Causes-of-death analysis of patients with cardiac resynchronization therapy: an analysis of the CeRtiTuDe cohort study

Aims

The choice of resynchronization therapy between with (CRT-D) and without (CRT-P) a defibrillator remains a contentious issue. Cause-of-death analysis among CRT-P, compared with CRT-D, patients could help evaluate the extent to which CRT-P patients would have additionally benefited from a defibrillator in a daily clinical practice.

Methods and results

A total of 1705 consecutive patients implanted with a CRT (CRT-P: 535 and CRT-D: 1170) between 2008 and 2010 were enrolled in CeRtiTuDe, a multicentric prospective follow-up cohort study, with specific adjudication for causes of death at 2 years. Patients with CRT-P compared with CRT-D were older (P < 0.0001), less often male (P < 0.0001), more symptomatic (P = 0.0005), with less coronary artery disease (P = 0.003), wider QRS (P = 0.002), more atrial fibrillation (P < 0.0001), and more co-morbidities (P = 0.04). At 2-year follow-up, the annual overall mortality rate was 83.80 [95% confidence interval (CI) 73.41–94.19] per 1000 person-years. The crude mortality rate among CRT-P patients was double compared with CRT-D (relative risk 2.01, 95% CI 1.56–2.58). In a Cox proportional hazards regression analysis, CRT-P remained associated with increased mortality (hazard ratio 1.54, 95% CI 1.07–2.21, P = 0.0209), although other potential confounders may persist. By cause-of-death analysis, 95% of the excess mortality among CRT-P subjects was related to an increase in non-sudden death.

Conclusion

When compared with CRT-D patients, excess mortality in CRT-P recipients was mainly due to non-sudden death. Our findings suggest that CRT-P patients, as currently selected in routine clinical practice, would not potentially benefit with the addition of a defibrillator.

The French registry of Acute ST elevation or non-ST-elevation Myocardial Infarction (FAST-MI): study design and baseline characteristics

The FAST MI registry was designed to evaluate the 'real world' management of patients with acute myocardial infarction (MI), and to assess their in-hospital, medium- and long-term outcomes. Patients were recruited consecutively from intensive care units over a period of one month (from October 2005), with an additional one-month recruitment period for diabetic patients. The study included 3059 MI patients in phase 1 and an additional 611 diabetic patients in phase 2. Altogether, 53% of the patients had a final diagnosis of Q wave MI and 47% had non Q wave MI. Patients with Q wave MI were more likely to be men, younger, more frequently with a family history or a history of smoking. Patients with non Q wave MI had worst baseline demographic and clinical characteristics mainly explained by their older age. Time from symptom onset to hospital admission was less than three hours for 22% of the patients with Q wave MI and for 14% of the non Q wave MI patients. Among patients with Q wave MI, 64% received reperfusion therapy, 35% with primary percutaneous coronary interventions, 19% with pre-hospital thrombolysis and 10% with in-hospital thrombolysis. Over 70% of patients received statin therapy during the hospital stay and over 90% anti platelet agents. In-hospital mortality was 5.8% in patients with Q wave MI and 4.9% in patients with non Q Wave MI. At discharge beta-adrenergic blockers and statins and, to a lesser extent, medications of the renin angiotensin system were commonly prescribed. Over 90% received antiplatelet agents.

Pediatric AIDS at Mount Sinai Medical Center 1988-89: a study of costs and social severity

Pediatric AIDS is a continuing problem because of maternal transmission. Medical management is often complicated by the loss of one or both parents and adverse home environments. This study explores the cost of inpatient and clinic care of children admitted with AIDS in 1988 or 1989 at Mount Sinai Medical Center in New York City, and also examines the social severity of the cases. Blue Shield allowances were used to price clinic visits and tests, and prices in a drug trade publication were used to determine medication costs. Inpatient costs calculated per person-month at risk amounted to $48,000 per year. Costs per person-month of the clinic care averaged $461 (38% of which was for drugs), annualized to around $5,500. These costs are higher than those shown by previous studies. A few cases requiring intensive inpatient services accounted for a large percentage of costs. The social severity analysis, based on the family environment at first admission and later, revealed that households were often stressed by chronic illnesses, drug abuse, marital problems and poor residential quality. Given the circumstances in which pediatric AIDS develops, the activities of social workers to strengthen families are essential to facilitating compliance, maintaining health and minimizing use of the hospital.