Use of Cardiac Resynchronization Therapy in Patients Hospitalized With Heart Failure

Abstract

Background-The frequency and characterization of patients receiving cardiac resynchronization therapy (CRT) are largely unknown since the publication of pivotal clinical trials and subsequent incorporation of CRT into the American College of Cardiology/American Heart Association guidelines for heart failure. Methods and Results-We analyzed 33 898 patients admitted from January 2005 through September 2007 to 228 hospitals participating in the American Heart Association's Get With the Guidelines-Heart Failure program. There were 4201 patients (12.4%) discharged alive with CRT, including 811 new implants. Patients discharged with CRT were older (median age, 75 versus 72 years) and had lower median left ventricular ejection fraction (30% versus 38%), more frequent ischemic cardiomyopathy (58% versus 45%), more history of atrial fibrillation (38% versus 27%), and higher rates of ␤-blocker and aldosterone antagonist use (PϽ0.0001 for all) than those without CRT. We found that 4.8% of patients with left ventricular ejection fraction Յ35% were discharged with a new CRT implant, which varied greatly by hospital. Ten percent of patients discharged with a new CRT implant had a left ventricular ejection fraction Ͼ35%. Major factors associated with lower rates of new CRT placement were treatment in the northeast (odds ratio, 0.40; 95% confidence interval, 0.30 to 0.53), black race (odds ratio, 0.45; 95% confidence interval, 0.36 to 0.57), increasing left ventricular ejection fraction per 10% (odds ratio, 0.56; 95% confidence interval, 0.52 to 0.60), and increasing age per 10 years in those Ͼ70 years of age (odds ratio, 0.56; 95% confidence interval, 0.48 to 0.65). Conclusions-Although CRT is a recent evidence-based therapy for heart failure, patterns of use differ significantly from clinical trials and published guidelines. Important variations also exist for CRT therapy based on race, geographic region, comorbidities, and age and need to be addressed through further study and/or quality-of-care initiatives.

Comparison of the Usefulness of Cardiac Resynchronization Therapy in Three Age-Groups (<65, 65-74 and ≥75 Years) (from the InSync/InSync ICD Italian Registry)

“…In an outpatient population with LVEF Յ35%, the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE-HF) showed that older subjects, particularly older women, were significantly less likely to receive guideline-recommended CHF therapies. 19 The results of the American Heart Association's Get With the Guidelines-Heart Failure (GWTG-HF) program, extending the observation to devices, further supported this evidence, demonstrating also that women had a lower probability than men to receive CRT 20 and implantable cardioverter-defibrillators. 21 In our study, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and ␤ blockers were significantly underused, particularly at advanced age.…”

Improving Evidence-Based Care for Heart Failure in Outpatient Cardiology Practices

“…Other studies have suggested very little change in the use of these 3 therapies for HF from 2005 to 2008, making it less likely that the improvements observed were a result of secular trends. 6,7,16 Although the baseline rates of ␤-blocker use were reasonably high, there was still significant improvement at 24 Table 3.…”

“…Other studies have suggested very little change in the use of these 3 therapies for HF from 2005 to 2008, making it less likely that the improvements observed were a result of secular trends. 6,7,16 Although the baseline rates of ␤-blocker use were reasonably high, there was still significant improvement at 24 Those quality measures with lower baseline use showed greater absolute and relative improvement over time. These findings may reflect a greater effort to improve those measures with the best opportunities to improve, a ceiling effect on measures with higher levels of conformity, or other factors.…”

“…2 Despite extensive clinical trial evidence and recommendations in national guidelines, prior studies have demonstrated that treatment guidelines are adopted slowly, are applied inconsistently, and thus often fail to lead to improvements in patient care quality and outcomes. [3][4][5][6][7][8][9] For hospitalized HF patients and outpatients, gaps, variations, and disparities between evidence-based guideline recommendations and actual treatments provided have been documented. [3][4][5][6][7][8][9] New, more effective approaches to improve the use of evidence-based, guideline-recommended therapies for HF are needed for each healthcare setting in which these patients are encountered.…”

Cardiac Resynchronization Therapy for Heart Failure

“…2 Although ongoing trials continue to test the efficacy and safety of CRT in patient groups who were underrepresented or excluded from prior trials, the CRT evidence base is evolving and following the well-established pattern of investigation for technological advances in which health services researchers follow the clinical trialists into an area to evaluate the uptake, effectiveness, and safety of new technologies when deployed in routine clinical practice. As a first step in this process, the study by Piccini and colleagues 3 in this week's Circulation examines who is, and who is not, receiving CRT in routine clinical practice.…”