Usefulness of the CRT-SCORE for Shared Decision Making in Cardiac Resynchronization Therapy in Patients With a Left Ventricular Ejection Fraction of ≤35%

Abstract

Individualized estimation of prognosis after cardiac resynchronization therapy (CRT) remains challenging. Our aim was to develop a multiparametric prognostic risk score (CRT-SCORE) that could be used for patient-specific clinical shared decision making about CRT implantation. The CRT-SCORE was derived from an ongoing CRT registry, including 1,053 consecutive patients (age 67 ± 10 years, 76% male). Using preimplantation variables, 100 multiple imputed datasets were generated for model calibration. Based on multivariate Cox regression models, cross-validated linear prognostic scores were calculated, as well as survival fractions at 1 and 5 years. Specifically, the CRT-SCORE was calculated using atrioventricular junction ablation, age, gender, etiology, New York Heart Association class, diabetes, hemoglobin level, renal function, left bundle branch block, QRS duration, atrial fibrillation, left ventricular systolic and diastolic functions, and mitral regurgitation, and showed a good discriminative ability (areas under the curve 0.773 at 1 year and 0.748 at 5 years). During the long-term follow-up (median 60 months, interquartile range 31 to 85), all-cause mortality was observed in 494 (47%) patients. Based on the distribution of the CRT-SCORE, lower- and higher-risk patient groups were identified. Estimated mean survival rates of 98% at 1 year and 92% at 5 years were observed in the lowest 5% risk group (L5 CRT-SCORE: -4.42 to -1.60), whereas the highest 5% risk group (H5 CRT-SCORE: 1.44 to 2.89) showed poor survival rates: 78% at 1 year and 22% at 5 years. In conclusion, the CRT-SCORE allows accurate prediction of 1- and 5-year survival rates after CRT using readily available and CRT-specific clinical, electrocardiographic, and echocardiographic parameters. The model may assist clinicians in counseling patients and in decision making.

Risk stratification in patients with cardiac resynchronisation therapy: the AL-FINE CRT risk score

“…This might reflect the inaccuracy of measuring EF by echocardiography [25]. However, in CRT cohorts, the prognostic importance of LVEF was confirmed by several studies [2,5,7,24,26], and our results are concordant with these in this respect. Hypothetically, EF might be prognostically more important in CRT patients due to the fact that in patients with a low EF, the magnitude of correctable dyssynchrony might be smaller, resulting in a markedly worse response to CRT.…”

“…The impact of the NYHA functional class on mortality in CRT patients was less thoroughly investigated; however, it can be easily appreciated when mortality in CRT trials that included NYHA class III-IV patients (COMPANION, MIRACLE, CARE-HF) and trials that predominantly included patients in NYHA class I-II (MADIT-CRT, RAFT) is compared. Moreover, in three of the previous CRT scores, NYHA class was the strongest predictor of mortality in multivariate analysis [2,5,24]. Similarly, in the current study the highest assigned NYHA class was on par with the furosemide dose as the strongest predictor of long-term mortality and morbidity.…”

Application of “AL-FINE CRT” risk score before cardiac resynchronisation therapy implantation

“…The presented results support the utility of the AL-FINE CRT model [6,7] and emphasise its importance and application.…”

“…While the presented risk score is useful in predicting the long-term clinical outcome, it has some weaknesses, such as the lack of procedure-related parameters, e.g. the targeted coronary sinus side branch or the activation delays between the right and left ventricular leads, which might also influence the outcome of patients after CRT implantation [5].The presented results support the utility of the AL-FINE CRT model [6,7] and emphasise its importance and application.…”

The VALID‐CRT risk score reliably predicts response and outcome of cardiac resynchronization therapy in a real‐world population

“…The HF‐CRT score, which combined clinical and readily available biomarker data, stratified CRT patients for HF progression and death . The CRT‐SCORE, based on clinical, electrocardiographic, and echocardiographic parameters, accurately predicted 1‐ and 5‐year survival rates after CRT …”