Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora.
Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut.
JAMA Netw Open. 2021 Jan 4;4(1):e2035470. doi: 10.1001/jamanetworkopen.2020.35470.
Frequent right ventricular (RV) pacing can cause and exacerbate heart failure. Cardiac resynchronization therapy (CRT) has been shown to be associated with improved outcomes among patients with reduced left ventricular ejection fraction who need frequent RV pacing, but the patterns of use of CRT vs dual chamber (DC) devices and the associated outcomes among these patients in clinical practice is not known.
To assess outcomes, variability in use of device type, and trends in use of device type over time among patients undergoing implantable cardioverter defibrillator (ICD) implantation who were likely to require frequent RV pacing but who did not have a class I indication for CRT.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used the National Cardiovascular Data Registry (NCDR) ICD Registry. A total of 3100 Medicare beneficiaries undergoing first-time implantation of CRT defibrillator (CRT-D) or DC-ICD from 2010 to 2016 who had a class I or II guideline ventricular bradycardia pacing indication but not a class I indication for CRT were included. Data were analyzed from August 2018 to October 2019.
Implantation of a CRT-D or DC-ICD.
All-cause mortality, heart failure hospitalization, and complications were ascertained from Medicare claims data. Multivariable Cox proportional hazards models and Fine-Gray models were used to evaluate 1-year mortality and heart failure hospitalization, respectively. Multivariable logistic regression was used to evaluate 30-day and 90-day complications. All models accounted for clustering. The median odds ratio (MOR) was used to assess variability and represents the odds that a randomly selected patient receiving CRT-D at a hospital with high implant rates would receive CRT-D if they had been treated at a hospital with low CRT-D implant rates.
A total of 3100 individuals were included. The mean (SD) age was 76.3 (6.4) years, and 2500 (80.6%) were men. The 1698 patients (54.7%) receiving CRT-D were more likely than those receiving DC-ICD to have third-degree atrioventricular block (828 [48.8%] vs 432 [30.8%]; P < .001), nonischemic cardiomyopathy (508 [29.9%] vs 255 [18.2%]; P < .001), and prior heart failure hospitalizations (703 [41.4%] vs 421 [30.0%]; P < .001). Following adjustment, CRT-D was associated with lower 1-year mortality (hazard ratio [HR], 0.70; 95% CI, 0.57-0.87; P = .001) and heart failure hospitalization (subdistribution HR, 0.77; 95% CI, 0.61-0.97; P = .02) and no difference in complications compared with DC-ICD. Hospital variation in use of CRT was present (MOR, 2.00), and the use of CRT in this cohort was higher over time (654 of 1351 [48.4%] in 2010 vs 362 of 594 [60.9%] in 2016; P < .001).
In this cohort study of older patients in contemporary practice undergoing ICD implantation with a bradycardia pacing indication but without a class I indication for CRT, CRT-D was associated with better outcomes compared with DC devices. Variability in use of device type was observed, and the rate of CRT implantation increased over time.
重要性：频繁的右心室（RV）起搏会导致并加剧心力衰竭。心脏再同步治疗（CRT）已被证明与需要频繁 RV 起搏且射血分数降低的患者的预后改善相关，但在临床实践中，这些患者使用 CRT 与双腔（DC）设备的模式以及相关结果尚不清楚。
目的：评估在接受植入式心脏复律除颤器（ICD）植入的患者中，在不太可能需要 CRT 但没有 CRT Ⅰ类适应证的情况下，使用设备类型的结果、使用设备类型的变化以及随时间推移的使用设备类型的趋势。
设计、设置和参与者：这是一项回顾性队列研究，使用了国家心血管数据登记处（NCDR）的 ICD 登记处。共纳入 2010 年至 2016 年期间首次接受 CRT 除颤器（CRT-D）或 DC-ICD 植入的 3100 名 Medicare 受益人的数据，这些患者有 I 类或 II 类指南性室性心动过缓起搏指征，但没有 CRT Ⅰ类适应证。数据于 2018 年 8 月至 2019 年 10 月进行分析。
暴露：植入 CRT-D 或 DC-ICD。
主要结果和措施：从医疗保险索赔数据中确定全因死亡率、心力衰竭住院率和并发症。多变量 Cox 比例风险模型和 Fine-Gray 模型分别用于评估 1 年死亡率和心力衰竭住院率。多变量逻辑回归用于评估 30 天和 90 天的并发症。所有模型都考虑了聚类。中位数优势比（MOR）用于评估变异性，并表示在医院高植入率下随机选择接受 CRT-D 治疗的患者，如果在低 CRT-D 植入率的医院接受治疗，他们接受 CRT-D 的可能性。
结果：共纳入 3100 人。平均（SD）年龄为 76.3（6.4）岁，2500 人（80.6%）为男性。接受 CRT-D 的 1698 名患者（54.7%）更有可能比接受 DC-ICD 的患者患有三度房室传导阻滞（828 [48.8%] vs 432 [30.8%]；P <.001）、非缺血性心肌病（508 [29.9%] vs 255 [18.2%]；P <.001）和心力衰竭住院史（703 [41.4%] vs 421 [30.0%]；P <.001）。调整后，与 DC-ICD 相比，CRT-D 与较低的 1 年死亡率（风险比[HR]，0.70；95%CI，0.57-0.87；P =.001）和心力衰竭住院率（亚分布 HR，0.77；95%CI，0.61-0.97；P =.02）相关，而与 DC-ICD 相比，并发症无差异。CRT 使用的医院差异存在（MOR，2.00），并且该队列中 CRT 的使用随着时间的推移而增加（2010 年的 1351 例中有 654 例[48.4%]，2016 年的 594 例中有 362 例[60.9%]；P <.001）。
结论和相关性：在这项当代实践中接受 ICD 植入且有心动过缓起搏指征但没有 CRT Ⅰ类适应证的老年患者的队列研究中，与 DC 设备相比，CRT-D 与更好的结果相关。观察到设备类型使用的变异性，并且 CRT 植入率随时间增加。
