Proven Heart Failure Therapy Not Standardized In US Hospitals

Ruzanna Harutyunyan's picture
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Cardiac resynchronization therapy (CRT) can help heart failure patients’ hearts beat more efficiently and effectively, but the therapy isn’t used in U.S. hospitals as much as it should be and often it’s not used as recommended in clinical trials and published guidelines, according to a report in Circulation: Journal of the American Heart Association.

CRT involves doctors implanting a device in heart failure patients that paces the heart’s main chambers to beat in sync.

“Studies have shown that, when used in combination with optimal medical therapy, CRT is associated with a 50 percent reduction in hospitalization for heart failure and a 36 percent reduction in mortality, or death,” said Adrian F. Hernandez, M.D., M.H.S., author of the study and assistant professor of medicine in the Duke Clinical Research Institute at Duke University in Durham, N.C. “We did this study to analyze if and how this new therapy is being used in U.S. hospitals.”

Hernandez and colleagues analyzed the American Heart Association’s Get With The Guidelines patient registry, which included 33,898 heart failure patient admissions at 228 hospitals from January 2005 through September 2007. They looked at whether CRT therapy was present at discharge, the types of patients receiving the therapy and patterns of use at hospitals.

They found that, while rates varied greatly from hospital to hospital, 12.4 percent of the hospitalized heart failure population in the registry was discharged with CRT.

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“That’s a small percentage when you consider that we estimate 30 percent to 50 percent of hospitalized patients with heart failure were eligible for CRT based on previous studies,” Hernandez said.

Patients who received the devices were more likely to have had more severe heart failure, as well as a history of heart attacks (58 percent in the CRT group versus 45 percent in the non-CRT group) and a history of atrial fibrillation (38 percent versus 27 percent).

Hernandez noted that, although clinical trials have shown benefit from CRT for patients with left ventricular ejection fraction (LVEF) – which shows how well the heart pumps – of 35 percent or less, in this study, the average use of CRT among hospitals was only 14.3 percent of these patients.

“That means that there are a lot of patients who potentially could benefit from the device who aren’t receiving it,” Hernandez said. “We also found that 10 percent of patients discharged with a new CRT implant had an LVEF of greater than 35 percent, which suggests that those patients are over-treated. They have not been shown in trials to benefit from the therapy.”

Geography seems to impact whether patients receive the therapy. For example, heart failure patients treated at hospitals in the Northeast were 60 percent less likely to receive CRT compared to other regions of the country.

Race also plays a role: Black patients were 55 percent less likely than whites to receive the devices.

The study sends a clear message that hospitals need to have systematic practices to employ best evidence, including treating patients with CRT, Hernandez said. Patients should also investigate their condition of heart failure and be their own advocate to get optimal care.

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