CRT, ICD devices reduced mortality regardless of race, ethnicity

The use of cardiac resynchronization therapy devices and implantable cardioverter defibrillators was associated with reduced mortality at 24 months, regardless of race or ethnicity, according to new data from the IMPROVE HF registry.

Perspective from Richard Fogel, MD, FHRS, CCDS

Black and Hispanic patients are less likely to receive ICDs and CRT devices than white patients, according to previous research. The new IMPROVE HF data could change that, researchers said.

“This is among the largest studies to address the question of race- and ethnicity-specific benefits with ICD or CRT therapies in real-world practice,” Gregg C. Fonarow, MD, Eliot Corday chair in cardiovascular medicine and science and director of the Ahmanson-UCLA Cardiomyopathy Center at the David Geffen School of Medicine at UCLA, said in a press release. “Our results are a reminder to physicians and patients that this proven life-extending therapy should be offered to all eligible [HF] patients without regard for race or ethnicity.”

Gregg C. Fonarow

Fonarow and colleagues analyzed data from the IMPROVE HF registry to determine the clinical effectiveness of CRT and ICD therapies as a function of race and ethnicity in outpatients with HF with reduced ejection fraction (≤35%). The primary outcome was mortality at 24 months.

The researchers analyzed two cohorts from the IMPROVE HF registry: those eligible for ICDs and cardiac resynchronization defibrillators (CRT-D; n=7,748; 44% non-Hispanic white; 9% non-Hispanic black; 47% other or undocumented races or ethnicities) and those eligible for cardiac resynchronization pacemakers (CRT-P) and CRT-Ds (n=1,188; 50% non-Hispanic white; 8% non-Hispanic black; 41% other or undocumented races or ethnicities).

According to the results, ICD/CRT-D therapy was associated with lower mortality at 24 months (adjusted OR=0.64; 95% CI, 0.52-0.79), and the benefit did not differ by race or ethnicity (P=.7861). In addition, CRT-P/CRT-D therapy was associated with reduced mortality at 24 months (adjusted OR=0.55; 95% CI, 0.33-0.91) and that there was no difference in benefit by race or ethnicity (P=.5413).

The underrepresentation of minorities in CRT trials should not be an excuse for not offering therapy, and while some mortality reductions for individual groups did not achieve significance the important message is that the treatment effect did not differ significantly between subgroups, Sean P. Pinney, MD, from the Zena and Michael A. Wiener Cardiovascular Institute at Mount Sinai Hospital, wrote in a related editorial.

“Knowing that there is equal benefit between racial/ethnic subgroups only heightens the need to eliminate disparities in care delivery,” Pinney wrote. “The big question is how best to achieve this. Some potential solutions include integrating performance improvement programs into clinical practice, leveraging information technologies to provide clinical decision support tools and broadening insurance coverage to all Americans to improve access to care.”

For more information:

Pinney SP. J Am Coll Cardiol. 2014;64:808-810.

Ziaeian B. J Am Coll Cardiol. 2014;64:797-807.

Disclosure: The study was funded by Medtronic. See the full study for a list of the researchers’ relevant financial disclosures. Pinney reports receiving consulting fees and honoraria from CareDx and Thoratec Inc.

Perspective

Richard Fogel, MD, FHRS, CCDS

ICDs and CRT devices have been shown to reduce mortality and improve clinical outcomes in selective patients with HF. However, many trials have underrepresented racial and ethnic minorities, leading to the question of whether the results of these trials can be generalized to all populations without racial or ethnic differentiation. This study answers that question.

Using data from the IMPROVE HF registry, the authors found that use of guideline-directed CRT and ICD therapy was associated with a reduced 24-month mortality that was independent of any ethnic or racial interaction. The authors conduce that “device therapy should be offered to all eligible patients without consideration of race or ethnicity.”

This is an important study that adds to our knowledge about the benefits of device therapy in selected patients with HF — specifically that the benefits of ICD and CRT therapy are applicable without regard to race or ethnicity despite these populations being underrepresented in clinical trials. As the authors write, “given the known existence of racial/ethnic disparities in the use of both CRT and ICD therapies, these data demonstrating the similarity of benefit elevate to the highest tier the need to eliminate racial/ethnic disparities in device-based therapy for heart failure.” I couldn’t agree more.

Richard Fogel, MD, FHRS, CCDS

Staff cardiologist and electrophysiologist, The Care Group, LLC, Indianapolis

Chief Executive Officer, St. Vincent Medical Group, Indianapolis

President, Heart Rhythm Society

Disclosures: Fogel reports no relevant financial disclosures.