Circulation: Hospitals are underusing CRTrace plays a role

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Only a small percentage of patients with severe heart dysfunction received cardiac resynchronization therapy (CRT), and those who did were disproportionately younger, white men, according to a study published online Aug. 12 in Circulation.

"We looked at figures nationwide, and we found that use of the therapy was extremely variable," says lead author Jonathan Piccini, MD, a cardiologist at Duke University Medical Center in Durham, N.C. "Basically, a lot of people who should be getting the therapy aren't, and some of the people who are getting it may not need it."

The researchers also found that in about 10 percent of the time, doctors who prescribed CRT did not follow published recommended clinical guidelines.

The investigators noted that their findings reveal a troubling picture. It has been estimated that anywhere from a third to a half of all patients hospitalized with heart failure could benefit from CRT, according to the authors. Previous studies have shown that when CRT is used with optimal medical treatment, it can dramatically reduce the need for repeated hospitalization and lower the risk of untimely death.

Two years ago, the American College of Cardiology (ACC)/American Heart Association (AHA) strongly recommended CRT therapy for selected patients with severe heart failure. But until now, it has not been known if the therapy is being used, or if it is being used appropriately.

Piccini and colleagues examined the records of nearly 34,000 admissions for heart failure from January 2005 to September 2007 in 228 hospitals enrolled in the ACC/AHA’s ‘Get with the Guidelines’ program, a project designed to improve the quality of heart failure care nationwide.

The researchers tracked which patients came into the hospital with CRT in place, and those who had it when they left. They found that the use of the therapy varied significantly, with some hospitals not using it at all, while other hospitals showed up to 23 percent of potentially eligible patients were receiving the treatment.

Piccini and colleagues also found that blacks were less likely than whites to receive CRT – even though blacks are twice as likely to suffer from heart failure as whites. In addition, researchers discovered that older, sicker patients and those who lived in the Northeast were less likely to receive CRT than were younger patients who lived in other parts of the country.

“Our findings parallel previous studies evaluating adoption of new medical technology in that they show racial disparity in who is receiving the newest therapies,” Piccini said. “In contrast to previous studies, however, we didn't find any gender gap in the use of CRT.” The study showed that roughly equal numbers of men and women received CRT for the first time during their hospital stay.

Cardiac resynchronization involves implanting a specialized pacemaker in the upper part of the chest and running leads into the heart to correct an electrical conduction problem that results in the two ventricles beating separately, instead of together. In "resetting" the electrical system, CRT enables the ventricles to pump in tandem again.

Clinical guidelines recommend that CRT be reserved for patients with left ventricular ejection fractions of 35 percent or less. But the authors wrote that in about 10 percent of cases, physicians were prescribing CRT for patients who had ejection fractions above 35 percent.

"We will be watching these trends closely," said study author Adrian Hernandez, MD, also a cardiologist at Duke. "CRT is an effective therapy for many patients, and this study suggests clinically practice varies greatly compared to what it should be, according to recommended guidelines."

AHA funded the study.