Better outcome at lower costs after implementing a CRT-care pathway: a comprehensive evaluation of real-world data

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Medtronic plc.

Background

Cardiac resynchronization therapy (CRT) requires intensive, complex and multi-disciplinary care to maximize clinical benefit in heart failure patients. In current practice, this is often incomplete due to limitations in time, resources and coordination of care.

Purpose

We evaluated the effect of the introduction of a novel multidisciplinary, standardized CRT care pathway (CRT-CPW) compared with usual care, on clinical outcome and costs.

Methods

The CRT care pathway (CRT-CPW) design, based on an expert consensus of experienced European CRT specialists; focussed on structuring patient selection, implantation and follow-up heart failure treatment and device management. To facilitate and guarantee quality, checklists fitted to each moment in the care pathway were designed, to aid contributors. The CRT-CPW was implemented in the Maastricht University Medical Centre in 2014. Data from patients receiving usual care (2012-2014, 222 patients) and patients receiving care under the CRT-CPW (2015-2018, 241 patients) were compared. Data was extracted from the hospital information system. The primary outcome was the composite of all-cause mortality and heart failure (HF) hospitalization. Hospital-related costs of cardiovascular care after CRT implantation was analysed to address cost-effectiveness.

Results

Patient demographics were comparable in both groups, except that the CRT-CPW group showed more AF and previous myocardial infarction at baseline. The combined endpoint of death from any cause and admission for HF occurred in 127 patients (57.2%) in the usual care group and 64 patients (26.6%) in the CRT- CPW group (adjusted HR 0.68 (95% CI, 0.49 to 0.93), p = 0.015) (Figure 1A). Total costs for cardiology related hospitalizations reduced significantly in the CRT care pathway group (€ 19.177 ± 9.692 vs 20.613 ± 7.066, p< 0.001, Table 4). Bootstrap analyses revealed that 90.7% of samples would show improved outcomes as well as reduction in costs in the CRT-CPW treatment group (Figure 1B).

Conclusion

The introduction of a novel CRT-CPW resulted in improved clinical outcome and reduced costs. Abstract Figure 1 Clinical outcome and costs

Rationale and perspective of endothelin-1 antagonism in acute heart failure

A role of the potent and long-acting vasoconstrictor peptide endothelin (ET)- I in the pathophysiology of chronic human heart failure has been postulated, based upon indirect evidence such as elevated plasma ET-1 levels and their relationship to the degree of haemodynamic impairment. Acute heart failure shares many features of chronic heart failure, albeit in an exaggerated fashion. As both the mixed ETA/ETB-receptor antagonist bosentan and the selective ETA receptor antagonist BQ 123 acutely improved the haemodynamics of chronic heart failure patients, there seems to be good reason to believe that ET-1 receptor antagonism may also be of benefit in the setting of acute heart failure. However, appropriate trials will have to be performed to document the clinical benefit of such an approach. Finally, the question remains open as to whether mixed ET-1 receptor antagonists like bosentan will prove better, worse or equal to antagonists that block the ETA, receptor only.