Age-Stratified Clinical Outcome in Patients with Known Heart Failure Who Receive Pacemaker, Resynchronization Therapy, or Defibrillator Implants

Abstract

Introduction: Patients with heart failure (HF) and bradycardia may be eligible for different types of cardiac implantable electronic devices (CIED), depending on the presence of atrioventricular conduction disease, age, and comorbidities. We aimed to assess the prognosis for these patients, after CIED implantation, stratified for the type of CIED device.

Methods: All patients with preexisting HF diagnosis who received a CIED with a right ventricular lead during the period 2005-2018 in Sweden were identified via the pacemaker registry. Data were crossmatched with the population registry and national disease registries. The outcome was 5-year risk of HF hospitalization and mortality.

Results: A total of 37,745 patients were included in the study. Comparing demographics for implantable cardioverter defibrillator versus pacemaker implants, median age was 66 years versus 83 years, 20% versus 41% were female, 64% versus 50% had ischemic heart disease, and 35% versus 67% had atrial fibrillation (all p < 0.001). Five-year mortality was highest in single-chamber pacemaker recipients (61% compared to average 40%, p < 0.001), but the proportion of cardiovascular mortality was highest for cardiac resynchronization therapy (CRT) recipients (68% vs. 63% p < 0.001). Adjusted mortality was higher for pacemaker patients in all age decile groups (ranging from <60 to >90 years old, all p < 0.001), HF hospitalization occurred in 28% (dual-chamber pacemaker) to 39% (CRT-P) of patients, and cause of death was HF in 15% (dual-chamber pacemaker) to 25% (CRT-D), all p < 0.001.

Conclusion: In this large real-world cohort of CIED-treated patients with prior HF, demography and mortality data indicate that clinicians chose devices according to the overall status of the patient. HF-related events occurred in all groups but were more common in CRT-treated patients.

Keywords: Cardiac resynchronization therapy; Heart failure; Pacemaker; Prognosis.

Fig. 1.

Flowchart of included patients.

Fig. 2.

Upgrades to ICD or CRT, stratified by device type at the index implant procedure.

Fig. 3.

Kaplan-Meier curves showing age and type of device-adjusted survival for all patients. Upper left image shows all patients, and the other curves show age-stratified results within age groups according to figure legends below. Variables in the adjusted model include age, gender, prior cerebrovascular disease, chronic obstructive lung disease, diabetes, hypertension, atrial fibrillation, ischemic heart disease, chronic kidney disease, and ECG indication. Log rank p value <0.0001.

Fig. 4.

Kaplan-Meier curves for patients with bradycardia indication “AV block,” showing adjusted survival stratified by type of device implanted. Variables in the adjusted model include age, gender, prior cerebrovascular disease, chronic obstructive lung disease, diabetes, hypertension, atrial fibrillation, ischemic heart disease, and chronic kidney disease. Log rank p value <0.0001.