Combined resynchronisation and implantable defibrillator therapy in left ventricular dysfunction

Combined resynchronisation and implantable defibrillator therapy in left ventricular dysfunction: Bayesian network meta-analysis of randomised controlled trials


BMJ, doi:10.1136/bmj.39343.511389.BE (published 11 October 2007)


Simon K H Lam, MSc student1, Andrew Owen, consultant2


1 National Heart and Lung Institute, London SW3 6LY, 2 Department of Cardiology, Kent and Canterbury Hospital, Canterbury


Abstract


Objective To review the evidence base from randomised controlled trials of combined cardiac resynchronisation therapy and implantable cardioverter defibrillator therapy in left ventricular impairment and symptomatic heart failure.

Review methods Two reviewers independently assessed trial eligibility and quality. Included trials compared cardiac resynchronisation therapy, implantable cardioverter defibrillator therapy, combined resynchronisation and implantable defibrillator therapy, and medical therapy alone, in patients with impaired left ventricular systolic function. Bayesian random effects network models were used to examine overall number of deaths.


Results 12 studies including 1636 events in 8307 patients were identified. Combined cardiac resynchronisation and implantable cardioverter defibrillator therapy reduced the number of deaths by one third compared with medical therapy alone (odds ratio 0.57, 95% credible interval 0.40 to 0.80) but did not further improve survival when compared with implantable defibrillator therapy (0.82, 0.57 to 1.18) or resynchronisation (0.85, 0.60 to 1.22) therapy alone.


Conclusion Evidence from randomised controlled trials is insufficient to show the superiority of combined cardiac resynchronisation and implantable cardioverter defibrillator therapy over cardiac resynchronisation therapy alone in patients with left ventricular impairment.

Sex and Race Disparities Found in ICD Use

Sex and Race Disparities Found in ICD Use


Wide racial and gender disparities exist in the use of implantable cardioverter-defibrillators (ICDs), according to two JAMA reports.

One, a study of some 230,000 Medicare beneficiaries, examined ICD use for primary or secondary prevention of sudden cardiac death. Researchers found that men were 3.2 times more likely than women to receive ICD therapy for primary prevention, and 2.4 times more likely for secondary prevention. There were no significant survival benefits in the primary-prevention cohort in the year following implantation.

The other study, of some 13,000 patients with heart failure, also found that women were less likely than men to receive ICDs and that black patients — both men and women — were less likely to get them.

An editorialist says that the results "highlight disturbing patterns of health care inequality." With regard to survival benefits, she writes that paradoxically the bad news may be for white men "who are undergoing a procedure that, for primary prevention, has not been shown to extend their lives."

JAMA article on sex differences (Free)

JAMA article on sex and race differences (Free abstract; full text requires subscription)

JAMA editorial (Subscription required)