Implantable Cardioverter-Defibrillators With Versus Without Resynchronization Therapy in Patients With a QRS Duration >180 ms

Varun Sundaram, Jayakumar Sahadevan, Albert L. Waldo, George J. Stukenborg, Yogesh N.V. Reddy, Samuel J Asirvatham, Judith A. Mackall, Anselma Intini, Brigid Wilson, Daniel I. Simon, Kenneth C. Bilchick

Research output: Contribution to journalArticle

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Abstract

Background More than 20% of Medicare beneficiaries receiving cardiac resynchronization therapy defibrillators (CRT-D) have a very wide (≥180 ms) QRS complex duration (QRSD). Outcomes of CRT-D in these patients are not well-established because they have been underrepresented in clinical trials. Objectives This study examined outcomes in patients with CRT-D in a very wide QRSD with left bundle branch block (LBBB) versus those without LBBB. Methods Medicare patients from the Implantable Cardioverter Defibrillator Registry (January 1, 2005, through April 30, 2006) with a CRT-D and confirmed Class I or IIa indications for CRT-D were matched to implantable cardioverter-defibrillator (ICD) patients without CRT despite having Class I or IIa indications for CRT. Mortality and heart failure hospitalizations longer than 4 years with CRT-D versus standard ICDs based on a QRSD and morphology were analyzed. Results We analyzed 24,960 patients. Among those with LBBB, patients with a QRSD ≥180 ms had a greater adjusted survival benefit with CRT-D versus standard ICD (hazard ration [HR] for death: 0.65; 95% confidence interval [CI]: 0.59 to 0.72) compared with those having a QRSD 120 to 149 ms (HR: 0.85; 95% CI: 0.80 to 0.92) and 150 to 179 ms (HR: 0.87; 95% CI: 0.81 to 0.93). CRT-D versus ICD was associated with an improvement in survival in those with LBBB and a QRSD ≥180 ms (adjusted HR for death: 0.78; 95% CI: 0.68 to 0.91), but not in those with LBBB and a QRSD 150 to 179 ms (adjusted HR for death: 1.06; 95% CI: 0.95 to 1.19). Conclusions Improvements in both survival and heart failure hospitalizations with CRT-D were greatest in patients with a QRSD ≥180 ms with or without LBBB, whereas patients with a QRSD 150 to 179 ms without LBBB had no improvement in survival with CRT-D, and those with a QRSD 150 to 179 ms and LBBB had only a modest improvement.

Original languageEnglish (US)
Pages (from-to)2026-2036
Number of pages11
JournalJournal of the American College of Cardiology
Volume69
Issue number16
DOIs
StatePublished - Apr 25 2017

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Cardiac Resynchronization Therapy
Defibrillators
Implantable Defibrillators
Bundle-Branch Block
Confidence Intervals
Therapeutics
Medicare
Survival
Hospitalization
Heart Failure
Registries
Outcome Assessment (Health Care)
Clinical Trials

Keywords

  • bundle branch block
  • cardiac resynchronization therapy
  • heart failure
  • outcomes
  • very wide QRS complex

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Implantable Cardioverter-Defibrillators With Versus Without Resynchronization Therapy in Patients With a QRS Duration >180 ms. / Sundaram, Varun; Sahadevan, Jayakumar; Waldo, Albert L.; Stukenborg, George J.; Reddy, Yogesh N.V.; Asirvatham, Samuel J; Mackall, Judith A.; Intini, Anselma; Wilson, Brigid; Simon, Daniel I.; Bilchick, Kenneth C.

In: Journal of the American College of Cardiology, Vol. 69, No. 16, 25.04.2017, p. 2026-2036.

Research output: Contribution to journalArticle

Sundaram, V, Sahadevan, J, Waldo, AL, Stukenborg, GJ, Reddy, YNV, Asirvatham, SJ, Mackall, JA, Intini, A, Wilson, B, Simon, DI & Bilchick, KC 2017, 'Implantable Cardioverter-Defibrillators With Versus Without Resynchronization Therapy in Patients With a QRS Duration >180 ms', Journal of the American College of Cardiology, vol. 69, no. 16, pp. 2026-2036. https://doi.org/10.1016/j.jacc.2017.02.042
Sundaram, Varun ; Sahadevan, Jayakumar ; Waldo, Albert L. ; Stukenborg, George J. ; Reddy, Yogesh N.V. ; Asirvatham, Samuel J ; Mackall, Judith A. ; Intini, Anselma ; Wilson, Brigid ; Simon, Daniel I. ; Bilchick, Kenneth C. / Implantable Cardioverter-Defibrillators With Versus Without Resynchronization Therapy in Patients With a QRS Duration >180 ms. In: Journal of the American College of Cardiology. 2017 ; Vol. 69, No. 16. pp. 2026-2036.
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title = "Implantable Cardioverter-Defibrillators With Versus Without Resynchronization Therapy in Patients With a QRS Duration >180 ms",
abstract = "Background More than 20{\%} of Medicare beneficiaries receiving cardiac resynchronization therapy defibrillators (CRT-D) have a very wide (≥180 ms) QRS complex duration (QRSD). Outcomes of CRT-D in these patients are not well-established because they have been underrepresented in clinical trials. Objectives This study examined outcomes in patients with CRT-D in a very wide QRSD with left bundle branch block (LBBB) versus those without LBBB. Methods Medicare patients from the Implantable Cardioverter Defibrillator Registry (January 1, 2005, through April 30, 2006) with a CRT-D and confirmed Class I or IIa indications for CRT-D were matched to implantable cardioverter-defibrillator (ICD) patients without CRT despite having Class I or IIa indications for CRT. Mortality and heart failure hospitalizations longer than 4 years with CRT-D versus standard ICDs based on a QRSD and morphology were analyzed. Results We analyzed 24,960 patients. Among those with LBBB, patients with a QRSD ≥180 ms had a greater adjusted survival benefit with CRT-D versus standard ICD (hazard ration [HR] for death: 0.65; 95{\%} confidence interval [CI]: 0.59 to 0.72) compared with those having a QRSD 120 to 149 ms (HR: 0.85; 95{\%} CI: 0.80 to 0.92) and 150 to 179 ms (HR: 0.87; 95{\%} CI: 0.81 to 0.93). CRT-D versus ICD was associated with an improvement in survival in those with LBBB and a QRSD ≥180 ms (adjusted HR for death: 0.78; 95{\%} CI: 0.68 to 0.91), but not in those with LBBB and a QRSD 150 to 179 ms (adjusted HR for death: 1.06; 95{\%} CI: 0.95 to 1.19). Conclusions Improvements in both survival and heart failure hospitalizations with CRT-D were greatest in patients with a QRSD ≥180 ms with or without LBBB, whereas patients with a QRSD 150 to 179 ms without LBBB had no improvement in survival with CRT-D, and those with a QRSD 150 to 179 ms and LBBB had only a modest improvement.",
keywords = "bundle branch block, cardiac resynchronization therapy, heart failure, outcomes, very wide QRS complex",
author = "Varun Sundaram and Jayakumar Sahadevan and Waldo, {Albert L.} and Stukenborg, {George J.} and Reddy, {Yogesh N.V.} and Asirvatham, {Samuel J} and Mackall, {Judith A.} and Anselma Intini and Brigid Wilson and Simon, {Daniel I.} and Bilchick, {Kenneth C.}",
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T1 - Implantable Cardioverter-Defibrillators With Versus Without Resynchronization Therapy in Patients With a QRS Duration >180 ms

AU - Sundaram, Varun

AU - Sahadevan, Jayakumar

AU - Waldo, Albert L.

AU - Stukenborg, George J.

AU - Reddy, Yogesh N.V.

AU - Asirvatham, Samuel J

AU - Mackall, Judith A.

AU - Intini, Anselma

AU - Wilson, Brigid

AU - Simon, Daniel I.

AU - Bilchick, Kenneth C.

PY - 2017/4/25

Y1 - 2017/4/25

N2 - Background More than 20% of Medicare beneficiaries receiving cardiac resynchronization therapy defibrillators (CRT-D) have a very wide (≥180 ms) QRS complex duration (QRSD). Outcomes of CRT-D in these patients are not well-established because they have been underrepresented in clinical trials. Objectives This study examined outcomes in patients with CRT-D in a very wide QRSD with left bundle branch block (LBBB) versus those without LBBB. Methods Medicare patients from the Implantable Cardioverter Defibrillator Registry (January 1, 2005, through April 30, 2006) with a CRT-D and confirmed Class I or IIa indications for CRT-D were matched to implantable cardioverter-defibrillator (ICD) patients without CRT despite having Class I or IIa indications for CRT. Mortality and heart failure hospitalizations longer than 4 years with CRT-D versus standard ICDs based on a QRSD and morphology were analyzed. Results We analyzed 24,960 patients. Among those with LBBB, patients with a QRSD ≥180 ms had a greater adjusted survival benefit with CRT-D versus standard ICD (hazard ration [HR] for death: 0.65; 95% confidence interval [CI]: 0.59 to 0.72) compared with those having a QRSD 120 to 149 ms (HR: 0.85; 95% CI: 0.80 to 0.92) and 150 to 179 ms (HR: 0.87; 95% CI: 0.81 to 0.93). CRT-D versus ICD was associated with an improvement in survival in those with LBBB and a QRSD ≥180 ms (adjusted HR for death: 0.78; 95% CI: 0.68 to 0.91), but not in those with LBBB and a QRSD 150 to 179 ms (adjusted HR for death: 1.06; 95% CI: 0.95 to 1.19). Conclusions Improvements in both survival and heart failure hospitalizations with CRT-D were greatest in patients with a QRSD ≥180 ms with or without LBBB, whereas patients with a QRSD 150 to 179 ms without LBBB had no improvement in survival with CRT-D, and those with a QRSD 150 to 179 ms and LBBB had only a modest improvement.

AB - Background More than 20% of Medicare beneficiaries receiving cardiac resynchronization therapy defibrillators (CRT-D) have a very wide (≥180 ms) QRS complex duration (QRSD). Outcomes of CRT-D in these patients are not well-established because they have been underrepresented in clinical trials. Objectives This study examined outcomes in patients with CRT-D in a very wide QRSD with left bundle branch block (LBBB) versus those without LBBB. Methods Medicare patients from the Implantable Cardioverter Defibrillator Registry (January 1, 2005, through April 30, 2006) with a CRT-D and confirmed Class I or IIa indications for CRT-D were matched to implantable cardioverter-defibrillator (ICD) patients without CRT despite having Class I or IIa indications for CRT. Mortality and heart failure hospitalizations longer than 4 years with CRT-D versus standard ICDs based on a QRSD and morphology were analyzed. Results We analyzed 24,960 patients. Among those with LBBB, patients with a QRSD ≥180 ms had a greater adjusted survival benefit with CRT-D versus standard ICD (hazard ration [HR] for death: 0.65; 95% confidence interval [CI]: 0.59 to 0.72) compared with those having a QRSD 120 to 149 ms (HR: 0.85; 95% CI: 0.80 to 0.92) and 150 to 179 ms (HR: 0.87; 95% CI: 0.81 to 0.93). CRT-D versus ICD was associated with an improvement in survival in those with LBBB and a QRSD ≥180 ms (adjusted HR for death: 0.78; 95% CI: 0.68 to 0.91), but not in those with LBBB and a QRSD 150 to 179 ms (adjusted HR for death: 1.06; 95% CI: 0.95 to 1.19). Conclusions Improvements in both survival and heart failure hospitalizations with CRT-D were greatest in patients with a QRSD ≥180 ms with or without LBBB, whereas patients with a QRSD 150 to 179 ms without LBBB had no improvement in survival with CRT-D, and those with a QRSD 150 to 179 ms and LBBB had only a modest improvement.

KW - bundle branch block

KW - cardiac resynchronization therapy

KW - heart failure

KW - outcomes

KW - very wide QRS complex

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