Long-Term Survival of Patients With Heart Failure and Ventricular Conduction Delay Treated With Cardiac Resynchronization Therapy

doi:10.1016/j.amjcard.2006.07.087

The American Journal of Cardiology

Volume 99, Issue 2, 15 January 2007, Pages 232-238

https://doi.org/10.1016/j.amjcard.2006.07.087 Get rights and content

This multicenter longitudinal observational trial was designed to analyze the long-term outcome of patients with heart failure (HF) treated with cardiac resynchronization therapy (CRT) alone or with implantable cardioverter-defibrillator (ICD) backup in a daily practice scenario. It is unknown whether the magnitude of survival benefits conferred by CRT in a daily practice scenario is comparable to what has been observed in randomized controlled trials and whether this benefit is sustained over the long term. The outcome of 1,303 consecutive patients with ischemic or nonischemic cardiomyopathy on optimal pharmacologic therapy treated from August 1, 1995 to August 1, 2004 at 4 European centers with CRT alone (44%) or with ICD backup for symptomatic HF and prolonged QRS duration was assessed. Cumulative event-free survival was evaluated for a combined end point, defined as death from any cause, urgent transplantation, or implantation of a left ventricular assist device. The cumulative incidence of competing events, HF, sudden cardiac death, and noncardiac death, was also assessed. Event-free survival was similar across the different centers. At 1 and 5 years, cumulative event-free survivals were 92% (95% confidence interval [CI] 91 to 94) and 56% (95% CI 48 to 64), respectively. The cumulative incidence of HF deaths was 25.1% (95% CI 19 to 31.7), whereas that of sudden death was 9.5% (95% CI 5.1 to 15.7). Using multivariate analysis, CRT with an ICD backup was associated with a nonsignificant decrease in mortality by 20% (hazard ratio 0.83, 95% CI 0.58 to 1.17, p = 0.284), with a highly significant protective effect against sudden cardiac death (hazard ratio 0.04, 95% CI 0.04 to 0.28, p <0.002). In conclusion, patients with advanced HF and a wide QRS complex routinely treated with CRT have a favorable long-term outcome that was reproducible at different centers. The leading cause of death in these patients remained HF, and this mode of death was competing with other causes in determining outcome. Total mortality was 20% lower with ICD backup (95% CI 42% lower to 17% higher) due to a protective effect against sudden cardiac death.

Section snippets

Patients

One thousand three hundred three adult patients with moderate to severe HF caused by left ventricular systolic dysfunction (ejection fraction ≤35%) of ischemic or nonischemic origin and with ventricular conduction delay (QRS duration ≥120 ms) treated with CRT were included. All patients were consecutively treated from August 1, 1995 to August 1, 2004 at 4 European institutions using a prospectively predefined registry protocol. Patients were referred because of persistent HF symptoms despite

Patient characteristics

Outcome information could not be retrieved in 5 patients who were therefore excluded from further analysis. Characteristics of the 1,298 patients are presented in Table 1. Origin was confirmed in all patients by coronary angiography, and the cause of HF was coronary artery disease in 54% of patients. Each patient was on a median of 4 active cardiovascular drugs. About 75% of patients presented with left bundle branch block QRS morphology, and 15% of patients had been constantly paced due to

Discussion

This is the first large, long-term, prospectively defined observational study on CRT in symptomatic patients with moderate to severe HF and ventricular conduction delay. Our results extend those of previous, randomized, controlled studies of CRT on mortality5, 6, 7 showing a very favorable outcome of patients treated with CRT in real-world clinical practice. Cumulative event-free survivals were 92% and 56% at 1 and 5 years, respectively, with a high consistency across the 4 European centers.

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Cited by (87)

Deep Natural Language Processing to Identify Symptom Documentation in Clinical Notes for Patients With Heart Failure Undergoing Cardiac Resynchronization Therapy
2020, Journal of Pain and Symptom Management
Citation Excerpt :
CRT is an established therapy for patients with both severe HFrEF and dyssynchronous ventricular activation,8–11 the latter of which is associated with reduced cardiac output and increased mortality.8,9,12,13 CRT leads to increased left ventricular ejection fraction (LVEF), decreased heart failure-related hospitalizations, improved survival, and higher quality of life in some, but not all patients.14–22 Identifying the patients who are most likely to benefit and the optimal timing for CRT insertion remain challenging.
Clinicians lack reliable methods to predict which patients with congestive heart failure (CHF) will benefit from cardiac resynchronization therapy (CRT). Symptom burden may help to predict response, but this information is buried in free-text clinical notes. Natural language processing (NLP) may identify symptoms recorded in the electronic health record and thereby enable this information to inform clinical decisions about the appropriateness of CRT.
To develop, train, and test a deep NLP model that identifies documented symptoms in patients with CHF receiving CRT.
We identified a random sample of clinical notes from a cohort of patients with CHF who later received CRT. Investigators labeled documented symptoms as present, absent, and context dependent (pathologic depending on the clinical situation). The algorithm was trained on 80% and fine-tuned parameters on 10% of the notes. We tested the model on the remaining 10%. We compared the model's performance to investigators' annotations using accuracy, precision (positive predictive value), recall (sensitivity), and F1 score (a combined measure of precision and recall).
Investigators annotated 154 notes (352,157 words) and identified 1340 present, 1300 absent, and 221 context-dependent symptoms. In the test set of 15 notes (35,467 words), the model's accuracy was 99.4% and recall was 66.8%. Precision was 77.6%, and overall F1 score was 71.8. F1 scores for present (70.8) and absent (74.7) symptoms were higher than that for context-dependent symptoms (48.3).
A deep NLP algorithm can be trained to capture symptoms in patients with CHF who received CRT with promising precision and recall.
Comparison between cardiac resynchronization therapy with and without defibrillator on long-term mortality: A propensity score matched analysis
2020, Journal of Cardiology
Citation Excerpt :
In the meanwhile, observational studies yielded conflicting results. An early report by the Multicenter Longitudinal Observational Study Group, which included 1060 patients with a median follow-up of 34 months, showed no difference in mortality between CRT-D and CRT-P groups at multivariable analysis [6]. However, Bai et al. reported survival benefit of CRT-D over CRT-P in a population of 542 patients after a median follow-up of 811 days, and implantation of CRT-D was independently associated with lower mortality in the multivariate regression analysis [7].
Cardiac resynchronization therapy (CRT)-defibrillator (CRT-D) has been more widely implanted than CRT-pacemaker (CRT-P) in patients of heart failure with reduced ejection fraction and prolonged QRS duration. However, the superiority of CRT-D over CRT-P in improving prognosis has not been well established.
Consecutive patients who underwent CRT implantation between 2005 and 2016 were retrospectively recruited and followed up to December 2017. Baseline characteristics were collected and all-cause mortality was compared between CRT-D and CRT-P recipients. Propensity score matched analysis was further performed to validate the results.
A total of 345 patients (219 CRT-D, 126 CRT-P) were included. During a median follow-up of 36 months, there were 81 deaths (37.0%) in the CRT-D group compared to 56 deaths (44.4%) in the CRT-P group. There was no significant difference in the risk of mortality between CRT-D and CRT-P groups [hazard ratio (HR) 0.99, 95% CI 0.70–1.40, p = 0.95]. Propensity score matching yielded 111 cases per group, and there was no significant difference in the risk of mortality between CRT-D and CRT-P groups (HR 0.87, 95%CI 0.57–1.34, p = 0.53). No significant difference between CRT-D and CRT-P in reducing mortality was observed in any pre-specified subgroups, although the difference between CRT-D and CRT-P was more pronounced in patients with left bundle branch block (p = 0.01 for interaction).
CRT-D did not reduce all-cause mortality compared with CRT-P in this retrospective propensity score matched study. A comprehensive score system incorporating multiple factors is needed for risk stratification and guidance on device selection.
Chronotropic Incompetence and Pacing in HPEF Heart Failure with Preserved Ejection Fraction
2020, Diastology: Clinical Approach to Heart Failure with Preserved Ejection Fraction
There are approximately 550,000 new cases added to the at least 5 million Americans living with heart failure (HF) each year. Of these cases, approximately 40% to 50% are classified as diastolic HF. Diastolic function is influenced by many physiologic variables, including cardiac cycle length and the relative timing of atrial and ventricular contraction. In this chapter the relationship between diastolic function and chronotropy will be explored with emphasis on the pathophysiology, diagnosis, treatment, and future technologies influencing this area of cardiology.
Atrial Fibrillation Ablation Should Be First-Line Therapy in Heart Failure Patients: CON
2019, Cardiology Clinics
Role of Atrioventricular Junctional Ablation and Cardiac Resynchronization Therapy in Patients with Chronic Atrial Fibrillation
2019, Cardiac Electrophysiology Clinics
Citation Excerpt :
In addition, common clinical practice applies CRT to patients with persistent atrial fibrillation (AF). Specifically in the population of patients with HF undergoing CRT, the prevalence of AF is substantial.3–5 The 2011 US National Cardiovascular Data indicated that 36% of 87,692 patients with cardiac resynchronization therapy-defibrillator (CRT-D) had AF, and in 2012, 31% of 326,000 patients with an implantable cardioverter defibrillator (ICD) had AF.6
What happens to non-responders in cardiac resynchronization therapy?
2017, Revista Portuguesa de Cardiologia
Left ventricular reverse remodeling (LVRR) is strongly related to the long-term prognosis of patients undergoing cardiac resynchronization therapy (CRT). The aim of this study was to assess the long-term clinical outcome of patients without LVRR at six months after CRT implantation and to determine the prognostic impact of clinical response in this population.
We analyzed 178 consecutive patients who underwent successful CRT device implantation (age 64±11 years; 69% male; 89% in New York Heart Association [NYHA] functional class III; 35% with ischemic cardiomyopathy). Clinical status and echocardiographic parameters were determined before and six months after CRT implantation. We identified those without criteria for LVRR (≥10% increase in left ventricular ejection fraction with ≥15% reduction in left ventricular end-systolic diameter compared to baseline). Clinical responders were defined by a sustained improvement of at least one NYHA functional class.
At six-month assessment after CRT, 109 (61%) patients showed LVRR. During a mean follow-up of 56±21 months, 47 (26%) patients died, with higher mortality in the group without LVRR (36% vs. 20%, p=0.023). Clinical response was greater in patients with LVRR (88% vs. 55%, p<0.001). In patients without LVRR, clinical response to CRT was the strongest independent predictor of survival (hazard ratio: 0.120; 95% confidence interval: 0.039-0.366; p<0.001).
Although patients without LVRR six months after CRT implantation had a worse prognosis, with higher all-cause mortality, clinical response can be an independent predictor of survival in this population.
A remodelagem reversa do ventrículo esquerdo (RRVE) tem sido fortemente relacionada com o prognóstico em longo prazo de doentes submetidos à terapia de ressincronização cardíaca (TRC). O objetivo deste estudo foi avaliar o desfecho clínico a longo prazo de doentes sem RRVE aos seis meses após a implantação de TRC e definir o impacto prognóstico da resposta clínica nessa população.
Foram analisados 178 doentes submetidos à implantação de TRC (64 ± 11 anos, 69% do sexo masculino, 89% da classe funcional III da New York Heart Association (NYHA), 35% com cardiomiopatia isquémica). O estadio clínico e a avaliação ecocardiográfica foram feitos antes e após seis meses de TRC. Foram identificados aqueles que não tinham critérios de RRVE (aumento ≥ 10% na fração de ejeção com uma redução de ≥ 15% na dimensão sistólica do ventrículo esquerdo). Os respondedores clínicos foram definidos por uma melhoria sustentada de pelo menos uma classe funcional NYHA.
Aos seis meses de avaliação após TRC, 109 (61%) doentes apresentaram RRVE. Durante um seguimento médio de 56 ± 21 meses, 47 (26%) doentes morreram, com maior mortalidade no grupo sem RRVE (36% versus 20%, p = 0,023). A resposta clínica foi maior no grupo de doentes com RRVE (88% versus 55%, p < 0,001). Em doentes sem RRVE, a resposta clínica à TRC foi o maior preditor independente de sobrevida (hazard ratio: 0,120; IC95%: 0,039-0,366; p < 0,001).
Embora doentes sem RRVE seis meses após a implantação da TRC apresentem um pior prognóstico com maior taxa de mortalidade por todas as causas, a resposta clínica pode ser um preditor independente de sobrevida nessa população.

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Heart failureLong-Term Survival of Patients With Heart Failure and Ventricular Conduction Delay Treated With Cardiac Resynchronization Therapy

Section snippets

Patients

Patient characteristics

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Randomized, controlled trials, observational studies and the hierarchy of research designs

N Engl J Med

A comparison of observational studies and randomized, controlled trials

N Engl J Med

Improved left ventricular mechanics from acute VDD pacing in patients with dilated cardiomyopathy and ventricular conduction delay

Circulation

Cardiac resynchronization in chronic heart failure

N Engl J Med

Cardiac resynchronisation therapy with or without an implantable defibrillator in advanced chronic heart failure

N Engl J Med

The effect of CRT on morbidity and mortality in heart failure

N Engl J Med

Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): the task force for the diagnosis and treatment of chronic heart failure of the European Society of Cardiology

Eur Heart J

Heart failure
Long-Term Survival of Patients With Heart Failure and Ventricular Conduction Delay Treated With Cardiac Resynchronization Therapy