Difference in long-term clinical outcome after cardiac resynchronisation therapy between ischaemic and non-ischaemic aetiologies of heart failure

Abstract

Objective: To examine the impact of heart failure (HF) aetiology on long-term outcome after cardiac resynchronisation therapy (CRT). Design: Prospective cohort study. Setting: University hospital. Patients: 119 patients (44% with ischaemic and 56% non-ischaemic aetiology) who underwent CRT. Interventions: Clinical follow-up for 39 (24) months. Main outcome measures: Cardiovascular mortality, HF and cardiovascular hospitalisation were compared by Kaplan-Meier curves between the two groups, followed by Cox regression analysis for prognostic predictor(s). Results: 41 (34%) patients died, in whom cardiovascular causes were identified in 32 (27%) patients. The ischaemic group had a higher cardiovascular mortality (log-rank x 2 = 4.293, p = 0.038) and cardiovascular hospitalisation (log-rank x 2 = 5.123, p = 0.024) when compared with the non-ischaemic group, though no difference was found in HF hospitalisation (log-rank x 2 = 0.019, p = 0.892). At three months, left ventricular reverse remodelling occurred in 52% of the ischaemic group and 55% of the non-ischaemic group (x 2 = 0.128, p = 0.720). By Cox regression analysis, ischaemic aetiology and absence of reverse remodelling at three months were independent predictors of cardiovascular mortality (HR = 2.698, p = 0.032; HR = 3.541, p = 0.030) and cardiovascular hospitalisation (HR = 1.905, p = 0.015; HR = 2.361, p = 0.004). Furthermore, these two factors had an incremental value in predicting cardiovascular mortality when compared with either alone (left ventricular reverse remodelling, logrank x 2 = 10.275 vs 6.311, p = 0.05; Ischaemic aetiology, log-rank x 2 = 10.275 vs 4.293, p,0.05). Conclusion: Ischaemic aetiology of HF is an independent predictor of higher cardiovascular mortality and hospitalisation after CRT. This may implicate the progressive nature of coronary heart disease leading to a worse outcome despite similar short-term benefits of CRT.Cardiac resynchronisation therapy (CRT) is an established treatment for patients with advanced heart failure (HF) who have electromechanical delay. Its beneficial effects on cardiac function, exercise capacity, quality of life, left ventricular (LV) reverse remodelling and long-term prognosis, including mortality and cardiovascular hospitalisation, have been confirmed in large clinical trials. [1][2][3][4][5][6][7] In the MIRACLE study, a lesser degree of reduction of LV volumes at one-year follow-up was observed in ischaemic than non-ischaemic patients. 9However, it is not known whether there is any attributable difference in aetiology on long-term prognosis after CRT. In the CARE-HF study, when compared with ischaemic patients, non-ischaemic patients showed a greater extent of reduction in the estimated absolute risk for death or unplanned hospitalisation after receiving CRT, though aetiology of HF was not found to be an independent predictor for the outcome measure of CRT.10 On the other hand, early LV reverse remodelling occurring at 3-6 months after CRT detected by echocardiography has been shown to heral...

Tissue Doppler velocity is superior to strain imaging in predicting long-term cardiovascular events after cardiac resynchronisation therapy

“…In the CRT group, patients with increasing systolic blood pressure or less severe interventricular delay showed less benefit from CRT 14. Our recent publication observed that cardiovascular mortality and hospitalisation after CRT were higher in ischaemic patients than in non-ischaemic patients, implicating that the progressive nature of coronary heart disease may lead to a worse outcome 20. Similarly, the INSYNC/INSYNC ICD Italian Registry demonstrated that patients with ischaemic cardiomyopathy or NYHA class IV before device implantation had a higher all-cause mortality during the 3-year follow-up 21.…”

“…Previous studies have identified prepacing factors which correlated with prognosis including NYHA class, aetiology of heart failure, systolic blood pressure, LV diameter, mitral regurgitation, interventricular delay as well as N-terminal probrain natriuretic peptide (NT-proBNP) level 14 20 – 22. In the CARE-HF study (with 813 patients randomised to medical therapy or CRT plus medical therapy and followed up for a mean of 29.4 months) ischaemic aetiology, more severe mitral regurgitation and increased NT-proBNP independently predicted the primary composite endpoint, that is death or unplanned cardiovascular hospitalisation, in heart-failure patients irrespective of CRT.…”

Incremental prognostic value of combining left ventricular lead position and systolic dyssynchrony in predicting long-term survival after cardiac resynchronization therapy

“…It appears that the presence of baseline systolic dyssynchrony is an important prerequisite for the occurrence of a favourable outcome, such as an early improvement in cardiac function, LV reverse remodelling [4,18] and longterm cardiovascular event rate [7,8]. On the other hand, there are other potentially important factors that might affect the CRT response apart from the status of dyssynchrony [19,20]; in particular, a suboptimal LV lead position may reduce treatment efficacy even when systolic dyssynchrony is present. Currently, it is recommended that the LV lead should be placed at the LV free wall region (or the PL region) to allow a more even spreading of the electrical propagation wave to overcome the regional delay.…”

Recent advances in cardiac resynchronization therapy: echocardiographic modalities, patient selection, optimization, non-responders—all you need to know for more efficient CRT

“…However, other studies have found a comparable degree of response to CRT in those two entities [77,78]. In a recent study, although it was found that left ventricular reverse remodelling, after CRT, occurred in similar degrees in both non-ischemic and ischemic groups, there was higher cardiovascular mortality in patients with ischemic Cardiomyopathy [79]. In another study [21], the number of segments with post-systolic shortening (PSS) appeared to be a good predictor for CRT response only in patients with non-ischemic cardiomyopathy, but more interestingly, the predictive values of all the TDI parameters were consistently higher in the non-ischemic than the ischemic group.…”