Guideline-directed device therapies in heart failure: A clinical practice-based analysis using electronic health record data

Abstract

Background: Guideline-directed device therapies (GDDT) improve outcomes for eligible patients with heart failure (HF) with reduced ejection fraction (HFrEF). Utilization rates of device therapies in HFrEF after the 2012 ACCF/AHA/HRS Focused Update for Device-based Therapies of Cardiac Rhythm Abnormalities have not been well studied.

Objective: Characterize the use of GDDT in newly indicated HFrEF patients from 2012 to 2019 using aggregated electronic health record (EHR) data.

Methods: Computable phenotyping algorithms for implantable cardioverter defibrillator/cardiac resynchronization therapy-defibrillator (ICD/CRT-D) indications from the GuideLine Indications Detected in EHR for Heart Failure program (GLIDE-HF) used diagnoses, procedures, measures, prescriptions, and the output of natural language processed provider notes from de-identified Optum® EHR data. Patients had a diagnosis of HF, dilated cardiomyopathy, or prior infarct, and were included if they had HFrEF with >1 year of records prior to a new Class 1 or Class 2a indication for an ICD or cardiac resynchronization therapy with defibrillator (CRT-D) from 2012 to 2019.

Results: Records showed 137,476 HFrEF patients were newly indicated for an ICD or CRT-D. GDDT was used in 14,892 of 36,358 (41.0%) CRT-D indicated patients and in 14,904 of 101,118 (14.7%) ICD-indicated patients. While GDDT use was low, 95.7% had echocardiography and 92.1% had prescriptions for beta-blockers or angiotensin-converting enzyme/angiotensin-receptor blockers medications.

Conclusions: In this modern cohort of HF patients, a large proportion of eligible patients did not receive ICDs or CRT-Ds, while frequently receiving other indicated cardiovascular interventions and treatments.

Keywords: Cardiac resynchronization therapy; Electronic health record; Guideline-directed device therapy; Heart failure; Implantable cardioverter defibrillator.

Fig. 1

Use of Guideline-directed Devices in HFrEF. The top flow chart shows the patients selected from each stage and the final cohort included in the analysis. The bottom right bar graph shows the distribution of the ICD eligible patients stratified by indication. The bottom left bar graph shows the distribution of the CRT-D eligible patients stratified by indication. *Note: Treated patients had received any defibrillator device, including ICD, CRT-D or S-ICD HF = Heart Failure, CRT-D = Cardiac Resynchronization Therapy Defibrillator, HFrEF = Heart Failure with reduced Ejection Fraction, ICD = Implantable Cardioverter Defibrillator, LBBB = Left Bundle Branch Block S-ICD = Subcutaneous Implantable Cardioverter Defibrillator.

Fig. 2

Other treatments in GDDT-indicated patients. The percent of HFrEF indicated for either an ICD or CRT-D are shown by the interventions for HF that they received. *ACE/ARB = angiotensin-converting enzyme inhibitor system antagonists/Angiotensin II Receptor Blockers, CABG = Coronary Artery Bypass Graft, CRT-D = Cardiac Resynchronization Therapy Defibrillator, GDDT = Guideline Directed Device Therapy HF = Heart Failure, HFrEF = Heart Failure with reduced Ejection Fraction, ICD = Implantable Cardioverter Defibrillator, PCI = Percutaneous Coronary Intervention, Rx = Medical Prescription.