Journal Article

Impact of implantable cardioverter defibrillators on mortality in heart failure receiving quadruple guideline-directed medical therapy: a propensity score-matched study

Celik, Ahmet, Ulgu, Mustafa Mahir, Sahin, Anil, Yilmaz, Mehmet Birhan, Colluoglu, Inci Tugce, Ata, Naim, Ural, Dilek, Kanik, Emine Arzu, Birinci, Suayip

2024

Overview

Background In the contemporary management of heart failure with reduced ejection fraction (HFrEF), the recommended quadruple guideline-directed medical therapy (GDMT) consists of angiotensin receptor-neprilysin inhibitor (ARNI), evidence-based beta-blockers (BB), mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter-2 inhibitors (SGLT-2i). This study explored the impact of adding implantable cardioverter-defibrillator (ICD) therapy to this comprehensive regimen in HFrEF patients. Methods Utilizing deidentified data from the National Electronic Database of the Turkish Ministry of Health, we conducted a nationwide retrospective cohort study on 5450 HFrEF patients receiving quadruple GDMT, including ARNI. Among them, 709 patients underwent additional ICD or cardiac resynchronization therapy defibrillator (CRT-D) implantation. Propensity score matching ensured balanced baseline characteristics between groups. Primary endpoint was determined as all-cause mortality. Results In the matched cohort, all-cause mortality occurred in 108 out of 619 patients (17.4%) in the GDMT group and 101 out of 619 patients (16.3%) in the ICD group, with a hazard ratio (HR) of 0.74 and a 95% confidence interval (CI) ranging from 0.57 to 0.98. The median follow-up time was 1365 days in the matched cohort, 1283 days in the GDMT group. Subgroup analyses consistently demonstrated benefits, particularly among individuals aged 61 years and older (HR: 0.60, 95% CI: 0.42–0.87, p  = 0.006), those with sinus rhythm (HR: 0.55, 95% CI: 0.34–0.89, p  = 0.013), individuals not using amiodarone (HR: 0.61, 95% CI: 0.42–0.89, p  = 0.011), and those with an estimated glomerular filtration rate lower than 61.9 (HR: 0.66, 95% CI: 0.48–0.91, p  = 0.011). Conclusions This study may offer a glimmer of hope that even after achieving the best current optimal medical therapy, the addition of device therapy could still yield positive outcomes in the management of patients with HFrEF. Graphical Abstract

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Adrenergic beta-Antagonists - therapeutic use / Aged / Amiodarone / Angiotensin / Angiotensin Receptor Antagonists - therapeutic use / Beta blockers / Biomedicine / Cardiac arrhythmia / Cardiomyopathy / Cardiovascular agents / Cardiovascular diseases / Care and treatment / Congestive heart failure / Defibrillators / Defibrillators, Implantable / Dosage and administration / Ejection fraction / Female / Glomerular filtration rate / Heart failure / Heart Failure - drug therapy / Heart Failure - mortality / Heart Failure - therapy / Hemoglobin / Humans / Hypertension / Implantable cardioverter-defibrillator / Implantable cardioverter-defibrillators / Kidney diseases / Male / Medicine / Medicine & Public Health / Middle Aged / Mineralocorticoid Receptor Antagonists - therapeutic use / Mineralocorticoid receptors / Mortality / Neprilysin / Patient outcomes / Propensity Score / Quadruple guideline-directed medical therapy / Receptors / Retrospective Studies / Sodium-glucose cotransporter / Sodium-Glucose Transporter 2 Inhibitors - therapeutic use / Subgroups / Survival analysis / Therapy / Trends / Turkey