Effects of Cardiac Resynchronization Therapy on Long-Term Quality of Life
Effects of Cardiac Resynchronization Therapy on Long-Term Quality of Life
Background: Cardiac resynchronization therapy (CRT) improves quality of life (QoL) when measured 3 to 6 months after implantation, but whether these effects are sustained is unknown. The CArdiac Resynchronisation-Heart Failure study is the only long-term randomized trial of CRT with repeated measures of QoL.
Methods: Quality of life was measured at baseline and 3 months using generic European Quality of Life-5 Dimensions and disease-specific (Minnesota Living with Heart Failure) questionnaires and at 18 months and study-end using the latter instrument. Median follow-up was 29.6 (interquartile range 23.6-34.6) months.
Results: At baseline, patients had a substantially impaired QoL (mean European Quality of Life-5 Dimensions score 0.60, 95% confidence interval [CI] 0.58-0.62) compared to an age-matched general population (0.78, 95% CI 0.76-0.80). Quality of life improved to a greater extent in patients assigned to CRT at each time point (P < .0001). By 18 months, the mean difference in disease-specific QoL score was 10.7 (95% CI 7.6-13.8) in favor of CRT, mostly due to improved physical functioning. Differences were sustained thereafter. Quality-adjusted life-years at 18 months increased by 0.13 (95% CI 0.07-0.182) and by 0.23 (95% CI 0.13-0.33) at study-end (both P < .0001). Little heterogeneity of effect across subgroups was observed.
Conclusion: Cardiac resynchronization therapy improves long-term QoL and survival in patients with moderate to severe heart failure. The effects appear sustained, and therefore, the gain in quality-adjusted life years with CRT should be even greater during longer term follow-up.
The aim of treating patients with advanced heart failure is to improve their well-being and to prolong life. To judge the clinical value of an intervention, both should be measured. The relative value placed on quality of life (QoL) and longevity will vary according to the clinical setting and patient preference. Knowledge of the impact of therapy on each outcome and the risks associated with treatment should help the patient make informed decisions regarding their care.
A large body of evidence indicates that heart failure impairs many aspects of QoL. Cardiac resynchronization therapy (CRT) improves both generic and heart failure disease-specific measures of QoL in the short-term and increases survival. The procedural success rate and safety of CRT implantations have been reported, allowing patients to assess the level of risk associated with therapy. However, the long-term effects of CRT on QoL have not been reported. Furthermore, it is unclear whether improvements in the QoL score are due to large effects in response to a few questions or a more generalized effect. Long-term QoL data provide a useful estimate of the potential experience among patients who survive. However, to avoid the confounding effects of death, which occurs more often in patients with poor QoL, it is necessary to integrate both quality and quantity of life to provide estimates of quality-adjusted life-years (QALYs). This analysis of the CArdiac Resynchronisation-Heart Failure (CARE-HF) trial reports the effects of CRT on QoL and the "patient journey."
Abstract and Introduction
Abstract
Background: Cardiac resynchronization therapy (CRT) improves quality of life (QoL) when measured 3 to 6 months after implantation, but whether these effects are sustained is unknown. The CArdiac Resynchronisation-Heart Failure study is the only long-term randomized trial of CRT with repeated measures of QoL.
Methods: Quality of life was measured at baseline and 3 months using generic European Quality of Life-5 Dimensions and disease-specific (Minnesota Living with Heart Failure) questionnaires and at 18 months and study-end using the latter instrument. Median follow-up was 29.6 (interquartile range 23.6-34.6) months.
Results: At baseline, patients had a substantially impaired QoL (mean European Quality of Life-5 Dimensions score 0.60, 95% confidence interval [CI] 0.58-0.62) compared to an age-matched general population (0.78, 95% CI 0.76-0.80). Quality of life improved to a greater extent in patients assigned to CRT at each time point (P < .0001). By 18 months, the mean difference in disease-specific QoL score was 10.7 (95% CI 7.6-13.8) in favor of CRT, mostly due to improved physical functioning. Differences were sustained thereafter. Quality-adjusted life-years at 18 months increased by 0.13 (95% CI 0.07-0.182) and by 0.23 (95% CI 0.13-0.33) at study-end (both P < .0001). Little heterogeneity of effect across subgroups was observed.
Conclusion: Cardiac resynchronization therapy improves long-term QoL and survival in patients with moderate to severe heart failure. The effects appear sustained, and therefore, the gain in quality-adjusted life years with CRT should be even greater during longer term follow-up.
Introduction
The aim of treating patients with advanced heart failure is to improve their well-being and to prolong life. To judge the clinical value of an intervention, both should be measured. The relative value placed on quality of life (QoL) and longevity will vary according to the clinical setting and patient preference. Knowledge of the impact of therapy on each outcome and the risks associated with treatment should help the patient make informed decisions regarding their care.
A large body of evidence indicates that heart failure impairs many aspects of QoL. Cardiac resynchronization therapy (CRT) improves both generic and heart failure disease-specific measures of QoL in the short-term and increases survival. The procedural success rate and safety of CRT implantations have been reported, allowing patients to assess the level of risk associated with therapy. However, the long-term effects of CRT on QoL have not been reported. Furthermore, it is unclear whether improvements in the QoL score are due to large effects in response to a few questions or a more generalized effect. Long-term QoL data provide a useful estimate of the potential experience among patients who survive. However, to avoid the confounding effects of death, which occurs more often in patients with poor QoL, it is necessary to integrate both quality and quantity of life to provide estimates of quality-adjusted life-years (QALYs). This analysis of the CArdiac Resynchronisation-Heart Failure (CARE-HF) trial reports the effects of CRT on QoL and the "patient journey."
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