Diabetes Mellitus and Outcomes of Cardiac Resynchronization With Implantable Cardioverter-Defibrillator Therapy in Older Patients With Heart Failure

Abstract

Background— Large-scale data on outcomes with cardiac resynchronization therapy with defibrillator in patients with diabetes mellitus are limited. We compared outcomes after cardiac resynchronization therapy with defibrillator implantation among patients with heart failure who have diabetes mellitus versus those without diabetes mellitus. Methods and Results— Survival curves and covariate adjusted hazard ratio (HR) or odds ratio were used to assess the risks for death, readmission, and device-related complications by diabetes mellitus status among 18 428 patients at least 65 years old receiving cardiac resynchronization therapy with defibrillator from the National Cardiovascular Data Registry, implantable cardioverter-defibrillator registry between 2006 and 2009, with up to 3 years of follow-up. Accounting for differences between groups, compared with those without diabetes mellitus (n=11 345), patients with diabetes mellitus (n=7083) had a higher risk of death both at 1 year (HR, 1.16 [95% confidence interval (CI), 1.05–1.29]; P =0.0037) and 3 years (HR, 1.21 [1.14–1.29]; P <0.001) after device implantation and higher risks of all-cause readmission (sub-HR, 1.16 [1.11–1.21] at 1 year; P <0.0001; sub-HR, 1.15 [1.11–1.19] at 3 years; P <0.0001) and heart failure–related readmission (sub-HR, 1.18 [1.09–1.28] at 1 year; P <0.0001; and sub-HR, 1.22 [1.15–1.30] at 3 years; P <0.0001). Device-related complications within 90 days did not differ between those with and without diabetes mellitus (odds ratio: 0.90 [0.77–1.06]; P =0.37). Interactions of age, sex, ischemic cardiomyopathy, renal failure, or QRS duration were not significant. Conclusions— In older patients with heart failure receiving cardiac resynchronization therapy with defibrillator, diabetes mellitus was independently associated with greater risks of death and rehospitalization, but similar risks of procedural complications.

The Impact of Diabetes and Comorbidities on the Outcome of Heart Failure Patients Treated With Cardiac Resynchronization Therapy

“…[12][13][14] It is noteworthy that the response to CRT in terms of reverse ventricular remodeling and improvement in functional status after CRT implantation was found to be independent from most common comorbidities (including diabetes mellitus and CKD), but diabetes mellitus and CKD had an important impact on outcome, with a 3-fold increase in mortality risk. 14 In a real-world long-term registry of around 700 CRT-D patients followed for 4 years, Boriani et al 15 found a 3-year 2 Boriani Diabetes, Comorbidities, and CRT mortality rate similar to that reported by Echouffo-Tcheugui et al 9 Moreover, comorbidities (expressed by the Charlson comorbidity index), as well as age, male sex, advanced NYHA class and implant during unplanned, urgent hospitalization were significant independent predictors of death/cardiac transplant. 15 The impact of diabetes mellitus as a comorbidity on the risk of hospitalizations and HF-related hospitalizations after CRT-D implantation is evident in the report by Echouffo-Tcheugui et al 9 The assessment of freedom from first rehospitalization, as done in this report, has some limitations in quantifying patient outcome.…”

“…14 In a real-world long-term registry of around 700 CRT-D patients followed for 4 years, Boriani et al 15 found a 3-year 2 Boriani Diabetes, Comorbidities, and CRT mortality rate similar to that reported by Echouffo-Tcheugui et al 9 Moreover, comorbidities (expressed by the Charlson comorbidity index), as well as age, male sex, advanced NYHA class and implant during unplanned, urgent hospitalization were significant independent predictors of death/cardiac transplant. 15 The impact of diabetes mellitus as a comorbidity on the risk of hospitalizations and HF-related hospitalizations after CRT-D implantation is evident in the report by Echouffo-Tcheugui et al 9 The assessment of freedom from first rehospitalization, as done in this report, has some limitations in quantifying patient outcome. Boriani et al 15 recently investigated the overall impact of ICD/CRT-D implantation on mortality and morbidity through the composite end point of Days Alive and Out of Hospital (DAOH).…”

“…18,19 Patient surveillance after implant of a CRT-D device has also to consider the risk of device system infections. In the report by Echouffo-Tcheugui et al, 9 no significant difference was found between diabetic and nondiabetic patients in the occurrence of device-related mechanical complications or device-related infections within 90 days after implant, even when other patient characteristics were taken into account. These data need to be interpreted in light of the observational nature of this study, and the actual risk of devicesystem infection in diabetic patients probably deserves some considerations.…”

“…7 Diabetes mellitus and CKD have a similar prevalence among HF patients with preserved and reduced left ventricular ejection fraction 6 and both may contribute to poorer outcomes. 6,8 In the present issue of the journal, Echouffo-Tcheugui et al 9 report on >18 000 patients implanted with a biventricular defibrillator (CRT-D device) using the framework of the National Cardiovascular Data Registry (NCDR). For this report, the implantable cardioverter-defibrillator (ICD) registry data were linked to Medicare claims data, thus providing a picture of patients aged ≥65 years, with a left ventricular ejection fraction ≤35% and a preimplant NYHA class predominantly III, and a QRS duration ≥120 ms, who had been hospitalized for denovo CRT-D implantation in the period 2006 to 2009 9 .…”

“…6,8 In the present issue of the journal, Echouffo-Tcheugui et al 9 report on >18 000 patients implanted with a biventricular defibrillator (CRT-D device) using the framework of the National Cardiovascular Data Registry (NCDR). For this report, the implantable cardioverter-defibrillator (ICD) registry data were linked to Medicare claims data, thus providing a picture of patients aged ≥65 years, with a left ventricular ejection fraction ≤35% and a preimplant NYHA class predominantly III, and a QRS duration ≥120 ms, who had been hospitalized for denovo CRT-D implantation in the period 2006 to 2009 9 . At the time of device implantation, patients who were diabetic, on the basis of medical history or new clinical diagnosis, accounted for 38% of the cohort.…”