National Trends in CRT-D and CRT-P Utilization
What are the contemporary patterns of the type of cardiac resynchronization therapy (CRT) device implantation: CRT-implantable cardioverter defibrillator (ICD) (CRT-D) versus CRT-pacemaker (CRT-P) in hospitalized patients in the United States?
The authors conducted a serial cross-sectional study using the National Inpatient Sample database between 2006 and 2012 in order to identify demographic, clinical, and geographic factors associated with the choice of CRT device.
The authors identified 311,086 admissions associated with CRT implant. CRT-D was the most common device-type (86.1%), including in patients ages ≥75 years with five or more comorbidities (75.5%). Multivariate predictors of CRT-D implant included: prior ventricular arrhythmia (rate ratio [RR], 1.14), ischemic heart disease (RR, 1.11), male gender (RR, 1.10; 95% confidence interval, 1.09-1.10), black race (RR, 1.06), and Northeast geographic region (RR, 1.06). There was significant interhospital variation in the use of CRT-D (10-90 percentile range, 72.9%-98.0% CRT-D). The proportion of CRT-D implants decreased between 2006 and 2012.
CRT-D implantation occurred in >75% of patients in subgroups for whom ICD benefit is probably attenuated due to advanced age and comorbidities.
Randomized controlled trials have shown reduced morbidity and mortality with both CRT-P and CRT with ICD (CRT-D). However, increasing age, peripheral vascular disease, diabetes, and chronic kidney disease likely attenuate the survival benefit of ICD therapy. In a prior study involving patient-level data from four major randomized trials of primary prevention ICD, the presence of >3 comorbidities nullified the survival benefit associated with ICD implant (Steinberg BA, et al., JACC Heart Fail 2014;2:623-9). In patients undergoing CRT implant, the addition of ICD therapy has implications in terms of device complications, inappropriate device therapy, higher rate of generator change associated with battery depletion, and ultimately cost-effectiveness. In the present study, the predictors of CRT-D implantation included demographic, clinical, and nonclinical factors. This study does not directly address issues of CRT-D vs. CRT-P efficacy, but compels us to consider the optimal device selection in the cohort of patients who have been grossly under-represented in clinical trials of both ICD and CRT therapy.
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