title: A clinical prediction rule to identify patients at heightened risk for early demise following cardiac resynchronization therapy.
abstract: BACKGROUND
  In patients with advanced heart failure, the decision of whether to pursue cardiac resynchronization therapy (CRT) or to proceed directly to advanced heart failure therapies can be challenging. We sought to create a prediction rule to identify patients with advanced systolic heart failure at heightened risk of rapid deterioration despite receiving CRT.
  
  
  METHODS
  Clinical data were collected on consecutive patients with advanced heart failure presenting for a new CRT device at the Cleveland Clinic between February 12, 2002 and July 8, 2008. Early demise was defined as death, left ventricular assist device, or heart transplant within 6 months following CRT implant. Using a multivariate model, variables associated with early demise were identified and a prediction rule created.
  
  
  RESULTS
  A total of 879 patients were included of whom 47 met criteria for early demise. Using forward stepwise regression followed by a bootstrapping analysis, the final model included: left ventricular end-diastolic diameter ≥6.5 cm (OR 3.23 [1.72-6.06 g], P < 0.001), the presence of a non-left bundle branch block (non-LBBB) morphology (OR 2.18 [1.18-4.04, P = 0.013]), creatinine ≥1.5 mg/dL (OR 2.98 [1.52-5.49], P < 0.001), and lack of or intolerance to β-blocker use (OR 2.80 [1.46-5.39], P = 0.002). The specificity for ≥2 and ≥3 risk factors was 72.6% and 94.6%, respectively.
  
  
  CONCLUSIONS
  Left ventricular dilatation, the presence of a non-LBBB morphology, renal dysfunction, and lack of or intolerance to β-blockers are associated with early demise following CRT. In patients with at least 3 of these factors, bypassing CRT with early adoption of advanced heart failure therapies may be considered given the high specificity for rapid decline.
authors: Division of Cardiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors: John
authors: J
authors: Rickard
authors: Alan
authors: A
authors: Cheng
authors: David
authors: D
authors: Spragg
authors: Daniel
authors: D
authors: Cantillon
authors: Bryan
authors: B
authors: Baranowski
authors: Niraj
authors: N
authors: Varma
authors: Bruce L
authors: BL
authors: Wilkoff
authors: W H Wilson
authors: WH
authors: Tang
mesh_terms: D000368:Aged; D058406:Cardiac Resynchronization Therapy / Q000009:adverse effects* / Q000639:trends; D015331:Cohort Studies; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D006801:Humans; D007674:Kidney Diseases / Q000175:diagnosis / Q000401:mortality; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis / Q000401:mortality
keywords: cardiac resynchronization therapy; heart failure; implantable cardiac defibrillator; left bundle branch block; mortality