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European Society of Cardiology

Clinical Articles, News & Views

Most CRT-P patients would not benefit from addition of defibrillator

Most patients with a cardiac resynchronisation therapy (CRT) pacemaker would not benefit from the addition of a defibrillator, according to results from the CeRtiTuDe cohort study presented for the first time recently at the European Society of Cardiology Congress 20151 and published in the European Heart Journal.2

The CeRtiTuDe study evaluated the characteristics of CRT-P versus CRT-D patients in a real-world scenario and analysed to what extent CRT-P patients would have benefited from the presence of a back-up defibrillator. It was a multicentre prospective follow-up cohort study that enrolled a total of 1,705 consecutive patients implanted with a CRT (CRT-P 535; CRT-D 1,170) between 2008 and 2010 in France. Adjudication for causes of death was conducted at two years follow up.

Patients with CRT-P compared to CRT-D were older (75.9 vs. 65.6 years, p<0.0001), less often male (69.5 vs. 80.8%, p<0.0001), more symptomatic (proportion of NYHA class III/IV, 88 vs. 80%, p=0.002), with less coronary artery disease (40.7 vs. 49.3%, p=0.003), wider QRS (161 ± 29 vs. 155 ± 26 msec, p=0.002), more atrial fibrillation (38.7 vs. 22.1%, p<0.0001) and more comorbidities (≥ 2 comorbidities 16.9 vs. 12.9 %, p=0.04).

“The choice between CRT with (CRT-D) or without (CRT-P) a defibrillator remains a contentious issue…No randomised clinical trial has been conducted to guide this choice,” said the presenter of the study Professor Jean-Yves Le Heuzey (Georges Pompidou Hospital, René Descartes University, Paris, France).

“Whether such a high rate of CRT-D use over CRT-P is justified is an important question to answer in terms of significant costs and device-related complications…Implantable cardioverter defibrillator (ICD) lead failures, inappropriate shocks and risk of infection are real problems with impacts on quality of life and possibly survival. But the ideal way to answer this question, a randomised controlled trial directly comparing CRT-P to CRT-D, would have to be large, expensive and is unlikely to ever be conducted,” Professor Le Heuzey added.

At two year follow up 267 patients had died, giving an annual overall mortality rate of 83.8 per 1,000. The crude mortality rate among CRT-P patients was double compared to CRT-D (relative risk [RR]=2.01, 95% confidence interval [CI]=1.56–2.58). “By cause-of-death analysis, 95% of the excess mortality among CRT-P subjects was related to an increase of non-sudden death,” said Professor Le Heuzey. “This could indicate that this excess mortality is due to heart failure and non cardiovascular events.”

He concluded: “Our findings suggest that patients selected for CRT-P in routine clinical practice would not benefit from the addition of a defibrillator. This indicates that CRT-D rates could be reduced, with consequent decreases in costs and device-related complications.”

References

1. Le Heuzey JY. CRT-P or CRT-D? The CeRtiTuDe Cohort Study. European Society of Cardiology 2015 Congress. Registry II – Interventions / Acute cardiovascular care.

2. Le Heuzey JY, Marijon E, et al. Causes of death analysis of patients with cardiac resynchronization therapy – an analysis of the CeRtiTuDe cohort study. Euro Heart J 2015;pii:ehv455.

Published on: October 30, 2015

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ENDORSED BY

  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association
 

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