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Implantable Defibrillators Improve Survival in Mildly Symptomatic Heart Failure Patients Receiving Cardiac Resynchronization Therapy: Analysis of the Long-Term Follow-Up of REVERSE
Study Questions:
What are the clinical outcomes and long-term survival among cardiac resynchronization therapy (CRT) patients with and without implantable cardioverter-defibrillators (ICDs)?
Methods:
REVERSE was a multicenter, randomized trial of CRT among patients with mild heart failure (HF). All patients underwent implantation of a CRT system (device and leads), with or without ICD capabilities, based on standard clinical criteria at the time of enrollment. Long-term annual follow-up for 5 years was preplanned. Patients who underwent successful implantation (n = 610) were randomly assigned in a 2:1 fashion to active CRT (CRT ON) or to a control group (CRT OFF).The present analysis was confined to the 419 patients who were randomized to CRT ON.
Results:
CRT pacemakers (CRT-P) or devices with defibrillator back-up (CRT-D) were implanted based on national guidelines at the time of enrollment, with 74 patients receiving CRT-P devices and the remaining 345 receiving CRT-D devices. After 12 months of CRT, changes in the Clinical Composite Score, left ventricular end-systolic volume index (LVESVi), 6-minute walk time, and quality-of-life indices were similar between CRT-P and CRT-D patients. However, long-term follow-up showed lower mortality in the CRT-D group. Specifically, multivariable analysis showed that CRT-D (hazard ratio, 0.35; p = 0.003) was a strong independent predictor of survival. Female sex, longer unpaced QRS duration, and smaller baseline LVESVi were also associated with better survival.
Conclusions:
The authors concluded that the addition of ICD therapy to CRT is associated with improved long-term survival compared with CRT pacing alone in mild HF.
Perspective:
This post-hoc subgroup analysis from the REVERSE trial suggests that the addition of ICD therapy to CRT (CRT-D) reduces long-term mortality compared with CRT pacing alone. Multivariable analysis demonstrated a highly significant 65% reduction of mortality rates with CRT-D during the 5-year follow-up. The study findings appear to suggest that CRT-D devices should be considered in mild HF patients; particularly those with good long-term life expectancy, but additional prospective validation of these findings are indicated.
Keywords: Defibrillators, Cardiac Resynchronization Therapy, Heart Diseases, Survivors, Walking, Cardiac Pacing, Artificial, Ventricular Remodeling, Heart Failure, Stroke Volume, Ventricular Dysfunction, Left, Pregnancy, Defibrillators, Implantable, Death, Sudden, Cardiac
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