Munir Muhammad Bilal, Althouse Andrew D, Rijal Shasank, Shah Maulin Bharat, Abu Daya Hussein, Adelstein Evan, Saba Samir
Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
J Cardiovasc Electrophysiol. 2016 Jun;27(6):730-4. doi: 10.1111/jce.12951. Epub 2016 Mar 14.
Cardiac resynchronization therapy (CRT) is commonly used to manage heart failure, yet published guidelines do not distinguish between recommendations for pacemakers (CRT-P) and defibrillators (CRT-D) despite significant differences in size, longevity, and cost between these devices. The purpose of this study is to compare the clinical characteristics and outcomes between elderly recipients of CRT-P and CRT-D.
Data from 512 patients (405 CRT-D, 107 CRT-P) aged ≥75 years with LV ejection fraction ≤35% and QRS duration >120 milliseconds were retrospectively analyzed for baseline characteristics and followed to the primary outcome of all-cause mortality. Cox proportional hazards models were used to adjust for possible confounders. Results were further validated through propensity matching cohorts. Compared to CRT-D recipients, CRT-P patients were older (83 years vs. 81 years, P < 0.001) and had more comorbid conditions (Charlson index = 5 [3-6] vs. 4 [3-5], P = 0.007). During 40.8 months of follow-up, there were 280 deaths. Compared to CRT-D patients, CRT-P recipients had higher unadjusted mortality (HR 1.54, 95% CI 1.15-2.08, P = 0.004). However, this difference lost significance after adjusting for baseline differences between the groups (HR 1.18, 95% CI 0.78-1.77, P = 0.435).
Higher all-cause mortality in older CRT-P versus CRT-D patients is largely explained by baseline clinical and demographic differences between the two groups, which are likely the drivers of device selection in real-world clinical practice, where the published guidelines remain ambiguous. There is a need for randomized studies to determine optimal CRT device selection.
心脏再同步治疗（CRT）常用于治疗心力衰竭，但尽管起搏器（CRT-P）和除颤器（CRT-D）在尺寸、使用寿命和成本上存在显著差异，已发布的指南并未对二者的推荐进行区分。本研究的目的是比较CRT-P和CRT-D老年接受者的临床特征和预后。
回顾性分析了512例年龄≥75岁、左心室射血分数≤35%且QRS时限>120毫秒的患者（405例CRT-D，107例CRT-P）的基线特征，并随访至全因死亡的主要结局。采用Cox比例风险模型对可能的混杂因素进行调整。通过倾向匹配队列进一步验证结果。与CRT-D接受者相比，CRT-P患者年龄更大（83岁对81岁，P<0.001），合并症更多（Charlson指数=5[3-6]对4[3-5]，P=0.007）。在40.8个月的随访期间，有280例死亡。与CRT-D患者相比，CRT-P接受者的未调整死亡率更高（风险比1.54，95%置信区间1.15-2.08，P=0.004）。然而，在调整两组之间的基线差异后，这种差异失去了显著性（风险比1.18，95%置信区间0.78-1.77，P=0.435）。
CRT-P老年患者较高的全因死亡率在很大程度上可由两组之间的基线临床和人口统计学差异来解释，这些差异可能是现实临床实践中设备选择的驱动因素，而已发布的指南对此仍不明确。需要进行随机研究以确定最佳的CRT设备选择。
