• CARDIAC PROCEDURES AND THERAPY

In heart failure patients with an indication for cardiac resynchronization therapy (CRT) or an implantable cardiac defibrillator (ICD), it remains a difficult clinical decision to choose the optimal device in an individual patient, many of whom do not match the clinical characteristics of patient groups studied in randomized clinical trials. To evaluate the effects of age and comorbidities on the relative effectiveness of different types of implanted electric cardiac devices, Wood and colleagues (see page 1800) performed a meta-analysis, including almost 13,000 patients, comparing the survival benefit of CRT alone, ICD alone, CRT with a pacer (CRT-P) or CRT with a defibrillator (CRT-D). The patients included in these trials had a mean age of 62–65 years, mean left ventricular ejection fraction of 23%, NYHA functional was class II or III in 85–90%, and ischemic disease was present in about 50%. Compared to medical therapy, CRT-D had the greatest effect on mortality with a relative reduction of 42%, compared to 29% with ICD and 28% with CRT-P on unadjusted analysis. In the final adjusted model, the strongest predictors of benefit were QRS duration, left bundle branch block (LBBB) morphology, age and gender.

The main results of this meta-analysis are summarized in a elegant figure by Kramer and colleagues (see …