Integrated care trumps standard treatment in HF patients receiving CRT

Issue: August 2012

When compared with conventional care, integrated multidisciplinary care resulted in a 38% reduction in risk for HF hospitalization, cardiac transplantation and/or mortality in patients receiving cardiac resynchronization therapy.

“The care of [patients who do not respond to cardiac resynchronization therapy devices] is fairly complex and involves the input of several subspecialists, including electrophysiologists and HF and imaging specialists,” Jagmeet Singh, MD, PhD, FHRS, associate professor of medicine at Harvard Medical School and member of the Cardiac Arrhythmia Service at Massachusetts General Hospital Heart Center, told Cardiology Today. “In most institutions there is no clear, structured cross-talk among these subspecialists looking after this patient cohort. As a result, most patients who are non-responsive to the therapy will come to the attention of the caregivers when they have already worsened significantly or have been hospitalized for HF.”

Jagmeet Singh

Integrated care vs. standard care

Singh and colleagues compared clinical outcomes in patients with HF who were receiving multidisciplinary care within the Massachusetts General Hospital CRT Program (n=254) with those receiving conventional care (n=173).

“Within the program, an HF and electrophysiology expert see the patients in clinic separately during the same visit … At their appointment, patients get their device interrogated and optimized with echocardiographic guidance. As part of an endeavor to gather objective clinical data during each visit, patients undergo a 6-minute walk test and complete a quality of life questionnaire. Importantly, all these data are collected prospectively and entered into a database.”

The multidisciplinary care group underwent follow-up visits at 1, 3 and 6 months after implantation. All patients had echocardiographic-guided optimization at their 1-month visits. Long-term outcome was a combined endpoint of HF hospitalization, cardiac transplantation or all-cause mortality.

Results revealed a significantly higher event-free survival rate in the multidisciplinary care group vs. the conventional care group (P=.0015). Additionally, data indicated a significant reduction in clinical events among those receiving multidisciplinary care, as compared with the conventional care group (HR=0.62; 95% CI, 0.46-0.83).

Moving forward

Singh noted that this study underscores a need for physicians to embrace integrated care, particularly among certain patient populations.

“We have to move away from current practice patterns of working in our individual silos towards coming together to provide integrated care,” Singh said. “This is especially important in conditions like HF, where the hospital readmission rates are high and are a major drain on resources.”

As the concept of multidisciplinary care grows in popularity, Singh said he and his colleagues are exploring broadening the scope of their research.

“Some of our next steps into the ‘integrated care arena’ have involved expanding our patient cohort to include those with implantable hemodynamic sensors. We have also moved into the realm of autonomic modulation and are looking at newer devices and interventions to shift the sympatho-vagal balance favorably to enhance ventricular remodeling. Other multidisciplinary investigative efforts that we are working on include biomarkers as well as regenerative cell therapy.” – by Melissa Foster

For more information:

Altman RK. Eur Heart J. 2012;doi:10.1093/eurheartj/ehs107.

Disclosure: The study was supported in part by a research grant from St. Jude Medical. Dr. Singh has received research grants from Biotronik, Boston Scientific, Medtronic, St. Jude Medical and Sorin. He is also a consultant to Biotronik, Boston Scientific, Cardio Insight Inc, Medtronic, Respiericardia, Sorin, St. Jude Medical and theheart.org.See the full study for a complete list of the researchers’ disclosures.