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Individual patient data network meta-analysis of mortality effects of implantable cardiac devices

Lookup NU author(s): Dr Chris Plummer

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Abstract

Objective Implantable cardioverter defibrillators (ICD), cardiac resynchronisation therapy pacemakers (CRT-P) and the combination therapy (CRT-D) have been shown to reduce all-cause mortality compared with medical therapy alone in patients with heart failure and reduced EF. Our aim was to synthesise data from major randomised controlled trials to estimate the comparative mortality effects of these devices and how these vary according to patients' characteristics. Methods Data from 13 randomised trials (12 638 patients) were provided by medical technology companies. Individual patient data were synthesised using network meta-analysis. Results Unadjusted analyses found CRT-D to be the most effective treatment (reduction in rate of death vs medical therapy: 42% (95% credible interval: 32-50%), followed by ICD (29% (20-37%)) and CRT-P (28% (15-40%)). CRT-D reduced mortality compared with CRT-P (19% (1-33%)) and ICD (18% (7-28%)). QRS duration, left bundle branch block (LBBB) morphology, age and gender were included as predictors of benefit in the final adjusted model. In this model, CRT-D reduced mortality in all subgroups (range: 53% (34-66%) to 28% (-1% to 49%)). Patients with QRS duration ≥150 ms, LBBB morphology and female gender benefited more from CRT-P and CRT-D. Men and those <60 years benefited more from ICD. Conclusions These data provide estimates for the mortality benefits of device therapy conditional upon multiple patient characteristics. They can be used to estimate an individual patient's expected relative benefit and thus inform shared decision making. Clinical guidelines should discuss age and gender as predictors of device benefits.


Publication metadata

Author(s): Woods B, Hawkins N, Mealing S, Sutton A, Abraham WT, Beshai JF, Klein H, Sculpher M, Plummer CJ, Cowie MR

Publication type: Article

Publication status: Published

Journal: Heart

Year: 2015

Volume: 101

Issue: 22

Pages: 1800-1806

Print publication date: 15/11/2015

Online publication date: 26/10/2015

Acceptance date: 01/01/1900

ISSN (print): 1355-6037

ISSN (electronic): 1468-201X

Publisher: BMJ Publishing Group

URL: http://doi.org/10.1136/heartjnl-2015-307634

DOI: 10.1136/heartjnl-2015-307634


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