Comparative Effectiveness of CRT-D Versus Defibrillator Alone in HF Patients With Moderate-to-Severe Chronic Kidney Disease

J Am Coll Cardiol. 2015 Dec 15;66(23):2618-2629. doi: 10.1016/j.jacc.2015.09.097.

Abstract

Background: Patients with moderate-to-severe chronic kidney disease (CKD) are poorly represented in clinical trials of cardiac resynchronization therapy (CRT).

Objectives: This study sought to assess the real-world comparative effectiveness of CRT with defibrillator (CRT-D) versus implantable cardioverter-defibrillator (ICD) alone in CRT-eligible patients with moderate-to-severe CKD.

Methods: We conducted an inverse probability-weighted analysis of 10,946 CRT-eligible patients (ejection fraction <35%, QRS >120 ms, New York Heart Association functional class III/IV) with stage 3 to 5 CKD in the National Cardiovascular Data Registry (NCDR) ICD Registry, comparing outcomes between patients who received CRT-D (n = 9,525) versus ICD only (n = 1,421). Outcomes were obtained via Medicare claims and censored at 3 years. The primary endpoint of heart failure (HF) hospitalization or death and the secondary endpoint of death were assessed with Cox proportional hazards models. HF hospitalization, device explant, and progression to end-stage renal disease were assessed using Fine-Gray models.

Results: After risk adjustment, CRT-D use was associated with a reduction in HF hospitalization or death (hazard ratio [HR]: 0.84; 95% confidence interval [CI]: 0.78 to 0.91; p < 0.0001), death (HR: 0.85; 95% CI: 0.77 to 0.93; p < 0.0004), and HF hospitalization alone (subdistribution HR: 0.84; 95% CI: 0.76 to 0.93; p < 0.009). Subgroup analyses suggested that CRT was associated with a reduced risk of HF hospitalization and death across CKD classes. The incidence of in-hospital, short-term, and mid-term device-related complications did not vary across CKD stages.

Conclusions: In a nationally representative population of HF and CRT-eligible patients, use of CRT-D was associated with a significantly lower risk of the composite endpoint of HF hospitalization or death among patients with moderate-to-severe CKD in the setting of acceptable complication rates.

Keywords: biventricular; cardiomyopathy; chronic kidney disease; pacemaker.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cardiac Resynchronization Therapy* / methods
  • Cardiac Resynchronization Therapy* / statistics & numerical data
  • Comorbidity
  • Comparative Effectiveness Research
  • Defibrillators, Implantable / statistics & numerical data
  • Electric Countershock* / instrumentation
  • Electric Countershock* / methods
  • Electric Countershock* / statistics & numerical data
  • Female
  • Glomerular Filtration Rate
  • Heart Failure* / diagnosis
  • Heart Failure* / epidemiology
  • Heart Failure* / therapy
  • Hospitalization / statistics & numerical data
  • Humans
  • Male
  • Medicare / statistics & numerical data
  • Proportional Hazards Models
  • Renal Insufficiency, Chronic* / diagnosis
  • Renal Insufficiency, Chronic* / epidemiology
  • Severity of Illness Index
  • Survival Analysis
  • Treatment Outcome
  • United States / epidemiology