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Original article
Individual patient data network meta-analysis of mortality effects of implantable cardiac devices
  1. B Woods1,2,
  2. N Hawkins2,3,
  3. S Mealing2,
  4. A Sutton4,
  5. W T Abraham5,
  6. J F Beshai6,
  7. H Klein7,
  8. M Sculpher1,2,
  9. C J Plummer8,
  10. M R Cowie9
  1. 1Centre for Health Economics, University of York, York, UK
  2. 2Department of Health Economics, ICON Clinical Research, Oxford, UK
  3. 3Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
  4. 4Department of Health Sciences, University of Leicester, Leicester, UK
  5. 5Ohio State University Medical Centre, Ohio, USA
  6. 6Mayo Clinic, Phoenix, Arizona, USA
  7. 7University of Rochester, New York, USA
  8. 8Freeman Hospital, Newcastle upon Tyne, UK
  9. 9Imperial College London (Royal Brompton Hospital), London, UK
  1. Correspondence to Beth Woods, Centre for Health Economics, University of York, Heslington, York YO10 5DD, UK; Beth.woods{at}york.ac.uk

Abstract

Objective Implantable cardioverter defibrillators (ICD), cardiac resynchronisation therapy pacemakers (CRT-P) and the combination therapy (CRT-D) have been shown to reduce all-cause mortality compared with medical therapy alone in patients with heart failure and reduced EF. Our aim was to synthesise data from major randomised controlled trials to estimate the comparative mortality effects of these devices and how these vary according to patients’ characteristics.

Methods Data from 13 randomised trials (12 638 patients) were provided by medical technology companies. Individual patient data were synthesised using network meta-analysis.

Results Unadjusted analyses found CRT-D to be the most effective treatment (reduction in rate of death vs medical therapy: 42% (95% credible interval: 32–50%), followed by ICD (29% (20–37%)) and CRT-P (28% (15–40%)). CRT-D reduced mortality compared with CRT-P (19% (1–33%)) and ICD (18% (7–28%)). QRS duration, left bundle branch block (LBBB) morphology, age and gender were included as predictors of benefit in the final adjusted model. In this model, CRT-D reduced mortality in all subgroups (range: 53% (34–66%) to 28% (−1% to 49%)). Patients with QRS duration ≥150 ms, LBBB morphology and female gender benefited more from CRT-P and CRT-D. Men and those <60 years benefited more from ICD.

Conclusions These data provide estimates for the mortality benefits of device therapy conditional upon multiple patient characteristics. They can be used to estimate an individual patient's expected relative benefit and thus inform shared decision making. Clinical guidelines should discuss age and gender as predictors of device benefits.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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