Racial and Ethnic Differences in Cardiac Resynchronization Therapy Outside of Published Guidelines

1. Racial and Ethnic Differences in Cardiac Resynchronization Therapy Outside of Published Guidelines Steven A. Farmer, MD PhD, James N. Kirkpatrick, MD University of Pennsylvania, Philadelphia, PA · Paul A. Heidenreich, MD MS, Stanford University, Palo Alto, CA · Jeptha P. Curtis, MD, Yongfei Wang, MS Yale University, New Haven, CT · Peter W. Groeneveld, MD MS, University of Pennsylvania, Philadelphia, PA; on behalf of the National Cardiovascular Data Registry Background and Objectives • Ethnic / racial disparities in cardiac care may partially result from over-provision of care among white patients. • We hypothesized that white patients were more likely than black and Hispanic patients to receive cardiac resynchronization therapy with defibrillator (CRT-D) devices outside of ACC/AHA/HRS guidelines. * Data are presented as number (percent) unless otherwise indicated. Methods Abbreviations: CRT–D Cardiac resynchronization therapy-Defibrillator; CHF–Congestive heart failure; RBBB–Right bundle branch block; LBBB–Left bundle branch block; LAFB-Left Anterior Fasciclular Block; LAPB-Left Posterior Fascicular Block; IVCD-Intraventricular Conduction Delay; SBP – systolic blood pressure; ESRD-End Stage Renal Disease • Data from the ACC-National Cardiovascular Data Registry (ACC-NCDR) for implantable cardioverter defibrillators (ICDs) from January 2005-April 2007. • We identified white, black and Hispanic patients who received CRT-D and then fit a multivariable hierarchical logistic regression model with full ACC/AHA/HRS guideline concordance (QRS duration ≥ 0.12ms, LVEF ≤ 35%, and class III or IV CHF) as a binary outcome variable. • Independent variables included race/ethnicity, age, gender, cardiomyopathy etiology, duration of CHF, blood pressure, QRS morphology, prior revascularization, atrial fibrillation / flutter, cerebrovascular disease, hypertension, diabetes, renal failure, and pulmonary disease. Conclusions Study Participants • After multivariate adjustment, we observed greater guideline-concordant use of CRT-D among black and Hispanic patients than among white patients. • Our findings suggest that racial /ethnic differences in CRT-D may be partially due to over-provision of this technology among white patients. Results • Of 108,341 registry patients, 39,088 CRT-D recipients were identified, including 33,310 (85%) white, 3,963 (10%) black, and 1,815 (5%) Hispanic patients. • Among CRT-D recipients, 9,430 (24%) patients lacked 1 CRT-D criterion, 1,840 (5%) patients lacked 2 criteria, and 217 (1%) patients lacked all 3 criteria. Specifically, 2,271 (6%) had an LVEF > 35%, 6,758 (17%) had class I/II CHF, and 4,732 (12%) had a QRS duration < 0.12 s • In multivariate analyses, black (OR 1.13, 1.04-1.23; p=0.004) and Hispanic (OR 1.10, 0.97-1.24; p=0.13) patients were more likely to meet all 3 CRT-D eligibility criteria than white patients. Implications • Nearly 30% of patients receiving CRT-D failed to meet one or more published criteria, and white patients were overrepresented in this group. • Receipt of CRT-D outside of guidelines exposes patients to the risks of implantation with less potential benefit. • Our findings indicate a need for more circumspect use of this expensive technology.