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Safdar NZ, Kamalathasan S, Gupta A, Wren J, Bird R, Papp D, Latto R, Ahmed A, Palin V, Gierula J, Witte KK, Straw S. Outcomes following cardiac resynchronisation therapy in older people. Age Ageing 2023; 52:afad222. [PMID: 38035797 PMCID: PMC10689176 DOI: 10.1093/ageing/afad222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/30/2023] [Indexed: 12/02/2023] Open
Abstract
INTRODUCTION Older patients may be less likely to receive cardiac resynchronisation therapy (CRT) for the management of heart failure. We aimed to describe the differences in clinical response, complications, and subsequent outcomes following CRT implantation compared to younger patients. METHODS We conducted a retrospective cohort study of unselected, consecutive patients implanted with CRT devices between March 2008 and July 2017. We recorded complications, symptomatic and echocardiographic response, hospitalisation for heart failure, and all-cause mortality comparing patients aged <70, 70-79 and ≥ 80 years. RESULTS Five hundred and seventy-four patients (median age 76 years [interquartile range 68-81], 73.3% male) received CRT. At baseline, patients aged ≥80 years had worse symptoms, were more likely to have co-morbidities, and less likely to be receiving comprehensive medical therapy, although left ventricular function was similar. Older patients were less likely to receive CRT-defibrillators compared to CRT-pacemakers. Complications were infrequent and not more common in older patients. Age was not a predictor of symptomatic or echocardiographic response to CRT (67.2%, 71.2% and 62.6% responders in patients aged <70, 70-79 and ≥ 80 years, respectively; P = 0.43), and time to first heart failure hospitalisation was similar across age groups (P = 0.28). Ten-year survival was lower for older patients (49.9%, 23.9% and 6.8% in patients aged <70, 70-79 and ≥ 80 years, respectively; P < 0.001). CONCLUSIONS The benefits of CRT on symptoms and left ventricular function were not different in older patients despite a greater burden of co-morbidities and less optimal medical therapy. These findings support the use of CRT in an ageing population.
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Affiliation(s)
- Nawaz Z Safdar
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Stephe Kamalathasan
- Department of Cardiology, Bradford Teaching Hospitals NHS Trust, Bradford, UK
| | - Ankit Gupta
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Joshua Wren
- Department of Cardiorespiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rory Bird
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Dorothy Papp
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Rebecca Latto
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Ali Ahmed
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Victoria Palin
- Department of Cardiorespiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - John Gierula
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Klaus K Witte
- Medicine Clinic 1, RWTH Aachen University, Aachen, Germany
| | - Sam Straw
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
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Behon A, Merkel ED, Schwertner WR, Kuthi LK, Veres B, Masszi R, Kovács A, Lakatos BK, Zima E, Gellér L, Kosztin A, Merkely B. Long-term outcome of cardiac resynchronization therapy patients in the elderly. GeroScience 2023; 45:2289-2301. [PMID: 36800059 PMCID: PMC10651580 DOI: 10.1007/s11357-023-00739-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 01/19/2023] [Indexed: 02/18/2023] Open
Abstract
Heart failure (HF) is a leading cause of mortality and hospitalization in the elderly. However, data are scarce about their response to device treatment such as cardiac resynchronization therapy (CRT). We aimed to evaluate the age-related differences in the effectiveness of CRT, procedure-related complications, and long-term outcome. Between 2000 and 2020, 2656 patients undergoing CRT implantation were registered and analyzed retrospectively. Patients were divided into 3 groups according to their age: group I, < 65; group II, 65-75; and group III, > 75 years. The primary endpoint was the echocardiographic response defined as a relative increase > 15% in left ventricular ejection fraction (LVEF) within 6 months, and the secondary endpoint was the composite of all-cause mortality, heart transplantation, or left ventricular assist device implantation. Procedure-related complications were also assessed. After implantation, LVEF showed significant improvement both in the total cohort [28% (IQR 24/33) vs. 35% (IQR 28/40); p < 0.01)] and in each subgroup (27% vs. 34%; p < 0.01, 29% vs. 35%; p < 0.01, 30% vs. 35%; p < 0.01). Response rate was similar in the 3 groups (64% vs. 62% vs. 56%; p = 0.41). During the follow-up, 1574 (59%) patients died. Kaplan-Meier curves revealed a significantly lower survival rate in the older groups (log-rank p < 0.001). The cumulative complication rates were similar among the three age groups (27% vs. 28% vs. 24%; p = 0.15). Our results demonstrate that CRT is as effective and safe therapy in the elderly as for young ones. The present data suggest that patients with appropriate indications benefit from CRT in the long term, regardless of age.
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Affiliation(s)
- Anett Behon
- Heart and Vascular Center, Semmelweis University, Varosmajor 68 H-1122, Budapest, Hungary
| | - Eperke Dóra Merkel
- Heart and Vascular Center, Semmelweis University, Varosmajor 68 H-1122, Budapest, Hungary
| | | | - Luca Katalin Kuthi
- Heart and Vascular Center, Semmelweis University, Varosmajor 68 H-1122, Budapest, Hungary
| | - Boglárka Veres
- Heart and Vascular Center, Semmelweis University, Varosmajor 68 H-1122, Budapest, Hungary
| | - Richard Masszi
- Heart and Vascular Center, Semmelweis University, Varosmajor 68 H-1122, Budapest, Hungary
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Varosmajor 68 H-1122, Budapest, Hungary
| | - Bálint Károly Lakatos
- Heart and Vascular Center, Semmelweis University, Varosmajor 68 H-1122, Budapest, Hungary
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, Varosmajor 68 H-1122, Budapest, Hungary
| | - László Gellér
- Heart and Vascular Center, Semmelweis University, Varosmajor 68 H-1122, Budapest, Hungary
| | - Annamária Kosztin
- Heart and Vascular Center, Semmelweis University, Varosmajor 68 H-1122, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Varosmajor 68 H-1122, Budapest, Hungary.
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Savelieva I, Fumagalli S, Kenny RA, Anker S, Benetos A, Boriani G, Bunch J, Dagres N, Dubner S, Fauchier L, Ferrucci L, Israel C, Kamel H, Lane DA, Lip GYH, Marchionni N, Obel I, Okumura K, Olshansky B, Potpara T, Stiles MK, Tamargo J, Ungar A. EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). Europace 2023; 25:1249-1276. [PMID: 37061780 PMCID: PMC10105859 DOI: 10.1093/europace/euac123] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 04/17/2023] Open
Abstract
There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.
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Affiliation(s)
- Irina Savelieva
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Stefano Fumagalli
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Florence, Italy
| | - Rose Anne Kenny
- Mercer’s Institute for Successful Ageing, Department of Medical Gerontology, St James’s Hospital, Dublin, Ireland
| | - Stefan Anker
- Department of Cardiology (CVK), Germany
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Germany
- German Centre for Cardiovascular Research (DZHK) partner site Berlin, Germany
- Charité Universitätsmedizin Berlin, Germany
| | - Athanase Benetos
- Department of Geriatric Medicine CHRU de Nancy and INSERM U1116, Université de Lorraine, Nancy, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Jared Bunch
- (HRS representative): Intermountain Medical Center, Cardiology Department, Salt Lake City,Utah, USA
- Stanford University, Department of Internal Medicine, Palo Alto, CA, USA
| | - Nikolaos Dagres
- Heart Center Leipzig, Department of Electrophysiology, Leipzig, Germany
| | - Sergio Dubner
- (LAHRS representative): Clinica Suizo Argentina, Cardiology Department, Buenos Aires Capital Federal, Argentina
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | | | - Carsten Israel
- Evangelisches Krankenhaus Bielefeld GmbH, Bielefeld, Germany
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, General Cardiology Division, University of Florence and AOU Careggi, Florence, Italy
| | - Israel Obel
- (CASSA representative): Milpark Hospital, Cardiology Unit, Johannesburg, South Africa
| | - Ken Okumura
- (APHRS representative): Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Brian Olshansky
- University of Iowa Hospitals and Clinics, Iowa CityIowa, USA
- Covenant Hospital, Waterloo, Iowa, USA
- Mercy Hospital Mason City, Iowa, USA
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Serbia
- Cardiology Clinic, Clinical Center of Serbia, Serbia
| | - Martin K Stiles
- (APHRS representative): Waikato Clinical School, University of Auckland and Waikato Hospital, Hamilton, New Zealand
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, CIBERCV, Universidad Complutense, Madrid, Spain
| | - Andrea Ungar
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Florence, Italy
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Zeitler EP, Austin AM, Leggett CG, Gilstrap LG, Friedman DJ, Skinner JS, Al-Khatib SM. Complications and Mortality Following CRT-D Versus ICD Implants in Older Medicare Beneficiaries With Heart Failure. JACC. HEART FAILURE 2022; 10:147-157. [PMID: 35241242 DOI: 10.1016/j.jchf.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 10/15/2021] [Accepted: 10/15/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES This study sought to assess the comparative effectiveness of cardiac resynchronization therapy with defibrillator (CRT-D) over implantable cardioverter-defibrillator (ICD) alone in older Medicare patients with heart failure with reduced ejection fraction (HFrEF). BACKGROUND Despite growing numbers of older patients with HFrEF, the benefits of cardiac resynchronization therapy (CRT) in this group are largely unknown. METHODS A cohort of fee-for-service Medicare beneficiaries ≥65 years of age with HFrEF and enrolled in Medicare Part D who underwent CRT-D or ICD implantation from January 2008 to August 2015 was identified. Beneficiaries were divided by age (65-74, 75-84, and 85+ years), and outcomes were compared between the CRT-D and ICD groups after inverse probability weighting. RESULTS Compared with the ICD group, the CRT-D group was older and more likely to be White, be female, and have left bundle branch block. After weighting, overall complications were high across age and device groups (14%-20%). The 1-year mortality was high across all groups. In the 2 oldest age strata, the hazard of death was lower in the CRT-D group (HR: 0.90; 95% CI: 0.86-0.95 and HR: 0.81; 95% CI: 0.72-0.90, respectively; P < 0.001); the hazard of heart failure hospitalization was lower for CRT-D vs ICD in the 85+ years age group (HR: 0.82; 95% CI: 0.74-0.92; P < 0.001). CONCLUSIONS In older Medicare beneficiaries undergoing ICD with or without CRT, complications and 1-year mortality were high. Compared with ICD alone, CRT-D was associated with a lower hazard of mortality in patients ≥74 years of age and lower hazard of HF hospitalization in those ≥85 years of age. These findings support the use of CRT in eligible older patients undergoing ICD implantation.
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Affiliation(s)
- Emily P Zeitler
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Christopher G Leggett
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Lauren G Gilstrap
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Daniel J Friedman
- Duke University Medical Center and Duke Clinical Research Institute, Durham North Carolina, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Sana M Al-Khatib
- Duke University Medical Center and Duke Clinical Research Institute, Durham North Carolina, USA
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5
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McKay B, Tseng NWH, Sheikh HI, Syed MK, Pakosh M, Caterini JE, Sharma A, Colella TJF, Konieczny KM, Connelly KA, Graham MM, McDonald M, Banks L, Randhawa VK. Sex, Race, and Age Differences of Cardiovascular Outcomes in Cardiac Resynchronization Therapy RCTs: A Systematic Review and Meta-analysis. CJC Open 2022; 3:S192-S201. [PMID: 34993449 PMCID: PMC8712541 DOI: 10.1016/j.cjco.2021.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/07/2021] [Indexed: 11/05/2022] Open
Abstract
Background Cardiac resynchronization therapy (CRT) is beneficial in patients who have heart failure with reduced ejection fraction or arrhythmic events. However, most randomized controlled trials (RCTs) showing survival benefits primarily enrolled older white men. This study aims to evaluate CRT efficacy by sex, race, and age in RCTs. Methods Five electronic databases (CINAHL, Embase, Emcare, Medline, and PubMed) were searched from inception to July 12, 2021 for RCTs with CRT in adult patients. Data were analyzed for clinical outcomes including all-cause or cardiovascular (CV) death, worsening heart failure (HF), and HF hospitalization (HFH) according to sex, race, and age. Results Among six RCTs with up to moderate risk of bias, 54% (n = 3,630 of 6,682; mean age 64 years, 22% female, 8% black patients) had CRT device implantation. All-cause death (odds ratio [OR], 0.51; P = 0.053) was reduced in female versus male CRT patients, whereas CV death, HFH, or all-cause death with worsening HF or HFH did not differ significantly. No difference was seen in CRT patients for all-cause death and worsening HF (OR, 1.32; P = 0.46) among white vs black patients or for all-cause death and HFH (OR, 1.19; P = 0.55) among ≥ 65 versus < 65 years. Conclusions Whereas all-cause death was lower in female CRT patients, other reported outcomes did not significantly differ by sex, race, or age. Only 6 studies partially reported outcomes. Thus, enhanced reporting and analyses are required to overcome such paucity of data to evaluate the impact of these factors on clinical outcomes in distinct patient cohorts with CRT indication.
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Affiliation(s)
- Bradley McKay
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | | | - Hassan I Sheikh
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Mohammad K Syed
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Maureen Pakosh
- Library & Information Services, University Health Network, Toronto, Ontario, Canada
| | | | - Abhinav Sharma
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tracey J F Colella
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, Faculty of Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Kaja M Konieczny
- Department of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Kim A Connelly
- Department of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle M Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michael McDonald
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Laura Banks
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada.,KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Varinder Kaur Randhawa
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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6
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Juggan S, Ponnamreddy PK, JrRiley C, Dodge SE, Gilstrap LG, Zeitler EP. Comparative effectiveness of CRT in older patients with heart failure: Systematic review and meta-analysis. J Card Fail 2021; 28:443-452. [PMID: 34774750 DOI: 10.1016/j.cardfail.2021.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 10/17/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To perform meta-analyses comparing safety and effectiveness of cardiac resynchronization therapy (CRT) in older versus younger patients with heart failure with reduced ejection fraction (HFrEF). BACKGROUND Pivotal CRT trials enrolled patients with HFrEF significantly younger than the typical contemporary patient with HFrEF. Thus, risks and benefits in this older population with HFrEF are largely unknown. METHODS PubMed, The Cochrane Library, Scopus, and Web of Science were queried for comparative effectiveness studies of CRT in older HFrEF patients. Title, abstract, and full text screening was performed to identify studies comparing at least one pre-specified endpoint between older and younger adult patients with at least 50 participants. Random effects meta-analysis in LVEF mean difference (older minus younger) and relative risk (RR) of death, improvement in New York Heart Association (NYHA) class, and complications are reported along with estimates of heterogeneity. RESULTS In 7 studies, there was similar LVEF improvement between groups [mean difference 1.14; 95% CI -0.04 - 2.32, p=0.06, I 2 =53%]. Older patients were equally likely as younger patients to see an improvement in NYHA class of at least 1 in 6 studies [RR 0.99; 95% CI, 0.93 - 1.06; p=0.76; I 2 =25%]. No significant differences in the incidence of hematoma, pneumothorax, lead dislodgment, cardiac perforation, or infection requiring explant was observed. RR of mortality in 11 studies demonstrated higher risk of all-cause mortality in older patients [RR 1.05; 95% CI, 1.03 - 1.08, p<0.01, I 2 =0%]. CONCLUSIONS Compared with younger patients, older patients receiving CRT were equally likely to experience improvement in LVEF, LVEDD, and NYHA class. There was no difference in procedural complications. The higher rate of all-cause mortality in older patients likely reflects a greater underlying risk of death from competing causes.
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Affiliation(s)
| | | | - Clifford JrRiley
- Robert Larner M.D. College of Medicine, University of Vermont, Burlington, VT
| | - Shayne E Dodge
- Dartmouth-Hitchcock Medical Center, Section of Cardiovascular Medicine, Lebanon, NH
| | - Lauren G Gilstrap
- Dartmouth-Hitchcock Medical Center, Section of Cardiovascular Medicine, Lebanon, NH; The Dartmouth Institute, Lebanon, NH
| | - Emily P Zeitler
- Dartmouth-Hitchcock Medical Center, Section of Cardiovascular Medicine, Lebanon, NH; The Dartmouth Institute, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH.
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Canterbury A, Saba S. Cardiac resynchronization therapy using a pacemaker or a defibrillator: Patient selection and evidence to support it. Prog Cardiovasc Dis 2021; 66:46-52. [PMID: 33865865 DOI: 10.1016/j.pcad.2021.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 11/25/2022]
Abstract
Cardiac resynchronization therapy (CRT) is an established treatment for patients with heart failure (HF), myocardial dysfunction and prolonged ventricular depolarization on surface electrocardiogram. CRT can be delivered by a pacemaker (CRT-P) or a combined pacemaker-defibrillator (CRT-D). Although these two types of devices are very different in size, function, and cost, current published guidelines do not distinguish between them, leaving the choice of which device to implant to the treating physician and the informed patient. In this paper, we review the published CRT clinical trial literature with focus on the outcomes of HF patients treated with CRT-P versus CRT-D. We also attempt to provide guidance as to the appropriate choice of CRT device type, in the absence of randomized prospective trials geared to answer this specific question.
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Affiliation(s)
- Ann Canterbury
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Samir Saba
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America.
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8
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Yokoyama H, Shishido K, Tobita K, Moriyama N, Murakami M, Saito S. Impact of age on mid-term clinical outcomes and left ventricular reverse remodeling after cardiac resynchronization therapy. J Cardiol 2020; 77:254-262. [PMID: 33036817 DOI: 10.1016/j.jjcc.2020.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The number of heart failure (HF) patients has been rapidly increasing in Japan, and considering the most explosive aging occurring in Asia, the management of elderly HF patients and longer life expectancy are critical issues. The aim of the present study was to evaluate whether the mid-term prognosis after cardiac resynchronization therapy (CRT) implantation was influenced by age and to investigate, in detail, the difference in the change ratio of echocardiographic parameters according to the age group of interest. METHODS AND RESULTS This retrospective analysis included 173 patients who underwent CRT implantation in our hospital from February 2008 to March 2019. Eighty patients (46%) were classified into the elderly group (≥75 years) and the rest in the non-elderly group. The study population was also classified with propensity score matching. The mid-term prognosis including all-cause death and hospitalization for HF, and the ratio of CRT responders were compared between the 2 groups. CRT response was defined as left ventricular (LV) end-systolic volume reduction ≥15% at follow-up echocardiography within a year. During a median follow-up of 1057 [interquartile range: 412, 2107] days, adverse events were not significantly different between the 2 groups before and after matching (before matching; all-cause death: log-rank p = 0.323, hospitalization for HF: log-rank p = 0.376, after matching; all-cause death: log-rank p = 0.325, hospitalization for HF: log-rank p = 0.516). Moreover, the rate of CRT responders was not significantly different between the 2 groups before and after matching (before matching, p = 0.718; after matching, p = 0.666). CONCLUSIONS In elderly HF patients, CRT provided the same clinical benefits as in non-elderly HF patients, furthermore, there was a similar trend in LV reverse remodeling between the 2 groups. The present study demonstrated that the indication of CRT implantation should not be determined by age.
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Affiliation(s)
- Hiroaki Yokoyama
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan
| | - Koki Shishido
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan.
| | - Kazuki Tobita
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan
| | - Noriaki Moriyama
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan
| | - Masato Murakami
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan
| | - Shigeru Saito
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan
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9
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Clinical outcomes and mortality in old and very old patients undergoing cardiac resynchronization therapy. PLoS One 2019; 14:e0225612. [PMID: 31790460 PMCID: PMC6886771 DOI: 10.1371/journal.pone.0225612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/07/2019] [Indexed: 11/19/2022] Open
Abstract
Aim Cardiac resynchronization therapy (CRT) is a valid therapeutic option for patients with heart failure (HF). However, the elderly population was not well represented in the guidelines. The primary end point was to evaluate the impact of advanced age on clinical response and cardiovascular and total mortality of patients undergoing CRT. The secondary end point was to assess the rate of acute complications related to the procedure. Methods and results A total of 249 consecutive patients with HF and optimized treatment, QRS ≥ 120 ms, ejection fraction (EF) ≤ 35% and functional class (FC) III/ IV (NYHA) underwent CRT and divided into 3 groups: Group I—< 65 years—88/ 249 (35%); Group II– 65 to 75 years (old)– 72/ 249 (29%); Group III—≥ 75 years (very old)– 89/ 249 (36%). The improvement in FC and increase in EF (>10%) and/ or decrease in the left ventricular end systolic diameter (LVESD) >15% were the criteria of responsiveness. The favorable clinical response (p = ns) and cardiovascular mortality (p = 0.737) was similar in the 3 groups. In the group of very old patients, a significant increase in total mortality was observed (p = 0.03). The rate of acute complications related to the procedure did not differ between the groups (p = ns). Conclusion The response to CRT and cardiovascular mortality were not affected by the advanced age and should not be an exclusion factor of this therapy. The procedure has been shown to be safe in elderly patients due to low rate of acute complications.
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AlTurki A, Proietti R, Alturki H, Dorian P, Healey JS, Greiss I, Kus T, Essebag V, Huynh T. Meta-Analysis Comparing Neurohumoral Antagonist Use in Patients ≥75 Years Versus <75 Years Receiving Cardiac Resynchronization Therapy. Am J Cardiol 2018; 121:975-980. [PMID: 29576235 DOI: 10.1016/j.amjcard.2018.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 12/23/2017] [Accepted: 01/04/2018] [Indexed: 12/31/2022]
Abstract
Neurohumoral antagonists are the foundation of heart failure therapy in patients with reduced left ventricular ejection fraction. Cardiac resynchronization therapy (CRT) has also been associated with improved outcomes in these patients. We aimed to evaluate the use of neurohumoral antagonists in patients ≥75 years compared with <75 years of age receiving CRT. We searched electronic databases, up to December 20, 2016 for all studies reporting medication use in patients ≥75 years and <75 years of age who received CRT. We used random-effects meta-analysis models to summarize the studies. We retained 12 studies (1 randomized trial and 11 observational studies) enrolling 5,728 ≥75 years old and 9,549 patients of <75 years old. There were lower use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers in patients ≥75 years compared with patients <75 years (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.47 to 0.74, p < 0.0001). In addition, there were lower use of mineralocorticoid receptor antagonists in patients ≥75 years compared with patients <75 years (OR 0.48, 95% CI 0.40 to 0.57, p < 0.0001). The use of β blockers was nonsignificantly lower in patients ≥75 years compared with patients <75 years (OR 0.70, 95% CI 0.47 to 1.03, p = 0.07). In conclusion, neurohumoral antagonists appeared to be underused in patients ≥75 years compared with patients <75 years receiving CRT. Consideration should be given to increase neurohumoral antagonism in patients ≥75 years referred for CRT.
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Affiliation(s)
- Ahmed AlTurki
- Division of Cardiology, McGill University Health Center, Quebec, Canada.
| | - Riccardo Proietti
- Cardiology Department, Morriston Hospital, Swansea University, Swansea, UK
| | - Hasan Alturki
- School of Medicine and Medical Science, University College Dublin. School of Medicine, Dublin, Ireland
| | - Paul Dorian
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Isabelle Greiss
- Division of Cardiology, Montreal University Hospital Center, Montreal, Quebec, Canada
| | - Teresa Kus
- Division of Cardiology, Hopital de Sacre Coeur & Department of Pharmacology & Physiology, Université de Montréal, Montreal, Quebec, Canada
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Center, Quebec, Canada
| | - Thao Huynh
- Division of Cardiology, McGill University Health Center, Quebec, Canada
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Saba S, Adelstein E, Wold N, Stein K, Jones P. Influence of patients' age at implantation on mortality and defibrillator shocks. Europace 2018; 19:802-807. [PMID: 27256416 DOI: 10.1093/europace/euw085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 03/09/2016] [Indexed: 02/05/2023] Open
Abstract
Aims Patients have increasing comorbidities and competing causes of death with advancing age, raising questions about the effectiveness of the implantable cardioverter defibrillators (ICD) in older age. We therefore investigated the effect of patients' age at initial device implantation on all-cause mortality and on the risk of ICD shocks in single-chamber (V-ICD), dual-chamber (D-ICD), and cardiac resynchronization therapy defibrillator (CRT-D) recipients. Methods and results We reviewed de-identified records of 67 128 ICD recipients enrolled in the Boston Scientific ALTITUDE database of remote monitored patients [V-ICD (n = 11 422), D-ICD (n = 23 974), and CRT-D (n = 31 732)]. Over a mean follow-up of 2.3 ± 1.4 years, patients in all ICD groups had increased all-cause mortality but decreased risk of defibrillator shocks and/or anti-tachycardia pacing per 10 year increase in age. Compared with the youngest age group (<50 years), patients in the oldest age group (≥80 years) had a 6.8-fold, 5.9-fold, and 3.4-fold increase in all-cause mortality (P < 0.001 for all comparisons) and a 31, 45, and 53% decrease in the risk of ICD shock (P ≤ 0.002 for all comparisons) for the V-ICD, D-ICD, and CRT-D groups, respectively. Conclusion Older recipients of standard and CRT defibrillators have higher mortality but fewer ICD shocks and/or therapies compared with younger patients. These data highly suggest less benefit of ICD therapy with increasing age, presumably because of competing risks of non-arrhythmic mortality. The role of defibrillator therapy in older patients may need to be evaluated with randomized controlled trials.
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Affiliation(s)
- Samir Saba
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Evan Adelstein
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | - Paul Jones
- Boston Scientific Inc., Minneapolis, MN, USA
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Fumagalli S, Potpara TS, Bjerregaard Larsen T, Haugaa KH, Dobreanu D, Proclemer A, Dagres N. Frailty syndrome: an emerging clinical problem in the everyday management of clinical arrhythmias. The results of the European Heart Rhythm Association survey. Europace 2017; 19:1896-1902. [DOI: 10.1093/europace/eux288] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 08/22/2017] [Indexed: 11/15/2022] Open
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Wilson DG, Zeljko HM, Leventopoulos G, Nauman A, Sylvester GEH, Yue A, Roberts PR, Thomas G, Duncan ER, Roderick PJ, Morgan JM. Increasing age does not affect time to appropriate therapy in primary prevention ICD/CRT-D: a competing risks analysis. Europace 2017; 19:275-281. [PMID: 28173045 DOI: 10.1093/europace/euw034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 02/02/2016] [Indexed: 11/14/2022] Open
Abstract
Aims To evaluate the impact of age on the clinical outcomes in a primary prevention implantable cardioverter defibrillator (ICD)/cardiac resynchronization therapy defibrillator (CRT-D) population. Methods and Results A retrospective, multicentre analysis of patients aged 60 years and over with primary prevention ICD/CRT-D devices implanted between 1 January 2006 and 1 November 2014 was performed. Survival to follow-up with no therapy (T1), death prior to follow-up with no therapy (T2), delivery of appropriate therapy with survival to follow-up (T3), and delivery of appropriate therapy with death prior to follow-up (T4) were measured. In total, 424 patients were eligible for inclusion in the analysis, mean follow-up of 32.6 months during which time 44 patients (10.1%) received appropriate therapy. The sub-hazard ratio (SHR) for the cumulative incidence of appropriate therapy (T3) according to age at implant was 1.00 (P = 0.851; 95% CI 0.96–1.04). The SHR for cumulative incidence of death (T2) according to age at implant was 1.06 (P < 0.001; 95% CI 1.03–1.01). Age at implant, ischaemic aetiology, baseline haemoglobin, and the presence of diabetes mellitus were predictors of all-cause mortality. Conclusion Age has no impact on the time to appropriate therapy, but risk of death prior to therapy increases by 6% for every year increment. As the ICD population ages, the proportion who die without receiving appropriate therapy increases due to competing risks. Characterizing competing risks predictive of death independent of ICD indication would focus therapy on those with potential to benefit and reduce unnecessary exposure to ICD-related morbidity.
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Affiliation(s)
- David G Wilson
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Ahmed Nauman
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Arthur Yue
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Paul R Roberts
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Glyn Thomas
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Edward R Duncan
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Paul J Roderick
- Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - John M Morgan
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Complications and 1-year benefit of cardiac resynchronization therapy in patients over 75 years of age - Insights from the German Device Registry. Int J Cardiol 2016; 228:784-789. [PMID: 27898337 DOI: 10.1016/j.ijcard.2016.11.212] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 10/17/2016] [Accepted: 11/07/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Evidence on cardiac resynchronization therapy (CRT) in older patients is scarce and conflicting. Nevertheless, CRT in the elderly is of major practical relevance as heart failure prevalence increases with age. METHODS The German Device Registry (DEVICE) is a nationwide, prospective registry with a longitudinal follow-up design investigating device implantations in 60 German centres. The present analysis of DEVICE focussed on perioperative complication rates and 1-year outcome of patients ≥75years (n=320) compared to younger patients (n=879) receiving a CRT device. RESULTS Comorbidities were more common in older patients (chronic kidney disease (CKD): 27.5% vs. 21.5%, p=0.029; atrial fibrillation (AF): 26.9% vs. 15.6%, p<0.001). Despite higher NYHA classes in the older age group, ejection fractions were comparable (27.2±7.1% ≥75years, 26.2±7.1% <75years, p=0.06). Perioperative complications and mortality rates did not show significant difference between groups. After new device implantation, absolute 1-year mortality was higher in older patients (11.0% ≥75years, 6.4% <75years, p=0.014), with a significantly lower proportion of cardiac deaths in the older group (p=0.05). Patients ≥75years being alive after 1year had lower response rates, with chronic kidney disease (OR 0.46, p<0.05) and smaller QRS complexes (OR 0.31, p<0.01) being particular risk factors for missing improvement of heart failure symptoms. As expected severe heart failure (NYHA IV) was a strong independent predictor of death (HR 1.95, p=0.01), whereas AF as underlying rhythm could be worked out as predictor for mortality especially in the younger patients (HR 2.31, p=0.002). CONCLUSIONS Patients ≥75years of age receiving a CRT device do not have a higher perioperative mortality and complication rate although comorbidities (CKD and AF) occur more frequently. The absolute 1-year mortality is higher; nevertheless, the proportion of cardiac deaths is even lower in the older patients reflecting a benefit of CRT in this group.
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