Nawaf S. Al-Majed, MBBS; Finlay A. McAlister, MD, MSc; Jeffrey A. Bakal, PhD; Justin A. Ezekowitz, MBBCh, MSc
Al-Majed NS, McAlister FA, Bakal JA, Ezekowitz JA. Meta-analysis: Cardiac Resynchronization Therapy for Patients With Less Symptomatic Heart Failure. Ann Intern Med. 2011;154:401-412. doi: 10.7326/0003-4819-154-6-201103150-00313
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Published: Ann Intern Med. 2011;154(6):401-412.
Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in patients with advanced symptoms of heart failure.
To assess the benefits and harms of CRT in patients with advanced heart failure and those with less symptomatic disease.
A search of electronic databases (1950 to December 2010), hand-searching of reference lists, and unpublished data from principal investigators. Searches were not limited to the English language.
Randomized, controlled trials of CRT compared with usual care and right or left ventricular pacing in adults with heart failure and a left ventricular ejection fraction of 0.40 or less.
Two reviewers performed independent study selection, data abstraction, and quality assessment by using the Cochrane tool for assessing risk for bias.
There were 9082 patients in 25 trials. In patients with New York Heart Association (NYHA) class I and II symptoms, CRT reduced all-cause mortality (6 trials, 4572 participants; risk ratio [RR], 0.83 [95% CI, 0.72 to 0.96]) and heart failure hospitalizations (4 trials, 4349 participants; RR, 0.71 [CI, 0.57 to 0.87]) without improving functional outcomes or quality of life. In patients with NYHA class III or IV symptoms, CRT improved functional outcomes and reduced both all-cause mortality (19 trials, 4510 participants; RR, 0.78 [CI, 0.67 to 0.91]) and heart failure hospitalizations (11 trials, 2663 participants; RR, 0.65 [CI, 0.50 to 0.86]). The implant success rate was 94.4%; peri-implantation deaths occurred in 0.3% of trial participants, mechanical complications in 3.2%, lead problems in 6.2%, and infections in 1.4%.
Subgroup analyses were underpowered and lack data for persons with NYHA class I symptoms, atrial fibrillation, chronic kidney disease, or right bundle branch block.
Cardiac resynchronization therapy is beneficial for patients with reduced left ventricular ejection fraction, symptoms of heart failure, and prolonged QRS, regardless of NYHA class.
Guidelines recommend cardiac resynchronization therapy (CRT) for patients with reduced left ventricular ejection fraction and advanced symptoms of heart failure.
This meta-analysis of 25 trials includes new evidence that CRT reduces mortality and heart failure hospitalizations in patients with left ventricular systolic dysfunction, prolonged QRS duration, and milder symptoms. The relative magnitude of the benefits in patients with milder symptoms seemed to be similar to those in patients with New York Heart Association class III or IV symptoms.
Few trial participants had atrial fibrillation or asymptomatic (New York Heart Association class I) heart failure.
Some patients with reduced left ventricular ejection fraction and mild symptoms may benefit from CRT.
Appendix Table 1.
Appendix Table 2.
For expansions of study names, see the Glossary. RCT = randomized, controlled trial.
Appendix Table 3.
Studies are stratified by NYHA classes of included patients. Risk ratios were calculated by using Mantel–Haenszel random-effects methods. For expansions of study names, see the Glossary. CRT = cardiac resynchronization therapy; NYHA = New York Heart Association.
Circles represent trial size (number of participants). Dashed lines are 95% CIs. The dotted line represents a relative risk of 1.0.
Studies are stratified by baseline NYHA classes of included patients. Risk ratios were calculated by using Mantel–Haenszel random-effects methods. For expansions of study names, see the Glossary. CRT = cardiac resynchronization therapy; NYHA = New York Heart Association.
Appendix Table 4.
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Cardiology, High Value Care, Heart Failure.
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