Article Impact Level: HIGH Data Quality: STRONG Summary of Frontiers in Cardiovascular Medicine, 10, 1237118. https://doi.org/10.3389/fcvm.2023.1237118 Dr. Ido Goldenberg et al.
Points
- The study investigates the effectiveness of implantable cardioverter defibrillators (ICDs) in patients with advanced chronic kidney disease (CKD) and heart failure with reduced ejection fraction (HFrEF) receiving cardiac resynchronization therapy (CRT).
- Patients with advanced CKD (Stage 3b to 5) receiving CRT had a significantly lower incidence of ventricular arrhythmias (Any VT/VF) compared to those with less advanced CKD (Stage 1 to 3a).
- However, advanced CKD patients receiving CRT had a substantially higher risk of death without experiencing any ventricular arrhythmias, highlighting a competing risk factor.
- The study suggests that the benefit of ICDs may be attenuated in CRT recipients with advanced CKD due to their lower arrhythmia incidence and higher mortality risk.
- Future research is needed to explore alternative treatment strategies, such as CRT without a defibrillator, for patients with advanced CKD and HFrEF to optimize their cardiac care.
Summary
The implantable cardioverter defibrillator (ICD) is effective for the prevention of sudden cardiac death (SCD) in patients with heart failure and a reduced ejection fraction (HFrEF). The benefit of the ICD in patients with advanced CKD remains elusive. Moreover, the benefit of the ICD in patients with advanced chronic kidney disease (CKD) and HFrEF who are cardiac resynchronization therapy (CRT) recipients may be attenuated.
The researchers hypothesized that patients with CKD who are CRT recipients may derive less benefit from the ICD due to the competing risk of dying before experiencing an arrhythmia.
The study population included 1,015 patients receiving CRT with defibrillator (CRT-D) device for primary prevention of SCD who were enrolled in either the Multicenter Automated Defibrillator Implantation Trial (MADIT-CRT) trial or the Ranolazine in High-Risk Patients with Implanted Cardioverter Defibrillator (RAID) trial. The cohort was divided into two groups based on the stage of CKD: those with Stage 1 to 3a KD, labeled as (S1-S3a)KD. The second group included patients with Stage 3b to Stage 5 kidney disease, labeled as (S3b-S5)KD. The primary endpoint was any ventricular tachycardia (VT) or ventricular fibrillation (VF) (Any VT/VF).
The cumulative incidence of Any VT/VF was 23.5% in patients with (S1-S3a)KD and 12.6% in those with (S3b-S5)KD (p < 0.001). The incidence of Death without Any VT/VF was 6.6% in patients with (S1-S3a)KD and 21.6% in patients with (S3b-S5)KD (p < 0.001). A Fine and Gray multivariate competing risk regression model showed that Patients with (S3b-S5)KD had a 43% less risk of experiencing Any VT/VF when compared to those with (S1-S3a)KD (HR = 0.56, 95% CI [0.33–0.94] p = 0.03. After two years of follow-up, there was almost a 5-fold increased risk of Death without Any VT/VF among patients with (S3b-S5)KD when compared to those with (S1-S3a)KD [HR = 4.63, 95% CI (2.46–8.72), p for interaction with time = 0.012].
Due to their lower incidence of arrhythmias and higher risk of dying before experiencing an arrhythmia, the benefit of the ICD may be attenuated in CRT recipients with advanced CKD. Future prospective trials should evaluate whether CRT without a defibrillator may be more appropriate for these patients. This research underscores the importance of tailoring treatment strategies for patients with complex comorbidities. It provides valuable insights into managing advanced CKD in the context of heart failure and arrhythmias.
Link to the article: https://www.frontiersin.org/articles/10.3389/fcvm.2023.1237118/full
References Goldenberg, I., Kutyifa, V., Zareba, W., Huang, D. T.-C., Rosero, S. Z., Younis, A., Schuger, C., Gao, A., McNitt, S., Polonsky, B., Steinberg, J. S., Goldenberg, I., & Aktas, M. K. (2023). Primary prevention implantable cardioverter defibrillator in cardiac resynchronization therapy recipients with advanced chronic kidney disease. Frontiers in Cardiovascular Medicine, 10, 1237118. https://doi.org/10.3389/fcvm.2023.1237118
