Ann Intern Med. 2014 May 6;160(9):603-11. doi: 10.7326/M13-1879.
Trials comparing implantable cardioverter-defibrillator (ICD) therapy with cardiac resynchronization therapy with a defibrillator (CRT-D) are limited to selected patients treated at centers with extensive experience.
To compare outcomes after CRT-D versus ICD therapy in contemporary practice.
Retrospective cohort study using the National Cardiovascular Data Registry's ICD Registry linked with Medicare claims.
780 U.S. hospitals implanting both CRT-D and ICD devices.
7090 propensity-matched patients older than 65 years with reduced left ventricular ejection fraction (<0.35) and prolonged QRS duration on electrocardiography (≥120 ms) having CRT-D or ICD implantation between 1 April 2006 and 31 December 2009.
Risks for death, readmission, and device-related complications over 3 years.
Compared with ICD therapy, CRT-D was associated with lower risks for mortality (cumulative incidence, 25.7% vs. 29.8%; adjusted hazard ratio [HR], 0.82 [99% CI, 0.73 to 0.93]), all-cause readmission (cumulative incidence, 68.6% vs. 72.8%; adjusted HR, 0.86 [CI, 0.81 to 0.93]), cardiovascular readmission (cumulative incidence, 45.0% vs. 52.4%; adjusted HR, 0.80 [CI, 0.73 to 0.88]), and heart failure readmission (cumulative incidence, 24.3% vs. 29.4%; adjusted HR, 0.78 [CI, 0.69 to 0.88]). It was also associated with greater risks for device-related infection (cumulative incidence, 1.9% vs. 1.0%; adjusted HR, 1.90 [CI, 1.07 to 3.37]). The lower risks for heart failure readmission associated with CRT-D compared with ICD therapy were most pronounced among patients with left bundle branch block or a QRS duration at least 150 ms and in women.
Patients were not randomly assigned to treatment groups, and few patients could be propensity-matched. The findings may not extend to younger patients or those outside of fee-for-service Medicare.
In older patients with reduced left ventricular ejection fraction and prolonged QRS duration, CRT-D was associated with lower risks for death and readmission than ICD therapy alone.
Agency for Healthcare Research and Quality.
比较植入式心脏复律除颤器 (ICD) 治疗与带除颤器的心脏再同步治疗 (CRT-D) 的试验仅限于在经验丰富的中心接受治疗的选定患者。
比较 CRT-D 与 ICD 治疗在当代实践中的结果。
使用全国心血管数据注册中心的 ICD 注册与医疗保险索赔相关联的回顾性队列研究。
在美国植入 CRT-D 和 ICD 设备的 780 家医院。
2006 年 4 月 1 日至 2009 年 12 月 31 日期间，年龄大于 65 岁，左心室射血分数降低（<0.35）和心电图 QRS 持续时间延长（>=120 ms）的 7090 名患者接受 CRT-D 或 ICD 植入，采用倾向评分匹配。
3 年内死亡、再入院和与设备相关的并发症风险。
与 ICD 治疗相比，CRT-D 与死亡率降低相关（累积发生率，25.7% 对 29.8%；调整后的危险比 [HR]，0.82 [99%CI，0.73 至 0.93]）、全因再入院（累积发生率，68.6% 对 72.8%；调整后的 HR，0.86 [CI，0.81 至 0.93]）、心血管再入院（累积发生率，45.0% 对 52.4%；调整后的 HR，0.80 [CI，0.73 至 0.88]）和心力衰竭再入院（累积发生率，24.3% 对 29.4%；调整后的 HR，0.78 [CI，0.69 至 0.88]）。它还与设备相关感染的风险增加相关（累积发生率，1.9% 对 1.0%；调整后的 HR，1.90 [CI，1.07 至 3.37]）。与 ICD 治疗相比，CRT-D 治疗与心力衰竭再入院风险降低相关，这在左束支传导阻滞或 QRS 持续时间至少 150 ms 的患者和女性中最为明显。
患者未随机分配到治疗组，且仅有少数患者可进行倾向评分匹配。研究结果可能不适用于年轻患者或医疗保险之外的患者。
在左心室射血分数降低和 QRS 持续时间延长的老年患者中，与单独使用 ICD 治疗相比，CRT-D 与较低的死亡率和再入院风险相关。
医疗保健研究与质量局。
