Review gives CRT with defibrillators, pacemakers high marks

Cardiac resynchronization with defibrillators (CRT-D) or pacemakers (CRT-P) fared well in an assessment of their benefits to Medicare beneficiaries. The document will remain available for review and comment through Dec. 15.

The Agency for Healthcare Research and Quality posted a 180-page analysis of research on the benefits and harms of cardiac resynchronization therapy compared with implantable cardiac defibrillators (ICDs) alone, findings that can be used for practice guidelines, quality programs and to determine reimbursement and coverage for Medicare patients. The study included 53 studies identified in literature searches through July 24, 2014.

The authors noted that CRT devices initially were indicated for patients with congestive heart failure  with left ventricular ejection fraction of 35 percent or less, New York Heart Association (NYHA) class III-IV heart failure symptoms and with a QRS duration 120ms or more on optimal medical therapy. The use has expanded to include NYHA class I and II patients. In both cases, many patients also receive an ICD.

The reviewers described the strength of evidence as high for a number of outcomes with CRT-D compared with ICD alone. Those included reducing heart failure hospitalizations, inducing ventricular reverse modeling, improving quality of life and increasing walking distances.

For CRT-P vs. optimal medical therapy, they termed the strength of evidence as moderate for improving all-cause survival and reducing heart failure hospitalizations. Reviewers also gave CRT-P the edge for inducing ventricular reverse modeling and increasing walking distances.

They identified female gender, left bundle branch block, a widened QRS duration, sinus rhythm and nonischemic cardiomyopathy as predictors of improved outcomes with CRT, but they added as a caveat that the findings may be skewed by reporting biases.

They found insufficient evidence to compare the effectiveness of CRT-D and CRT-P. But they deemed the evidence for CRT-D vs. ICD and CRT-P vs. optimal medical therapy to be convincing for showing effectiveness in several clinical outcomes and endpoints.

The document is available online here.