICD or CRT, but only 30% of the CRT candidates were prescribed for CRT device implantation.…”

Future research prioritization in cardiac resynchronization therapy

“…The importance of this gap is further highlighted by the lower implantation rates of CRT among patients with common comorbid conditions. While lower rates could be due to the perceived higher procedural complications and concerns over competing risks of non-cardiac death, the paucity of data and conflicting data on outcomes of CRT in these patients also likely play a role (25). A total of 36 findings for gap #6 demonstrated variable results, mostly suggesting that CRT was beneficial for patients with commonly encountered comorbid conditions such as diabetes mellitus or chronic kidney disease.…”

273Renal function and the long term clinical outcomes of cardiac resynchronization therapy with or without defibrillation

“…Physicians may be tempted to avoid device therapy in patients with renal dysfunction, (20) given reports of poor outcomes and an increased risk of complications. (2) This study shows that after CRT, patients with CKD had a worse prognosis than patients with normal or mildly impaired renal function.…”