Cause-of-death analysis in patients with cardiac resynchronization therapy with or without a defibrillator: a systematic review and proportional meta-analysis

Barra, Sérgio; Providência, Rui; Duehmke, Rudolf; Bovéda, Serge; Begley, David; Grace, Andrew A.; Narayanan, Kumar; Tang, Anthony; Marijon, Éloi; Agarwal, Sharad

doi:10.1093/europace/eux094

Cited by 16 publications

(10 citation statements)

References 65 publications

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“…Partly in line with our results, a recent meta-analysis of Barra et al [28], which included 18,874 patients from 44 studies and, demonstrated that CRT-D recipients were more often male, were younger, had less severe symptoms, less often experienced atrial fibrillation, were more often diagnosed with ischaemic heart disease, and more often received b-blocker therapy compared to CRT-P patients. The mortality rate was approximately twofold higher in CRT-P recipients, while sudden cardiac death was more prevalent in men, patients with ischaemic cardiomyopathy, and patients with severe HF symptoms (≥ NYHA class III).…”

Section: The Decision Between Crt-p Vs Crt-dsupporting

confidence: 91%

Cardiac resynchronisation therapy: current benefits and pitfalls

et al. 2018

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Cardiac resynchronisation therapy (CRT) has been shown to reduce all-cause mortality, heart failure events, and symptoms while improving exercise capacity and quality of life. Nevertheless, despite a large number of multicentre randomised trials and clear evidence confirming the above, there is still a higher number of patients who fail to develop reverse remodelling. In order to select the optimal patient population, the current European Society of Cardiology guidelines recommend a simultaneous evaluation of QRS morphology and width. However, based on recent data, QRS width itself is a less accurate parameter in the prediction of the outcome, as compared to QRS morphology. Furthermore, the baseline left ventricular (LV) ejection fraction (LVEF), which is also an known criterion for selecting CRT candidates (partly applied due to cost-benefit reasons), can be misleading. Data showed that patients with LVEF > 35% might also benefit from this type of treatment. Thus, LVEF should be evaluated less rigorously when screening patients for resynchronisation therapy. While the subsequent beneficial response to CRT is multifactorial, procedure-related parameters, such as LV lead position, are also crucial. The first data released recently confirmed the previous empiric clinical experience indicating that the LV lead should be implanted into the lateral or posterior coronary sinus side branch. This location was associated with a better long-term clinical outcome in terms of death and heart failure events. Some issues related to CRT are awaiting further clarification, such as the choice of the type of the implanted device (pacemaker or defibrillator) or the decision about CRT device upgrade. This review discusses the current evidence regarding the above, focusing on the questions that should be handled with caution or require clarification.

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Section: The Decision Between Crt-p Vs Crt-dsupporting

confidence: 91%

Cardiac resynchronisation therapy: current benefits and pitfalls

et al. 2018

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“…Responders, especially superresponders to CRT, are at relatively lower risk of long-term cardiac mortality (3). Whether the primary prevention implantable cardioverter-defibrillator (ICD) improves outcomes over and above CRT is a matter of ongoing debate (4)(5)(6)(7), with the recent CeRtiTuDe cohort study revealing that the majority of the excess mortality among CRT-Pacemaker (CRT-P) subjects at 2-year follow-up is related to an increase in non-SCD (8).…”

Section: Introductionmentioning

confidence: 99%

Very long-term survival and late sudden cardiac death in cardiac resynchronization therapy patients

Barra

Duehmke

Providência

et al. 2019

European Heart Journal

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Aims The very long-term outcome of patients who survive the first few years after receiving cardiac resynchronization therapy (CRT) has not been well described thus far. We aimed to provide long-term outcomes, especially with regard to the occurrence of sudden cardiac death (SCD), in CRT patients without (CRT-P) and with defibrillator (CRT-D). Methods and results A total of 1775 patients, with ischaemic or non-ischaemic dilated cardiomyopathy, who were alive 5 years after CRT implantation, were enrolled in this multicentre European observational cohort study. Overall long-term mortality rates and specific causes of death were assessed, with a focus on late SCD. Over a mean follow-up of 30 months (interquartile range 10–42 months) beyond the first 5 years, we observed 473 deaths. The annual age-standardized mortality rates of CRT-D and CRT-P patients were 40.4 [95% confidence interval (CI) 35.3–45.5] and 97.2 (95% CI 85.5–109.9) per 1000 patient-years, respectively. The adjusted hazard ratio (HR) for all-cause mortality was 0.99 (95% CI 0.79–1.22). Twenty-nine patients in total died of late SCD (14 with CRT-P, 15 with CRT-D), corresponding to 6.1% of all causes of death in both device groups. Specific annual SCD rates were 8.5 and 5.8 per 1000 patient-years in CRT-P and CRT-D patients, respectively, with no significant difference between groups (adjusted HR 1.0, 95% CI 0.45–2.44). Death due to progressive heart failure represented the principal cause of death (42.8% in CRT-P patients and 52.6% among CRT-D recipients), whereas approximately one-third of deaths in both device groups were due to non-cardiovascular death. Conclusion In this first description of very long-term outcomes among CRT recipients, progressive heart failure death still represented the most frequent cause of death in patients surviving the first 5 years after CRT implant. In contrast, SCD represents a very low proportion of late mortality irrespective of the presence of a defibrillator.

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“…We chose the analysis of Woods et al [12] because they were the only ones who performed a network meta-analysis of RCTs with individual patient data of CRT-D, CRT-P, OMT and ICD trials. More recent meta-analyses such as Barra et al [13] have not included other relevant RCTs. Input parameters for the transition probabilities and device longevity calculations are based on single RCTs used by six meta-analyses [11][12][13][22][23][24].…”

Section: Model Parametersmentioning

confidence: 99%

“…More recent meta-analyses such as Barra et al [13] have not included other relevant RCTs. Input parameters for the transition probabilities and device longevity calculations are based on single RCTs used by six meta-analyses [11][12][13][22][23][24]. Two additional references [9,25] were found by literature search via Pub-Med.…”

Section: Model Parametersmentioning

confidence: 99%

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Cardiac Resynchronisation Therapy in Patients with Moderate to Severe Heart Failure in Germany: A Cost-Utility Analysis of the Additional Defibrillator

Hadwiger

Frielitz

Eisemann

et al. 2020

Appl Health Econ Health Policy

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Background Cardiac resynchronisation therapy (CRT) is a well-established form of treatment for patients with heart failure and cardiac dyssynchrony. There are two different types of CRT devices: the biventricular pacemaker (CRT-P) and the biventricular defibrillator (CRT-D). The latter is more complex but also more expensive. For the majority of patients who are eligible for CRT, both devices are appropriate according to current guidelines. The purpose of this study was to conduct a cost-utility analysis for CRT-D compared to CRT-P from a German payer's perspective. Methods A cohort Markov-model was developed to assess average costs and quality-adjusted life-years (QALY) for CRT-D and CRT-P. The model consisted of six stages: one for the device implementation, one for the absorbing state death, and two stages ("Stable" and "Hospital") for either a CRT device or medical therapy. The time horizon was 20 years. Deterministic and probabilistic sensitivity analyses and scenario analyses were conducted. Results The incremental cost-effectiveness ratio (ICER) of CRT-D compared with CRT-P was €24,659 per additional QALY gained. In deterministic sensitivity analysis, the survival advantage of CRT-D to CRT-P was the most influential input parameter. In the probabilistic sensitivity analysis 96% of the simulated cases were more effective but also more costly. Conclusions Therapy with CRT-D compared to CRT-P resulted in an additional gain of QALYs, but was more expensive. In addition, the ICER was subject to uncertainty, especially due to the uncertainty in the survival benefit. A randomised controlled trial and subgroup analyses would be desirable to further inform decision making.

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Cause-of-death analysis in patients with cardiac resynchronization therapy with or without a defibrillator: a systematic review and proportional meta-analysis

Abstract: Background: The additional benefit of a defibrillator in cardiac resynchronization therapy

Cited by 16 publications

References 65 publications

Cardiac resynchronisation therapy: current benefits and pitfalls

Cardiac resynchronisation therapy: current benefits and pitfalls

Very long-term survival and late sudden cardiac death in cardiac resynchronization therapy patients

Cardiac Resynchronisation Therapy in Patients with Moderate to Severe Heart Failure in Germany: A Cost-Utility Analysis of the Additional Defibrillator

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