12The effect of new NICE guidelines on cardiac device therapy

Abstract

Introduction: The National Institute for Health and Care Excellence (NICE) published guidelines on implantable cardioverter defibrillators (ICD) in 2006 and cardiac resynchronisation therapy (CRT) in 2007. Since then, trials have shown benefit in additional populations including ICDs in non-ischaemic cardiomyopathy and CRT in patients with atrial fibrillation or less symptomatic heart failure, while echocardiography dyssynchrony has shown low correlation with clinical response. NICE's 2014 device therapy guidelines recognise these changes. We sought to explore the impact of these updated guidelines on our patient population, and their implications for future device implantation practice. Methods: The clinical and pacing notes of 223 patients receiving an ICD, CRT-P or CRT-D between April 2006 and December 2007 were reviewed to establish what device was recommended by contemporary NICE guidance at implantation. 2014 guidelines were then applied to the same population to determine their potential impact. Results: 170 patients received an ICD of whom 89 had records available for audit. 71 patients received CRT-P and 63 received CRT-D, all of whom were audited. Mean age was 64.5, 72.2 and 65.5 years and females accounted for 15%, 34% and 13% in the three groups respectively. Defibrillators were implanted for secondary prevention in 64/152 (42%) patients. The device implanted, the device indicated by the 2006/07 guidelines and that recommended by applying the 2014 guidelines are compared in figure 1. The device patients received did not always fulfil NICE guidance. Reasons included implantation of primary prevention ICDs in patients with non-ischaemic cardiomyopathy or chanelopathy (24), CRT in AF (23) or NYHA class 2 (15) not fulfilling certain investigative criteria such as echocardiographic dyssynchrony (16) or non-sustained and inducible VT (12), or patient choice, e.g. in declining a defibrillator when receiving CRT (2). The main effect of the 2014 guidance is a 51% increase number of CRT devices indicated - 85 in 2006/7 to 128 in 2014. Many investigations are now not required, including 25 dyssynchrony echos, 20 Holter monitors and 14 VT stimulation studies. Seventy-eight patients from the original cohort survived to generator replacement of whom five were upgraded to CRT-D, two were upgraded from single to dual chamber devices and 11 had device or lead revisions (predominantly due to lead advisories). One patient chose to have their device downgraded from CRT-D to CRT-P. Conclusions: New NICE guidance for device therapy increases the numbers of patients with both CRT and ICD indications. The most significant change is however, the increasing number of patients for whom CRT is recommended, highlighting the need for careful consideration of the patient's clinical condition and treatment preference, particularly as more patients now approach generator change. ![Graphic][1] [1]: /embed/inline-graphic-1.gif