Objective To determine the incremental value of implantable cardioverter defibrillators (ICD) in contemporary optimally treated patients with heart failure (HF) undergoing cardiac resynchronisation therapy (CRT).
Methods Consecutive patients with HF undergoing CRT-pacemaker (CRT-P) or CRT-defibrillator (CRT-D) implantation in a single tertiary care centre between October 2008 and August 2015 were retrospectively evaluated. For patients with a primary prevention indication of the CRT-D, no benefit of the ICD was defined as absence of appropriate therapy (device analysis) or lethal ventricular tachyarrhythmias (mode of death analysis) during follow-up.
Results 687 patients (CRT-P/CRT-D; n=361/326) were followed for 38±22 months. CRT-P recipients were older (75.7±9.1 vs 71.8±9.3 years; p<0.001) and had a higher comorbidity burden. Five patients with CRT-P (1%) experienced episodes of sustained ventricular-tachycardia vs 64 (20%) patients with CRT-D (p<0.001). Remote tele-monitoring detected the episodes of sustained ventricular tachycardia in four patients with CRT-P, allowing for elective upgrade to CRT-D. All-cause mortality was higher in patients with CRT-P versus CRT-D (21% vs 12%, p=0.003), even after adjusting for baseline characteristics (HR 2.5; 95% CI 1.36 to 4.60; p=0.003). However, mode of death analysis revealed a predominant non-cardiac mode of death in CRT-P recipients (n=47 (71%) vs n=13 (38%) in CRT-D, p=0.002). Multivariate analysis revealed that age >80 years, New York Heart Association class IV, intolerance to beta-blockers and underlying non-ischaemic cardiomyopathy were independently associated with little incremental value of a primary prevention ICD on top of CRT.
Conclusions The majority of patients with contemporary HF as currently selected for CRT-P exhibit mainly non-cardiac-driven mortality. Weighing risk of ventricular-tachyarrhythmic death versus risk of all-cause mortality helps to address the incremental value of an ICD to CRT-P.
- cardiac resynchronization therapy
- implantable defibrillators
- mortality outcome
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Contributors PM, FHV, MD and WM collected the data. PM and WM designed the research concept. PM wrote the manuscript. PM and WM submitted the work. FHV, PN, MD, DN, HVH, MR-A and WHT critically revised the manuscript and made changes accordingly. All authors had full access to the data. PM and WM take responsibility for the manuscript.
Competing interests None declared.
Patient consent The Ethics Committee/Institutional Review Board does not demand a written informed consent for retrospective analysis.
Ethics approval ZOL genk.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement This manuscript reports on a monocentre retrospective analysis of consecutive patients undergoing cardiac resynchronisation therapy. Numerous variables are collected. Collaboration and data sharing is possible on written request to Dr Pieter Martens.