Highlights
- •The benefits and risks of cardiac resynchronization therapy in older patients with heart failure are uncertain despite broad use.
- •Eighteen cardiac resynchronization therapy studies in older vs younger patients were identified with mean age of 78 and 65 years, respectively.
- •A meta-analysis demonstrated increased mortality in older patients with cardiac resynchronization therapy.
- •Left ventricular ejection fraction, left ventricular end-diastolic diameter, and New York Heart Association functional class improvements were similar with no difference in complications.
- •Cardiac resynchronization therapy should be considered for eligible patients with heart failure regardless of age.
Abstract
Background
Pivotal CRT trials enrolled patients with HFrEF significantly younger than the typical
contemporary patient with HFrEF. Thus, the risks and benefits in this older population
with HFrEF are largely unknown. We sought to perform meta-analyses comparing safety
and effectiveness of cardiac resynchronization therapy (CRT) in older vs younger patients
with heart failure with reduced ejection fraction (HFrEF).
Methods and Results
PubMed, The Cochrane Library, Scopus, and Web of Science were queried for comparative
effectiveness studies of CRT in older patients with HFrEF. Title, abstract, and full-text
screening was performed to identify studies comparing at least 1 prespecified end
point between older and younger adult patients with at least 50 participants. Random
effects meta-analysis in the left ventricular ejection fraction (LVEF) mean difference
(older minus younger) and the relative risk (RR) of death, improvement in New York
Heart Association (NYHA) functional class, and complications are reported along with
estimates of heterogeneity. In 7 studies, there was similar LVEF improvement between
groups (mean difference 1.14, 95% confidence interval [CI] –0.04 to 2.32, P = .06, I2 = 53%). Older patients were equally likely as younger patients to see an improvement
in NYHA functional class of at least 1 in 6 studies (RR 0.99, 95% CI 0.93–1.06, P = .76, I2 = 25%). No significant differences in the incidence of hematoma, pneumothorax, lead
dislodgment, cardiac perforation, or infection requiring explant was observed. The
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 < .01, I2 = 0%).
Conclusions
Compared with younger patients, older patients receiving CRT were equally likely to
experience improvement in LVEF, left ventricular end-diastolic diameter, and NYHA
functional 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.
Key Words
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Article info
Publication history
Published online: November 10, 2021
Accepted:
October 19,
2021
Received in revised form:
October 17,
2021
Received:
May 24,
2021
Identification
Copyright
© 2021 Elsevier Inc. All rights reserved.
