Timing of cardiac resynchronization therapy implantation

Aims The optimum timing of cardiac resynchronization therapy (CRT) implantation is unknown. We explored long-term outcomes after CRT in relation to the time interval from a first heart failure hospitalization (HFH) to device implantation. .Methods A database covering the population of England (56.3 million in 2019) was used to quantify clinical outcomes after CRT im- and results plantation in relation to first HFHs. From 2010 to 2019, 64 968 patients [age: 71.4 ± 11.7 years; 48 606 (74.8%) male] underwent CRT implantation, 57% in the absence of a previous HFH, 12.9% during the first HFH, and 30.1% after ≥1 HFH. Over 4.54 (2.80–6.71) years [median (interquartile range); 272 989 person-years], the time in years from the first HFH to CRT implantation was associated with a higher risk of total mortality [hazard ratio (HR); 95% confidence intervals (95% CI)] (1.15; 95% CI 1.14–1.16, HFH (HR: 1.26; 95% CI 1.24–1.28), and the combined endpoint of total mortality or HFH (HR: 1.19; 95% CI 1.27–1.20) than CRT in patients with no previous HFHs, after co-variate adjustment. Total mortality (HR: 1.67), HFH (HR: 2.63), and total mortality or HFH (HR: 1.92) (all P < 0.001) were highest in patients undergoing CRT ≥2 years after the first HFH. Conclusion In this study of a healthcare system covering an entire nation, delays from a first HFH to CRT implantation were associated with progressively worse long-term clinical outcomes. The best clinical outcomes were observed in patients with no previous HFH and in those undergoing CRT implantation during the first HFH. Condensed The optimum timing of CRT implantation is unknown. In this study of 64 968 consecutive patients, delays from a first heart abstract failure hospitalization (HFH) to CRT implantation were associated with progressively worse long-term clinical outcomes. Each year from a first HFH to CRT implantation was associated with a 21% higher risk of total mortality and a 34% higher risk of HFH. The best outcomes after CRT were observed in patients with no previous HFHs and in those undergoing implantation during their first HFH. The left upper panel shows the timing (y-axis) and numbers (x-axis) of cardiac resynchronization therapy (CRT) implantations in relation to the timing of first heart failure hospitalizations (HFHs); the right upper panel shows CRT implantations undertaken during a first HFH as a percentage of all implantations, according to year. Patients were regarded as not having had a HFH if this had not occurred within 5 years prior to CRT implantation. The left lower panel shows the Kaplan–Meier survival curve for total mortality. Event rates (per 100 person-years) for the three endpoints according to the timing of CRT implantation in relation to a first HFH are shown in the right lower panel

Long-term clinical outcomes of cardiac resynchronization therapy with or without defibrillation:impact of the aetiology of cardiomyopathy

Background: There is a continuing debate as to whether cardiac resynchronization therapy-defibrillation (CRT-D) is superior to CRT-pacing (CRT-P), particularly in patients with non-ischemic cardiomyopathy (NICM). Objective: We sought to quantify clinical outcomes after primary prevention CRT-D and CRT-P and whether clinical outcomes differ according to the etiology of cardiomyopathy. Methods: Clinical events were quantified in patients undergoing CRT-D (n = 551) or CRT-P (n = 999). Analyses were undertaken in the total study population and in propensity-matched samples. Device choice was governed by clinical guidelines in the United Kingdom. Results: In univariable analyses of the total study population, (maximum follow-up: 16 years; median of 4.7 years (interquartile range [IQR]: 2.4-7.1), CRT-D was associated with a lower total mortality (HR:0.71) and the composite endpoints of total mortality or HF hospitalization (HR:0.72) and total mortality or hospitalization for major adverse cardiac events (MACE; HR:0.71) (all p < 0.001). After propensity-matching (n = 796), CRT-D was associated with a lower total mortality (HR:0.72) and the composite endpoints (all p < 0.01). When further stratified according to etiology, CRT-D was associated with a lower total mortality (HR:0.62), total mortality or HF hospitalization (HR: 0.63) and total mortality or hospitalization for MACE (HR:0.59) (all p < 0.001) in patients with ischaemic cardiomyopathy (ICM). No difference in outcomes between CRT-D and CRT-P emerged in patients with NICM. Conclusions: In this study of real-world clinical practice, CRT-D was superior to CRT-P with respect to total mortality and composite endpoints, independent of known confounders. The benefit of CRT-D was evident in ICM, but not in NICM