0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Original Research |

Comparative Effectiveness of Cardiac Resynchronization Therapy With an Implantable Cardioverter-Defibrillator Versus Defibrillator Therapy Alone: A Cohort StudyComparative Effectiveness of Cardiac Resynchronization Therapy

Frederick A. Masoudi, MD, MSPH; Xiaojuan Mi, PhD; Lesley H. Curtis, PhD; Pamela N. Peterson, MD, MSPH; Jeptha P. Curtis, MD; Gregg C. Fonarow, MD; Stephen C. Hammill, MD; Paul A. Heidenreich, MD; Sana M. Al-Khatib, MD, MHS; Jonathan P. Piccini, MD, MHS; Laura G. Qualls, MS; and Adrian F. Hernandez, MD, MHS
[+] Article and Author Information

From the University of Colorado Anschutz Medical Campus, Aurora, Colorado; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Denver Health Medical Center, Denver, Colorado; Yale University School of Medicine, New Haven, Connecticut; Ahmanson–University of California, Los Angeles, Cardiomyopathy Center, Los Angeles, California; Mayo Clinic, Rochester, Minnesota; and Veterans Affairs Palo Alto Healthcare System, Palo Alto, California.

Disclaimer: The authors of this article are responsible for its content. Statements in this article should not be construed as endorsement by the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, or National Cardiovascular Data Registry or its associated professional societies identified at www.ncdr.com.

Acknowledgment: The authors thank Damon M. Seils, MA, from Duke University, who provided editorial assistance and prepared the manuscript.

Financial Support: By contract HHSA29020050032I (Duke University Developing Evidence to Inform Decisions about Effectiveness Center) from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, as part of the Developing Evidence to Inform Decisions about Effectiveness program, and the American College of Cardiology Foundation's National Cardiovascular Data Registry. The ICD Registry is an initiative of the American College of Cardiology Foundation and the Heart Rhythm Society. Dr. Peterson is supported by grant K08HS019814 from the Agency for Healthcare Research and Quality.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1879.

Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Curtis (e-mail, lesley.curtis@duke.edu). Data set: Available at www.ncdr.com/research.

Requests for Single Reprints: Frederick A. Masoudi, MD, MSPH, Division of Cardiology, University of Colorado Anschutz Medical Campus, Box B132, Room 522, 12401 East 17th Avenue, Aurora, CO 80045; e-mail, fred.masoudi@ucdenver.edu.

Current Author Addresses: Dr. Masoudi: Division of Cardiology, Anschutz Medical Campus, Box B132, Room 522, 12401 East 17th Avenue, Aurora, CO 80045.

Drs. Mi, Curtis, Al-Khatib, Piccini, Qualls, and Hernandez: Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715.

Dr. Peterson: Division of Cardiology, Denver Health Medical Center, Box 0960, 777 Bannock Street, Denver, CO 80204.

Dr. Curtis: Yale School of Medicine, PO Box 208056, 333 Cedar Street, New Haven, CT 06520-8056.

Dr. Fonarow: Ahmanson–University of California, Los Angeles, Cardiomyopathy Center, 200 UCLA Medical Plaza, Suite 224, Los Angeles, CA 90095.

Dr. Hammill: Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

Dr. Heidenreich: Veterans Affairs Palo Alto Medical Center, 111C Cardiology, 3801 Miranda Avenue, Palo Alto, CA 94304.

Author Contributions: Conception and design: F.A. Masoudi, L.H. Curtis, G.C. Fonarow, S.M. Al-Khatib, L.G. Qualls, A.F. Hernandez.

Analysis and interpretation of the data: F.A. Masoudi, X. Mi, L.H. Curtis, J.P. Curtis, G.C. Fonarow, P.A. Heidenreich, S.M. Al-Khatib, J.P. Piccini, A.F. Hernandez.

Drafting of the article: F.A. Masoudi, X. Mi.

Critical revision of the article for important intellectual content: F.A. Masoudi, L.H. Curtis, P.N. Peterson, J.P. Curtis, G.C. Fonarow, S.C. Hammill, P.A. Heidenreich, S.M. Al-Khatib, J.P. Piccini, L.G. Qualls, A.F. Hernandez.

Final approval of the article: F.A. Masoudi, L.H. Curtis, P.N. Peterson, J.P. Curtis, G.C. Fonarow, S.C. Hammill, P.A. Heidenreich, S.M. Al-Khatib, J.P. Piccini, A.F. Hernandez.

Provision of study materials or patients: G.C. Fonarow.

Obtaining of funding: L.H. Curtis, A.F. Hernandez.

Administrative, technical, or logistic support: L.H. Curtis, S.C. Hammill, L.G. Qualls, A.F. Hernandez.

Collection and assembly of data: F.A. Masoudi, G.C. Fonarow, S.C. Hammill


Ann Intern Med. 2014;160(9):603-611. doi:10.7326/M13-1879
Text Size: A A A

Background: Trials comparing implantable cardioverter-defibrillator (ICD) therapy with cardiac resynchronization therapy with a defibrillator (CRT-D) are limited to selected patients treated at centers with extensive experience.

Objective: To compare outcomes after CRT-D versus ICD therapy in contemporary practice.

Design: Retrospective cohort study using the National Cardiovascular Data Registry's ICD Registry linked with Medicare claims.

Setting: 780 U.S. hospitals implanting both CRT-D and ICD devices.

Patients: 7090 propensity-matched patients older than 65 years with reduced left ventricular ejection fraction (<0.35) and prolonged QRS duration on electrocardiography (≥120 ms) having CRT-D or ICD implantation between 1 April 2006 and 31 December 2009.

Measurements: Risks for death, readmission, and device-related complications over 3 years.

Results: Compared with ICD therapy, CRT-D was associated with lower risks for mortality (cumulative incidence, 25.7% vs. 29.8%; adjusted hazard ratio [HR], 0.82 [99% CI, 0.73 to 0.93]), all-cause readmission (cumulative incidence, 68.6% vs. 72.8%; adjusted HR, 0.86 [CI, 0.81 to 0.93]), cardiovascular readmission (cumulative incidence, 45.0% vs. 52.4%; adjusted HR, 0.80 [CI, 0.73 to 0.88]), and heart failure readmission (cumulative incidence, 24.3% vs. 29.4%; adjusted HR, 0.78 [CI, 0.69 to 0.88]). It was also associated with greater risks for device-related infection (cumulative incidence, 1.9% vs. 1.0%; adjusted HR, 1.90 [CI, 1.07 to 3.37]). The lower risks for heart failure readmission associated with CRT-D compared with ICD therapy were most pronounced among patients with left bundle branch block or a QRS duration at least 150 ms and in women.

Limitations: Patients were not randomly assigned to treatment groups, and few patients could be propensity-matched. The findings may not extend to younger patients or those outside of fee-for-service Medicare.

Conclusion: In older patients with reduced left ventricular ejection fraction and prolonged QRS duration, CRT-D was associated with lower risks for death and readmission than ICD therapy alone.

Primary Funding Source: Agency for Healthcare Research and Quality.

Figures

Grahic Jump Location
Appendix Figure 1.

Distribution of propensity scores in the unmatched cohort.

The cohort included 29 777 patients. CRT-D = cardiac resynchronization therapy with a defibrillator; ICD = implantable cardioverter-defibrillator.

Grahic Jump Location
Grahic Jump Location
Figure.

Cumulative incidence in the within-hospital propensity-matched cohort.

The cohort included 7090 patients. CRT-D = cardiac resynchronization therapy with a defibrillator; CVD = cardiovascular disease; HR = hazard ratio; ICD = implantable cardioverter-defibrillator.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 2.

Cumulative incidence in the unmatched cohort.

The cohort included 29 777 patients. CRT-D = cardiac resynchronization therapy with a defibrillator; CVD = cardiovascular disease; HR = hazard ratio; ICD = implantable cardioverter-defibrillator.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 3.

Cumulative incidence in the across-hospital propensity-matched cohort.

The cohort included 10 944 patients. CRT-D = cardiac resynchronization therapy with a defibrillator; CVD = cardiovascular disease; HR = hazard ratio; ICD = implantable cardioverter-defibrillator.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 4.

Associations between CRT-D versus ICD therapy alone and mortality in the within-hospital propensity-matched cohort, by patient characteristic.

The cohort included 7090 patients. CRT-D = cardiac resynchronization therapy with a defibrillator; eGFR = estimated glomerular filtration rate; ICD = implantable cardioverter-defibrillator; LBBB = left bundle branch block; NYHA = New York Heart Association.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 5.

Associations between CRT-D versus ICD therapy alone and all-cause readmission in the within-hospital propensity-matched cohort, by patient characteristic.

The cohort included 7090 patients. CRT-D = cardiac resynchronization therapy with a defibrillator; eGFR = estimated glomerular filtration rate; ICD = implantable cardioverter-defibrillator; LBBB = left bundle branch block; NYHA = New York Heart Association.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 6.

Associations between CRT-D versus ICD therapy alone and cardiovascular readmission in the within-hospital propensity-matched cohort, by patient characteristic.

The cohort included 7090 patients. CRT-D = cardiac resynchronization therapy with a defibrillator; eGFR = estimated glomerular filtration rate; ICD = implantable cardioverter-defibrillator; LBBB = left bundle branch block; NYHA = New York Heart Association.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 7.

Associations between CRT-D versus ICD therapy alone and heart failure readmission in the within-hospital propensity-matched cohort, by patient characteristic.

The cohort included 7090 patients. CRT-D = cardiac resynchronization therapy with a defibrillator; eGFR = estimated glomerular filtration rate; ICD = implantable cardioverter-defibrillator; LBBB = left bundle branch block; NYHA = New York Heart Association.

Grahic Jump Location

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Submit a Comment

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections
PubMed Articles

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)