Among Medicare recipients, the de novo use of CRT-D therapy increased in line with guideline recommendations, and in-hospital complications and other long-term outcomes were reduced, after the 2012 guideline update, according to a study published April 1 in Heart Rhythm Open.

Douglas Darden, MD, et al., examined ACC’s EP Device Implant Registry data from 53,174 patients (mean age, 75.6 years; 29.7% women) implanted with a CRT-D between 2011 and 2015 to determine the effect on patient selection by the update in 2012 to the ACC/AHA/HRS guideline for device-based therapy for cardiac rhythm abnormalities. The update narrowed the class I indication to patients with left bundle branch block and QRS ≥150 ms and expanded the class I indication to include patients with NYHA class II heart failure.

Results showed that for the proportion of CRT-D implantations meeting clinical guidelines, there was an increase from 81% to 84.7% (p<0.001). In-hospital procedural complications decreased from 2011 to 2015, from 3.9% to 2.9%, driven in part by decreased lead dislodgement (1.4% vs. 1.0%).

After multivariable adjustment, there was a lower risk of all-cause hospitalization, cardiovascular hospitalization, and mortality at the two-year follow-up, while there were no differences in heart failure hospitalizations.

“Although promising data, the elderly are underrepresented in clinical trials and advanced age is a known risk factor for complications associated with CRT,” write Darden, et al. “We show in this analysis that approximately 15% of elderly patients are receiving guideline-discordant CRT implantations, suggesting room for continued improvement in assessing CRT candidacy among older patients.”

The researchers conclude that improvements in areas such as management of comorbidities, patient selection resulting in less frail patients, and overall closer outpatient follow-up may play an important role in the aging population with CRT-D.

Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Implantable Devices, EP Basic Science, Acute Heart Failure

Keywords: Cardiac Resynchronization Therapy Devices, Cardiac Resynchronization Therapy, Risk Factors, Hospitalization, Heart Failure, Medicare, Outpatients, Frail Elderly, Patient Selection, Follow-Up Studies, Bundle-Branch Block, National Cardiovascular Data Registries, EP Device Implant Registry

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