Comparative Effectiveness of Cardiac Resynchronization Therapy Among Patients With Heart Failure and Atrial Fibrillation: Findings From the National Cardiovascular Data Registry's Implantable Cardioverter-Defibrillator Registry.
Atrial fibrillation is common in patients with heart failure, but outcomes of patients with both conditions who receive cardiac resynchronization therapy with defibrillator (CRT-D) compared with an implantable cardioverter-defibrillator (ICD) alone are unclear.



Using the National Cardiovascular Data Registry's ICD Registry linked with Medicare claims, we identified 8951 patients with atrial fibrillation who were eligible for CRT-D and underwent first-time device implantation for primary prevention between April 2006 and December 2009. We used Cox proportional hazards models and inverse probability-weighted estimates to compare outcomes with CRT-D versus ICD alone. Cumulative incidence of mortality (744 [33%] for ICD; 1893 [32%] for CRT-D) and readmission (1788 [76%] for ICD; 4611 [76%] for CRT-D) within 3 years and complications within 90 days were similar between groups. After inverse weighting for the probability of receiving CRT-D, risks of mortality (hazard ratio, 0.83; 95% confidence interval, 0.75-0.92), all-cause readmission (hazard ratio, 0.86; 95% confidence interval, 0.80-0.92), and heart failure readmission (hazard ratio, 0.68; 95% confidence interval, 0.62-0.76) were lower with CRT-D compared with ICD alone. There was no significant difference in the 90-day complication rate (hazard ratio, 0.88; 95% confidence interval, 0.60-1.29). We observed hospital-level variation in the use of CRT-D among patients with atrial fibrillation.



Among eligible patients with heart failure and atrial fibrillation, CRT-D was associated with lower risks of mortality, all-cause readmission, and heart failure readmission, as well as with a similar risk of complications compared with ICD alone.
From the Duke Clinical Research Institute (P.K., M.A.G., S.M.A.-K., J.P.P., L.H.C., A.F.H.) and Department of Medicine (P.K., S.M.A.-K., J.P.P., L.H.C., A.F.H.), Duke University School of Medicine, Durham, NC; Veterans Affairs Eastern Colorado Healthcare System, Denver, CO (P.D.V.); University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M.); and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA and Stanford University School of Medicine, CA (M.P.T.).
Prateeti
P
Khazanie
From the Duke Clinical Research Institute (P.K., M.A.G., S.M.A.-K., J.P.P., L.H.C., A.F.H.) and Department of Medicine (P.K., S.M.A.-K., J.P.P., L.H.C., A.F.H.), Duke University School of Medicine, Durham, NC; Veterans Affairs Eastern Colorado Healthcare System, Denver, CO (P.D.V.); University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M.); and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA and Stanford University School of Medicine, CA (M.P.T.).
Melissa A
MA
Greiner
From the Duke Clinical Research Institute (P.K., M.A.G., S.M.A.-K., J.P.P., L.H.C., A.F.H.) and Department of Medicine (P.K., S.M.A.-K., J.P.P., L.H.C., A.F.H.), Duke University School of Medicine, Durham, NC; Veterans Affairs Eastern Colorado Healthcare System, Denver, CO (P.D.V.); University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M.); and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA and Stanford University School of Medicine, CA (M.P.T.).
Sana M
SM
Al-Khatib
From the Duke Clinical Research Institute (P.K., M.A.G., S.M.A.-K., J.P.P., L.H.C., A.F.H.) and Department of Medicine (P.K., S.M.A.-K., J.P.P., L.H.C., A.F.H.), Duke University School of Medicine, Durham, NC; Veterans Affairs Eastern Colorado Healthcare System, Denver, CO (P.D.V.); University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M.); and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA and Stanford University School of Medicine, CA (M.P.T.).
Jonathan P
JP
Piccini
From the Duke Clinical Research Institute (P.K., M.A.G., S.M.A.-K., J.P.P., L.H.C., A.F.H.) and Department of Medicine (P.K., S.M.A.-K., J.P.P., L.H.C., A.F.H.), Duke University School of Medicine, Durham, NC; Veterans Affairs Eastern Colorado Healthcare System, Denver, CO (P.D.V.); University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M.); and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA and Stanford University School of Medicine, CA (M.P.T.).
Mintu P
MP
Turakhia
From the Duke Clinical Research Institute (P.K., M.A.G., S.M.A.-K., J.P.P., L.H.C., A.F.H.) and Department of Medicine (P.K., S.M.A.-K., J.P.P., L.H.C., A.F.H.), Duke University School of Medicine, Durham, NC; Veterans Affairs Eastern Colorado Healthcare System, Denver, CO (P.D.V.); University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M.); and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA and Stanford University School of Medicine, CA (M.P.T.).
Paul D
PD
Varosy
From the Duke Clinical Research Institute (P.K., M.A.G., S.M.A.-K., J.P.P., L.H.C., A.F.H.) and Department of Medicine (P.K., S.M.A.-K., J.P.P., L.H.C., A.F.H.), Duke University School of Medicine, Durham, NC; Veterans Affairs Eastern Colorado Healthcare System, Denver, CO (P.D.V.); University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M.); and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA and Stanford University School of Medicine, CA (M.P.T.).
Frederick A
FA
Masoudi
From the Duke Clinical Research Institute (P.K., M.A.G., S.M.A.-K., J.P.P., L.H.C., A.F.H.) and Department of Medicine (P.K., S.M.A.-K., J.P.P., L.H.C., A.F.H.), Duke University School of Medicine, Durham, NC; Veterans Affairs Eastern Colorado Healthcare System, Denver, CO (P.D.V.); University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M.); and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA and Stanford University School of Medicine, CA (M.P.T.).
Lesley H
LH
Curtis
From the Duke Clinical Research Institute (P.K., M.A.G., S.M.A.-K., J.P.P., L.H.C., A.F.H.) and Department of Medicine (P.K., S.M.A.-K., J.P.P., L.H.C., A.F.H.), Duke University School of Medicine, Durham, NC; Veterans Affairs Eastern Colorado Healthcare System, Denver, CO (P.D.V.); University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M.); and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA and Stanford University School of Medicine, CA (M.P.T.). adrian.hernandez@duke.edu.
Adrian F
AF
Hernandez
D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D058406:Cardiac Resynchronization Therapy / Q000009:adverse effects / Q000401:mortality; D058409:Cardiac Resynchronization Therapy Devices; D016009:Chi-Square Distribution; D057186:Comparative Effectiveness Research; D016757:Death, Sudden, Cardiac / Q000209:etiology / Q000517:prevention & control*; D017147:Defibrillators, Implantable; D004554:Electric Countershock / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D006278:Medicare; D010359:Patient Readmission; D011322:Primary Prevention / Q000295:instrumentation*; D057216:Propensity Score; D016016:Proportional Hazards Models; D012042:Registries; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
atrial fibrillation; cardiac resynchronization therapy; heart failure; hospitalization; prevalence