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.