Socio-economic analysis of cardiac resynchronization therapy.

The field of electrical device therapy has benefited from two basically independent lines of investigation demonstrating mortal benefit from either cardiac resynchronization therapy (CRT) or implantable cardioverter-defibrillator (ICD) therapy in patients with heart failure. Current clinical evidence data is insufficient to conclude that CRT-defibrillation (CRTD) offers an advantage over CRT-pacing (CRTP) alone. The cost of adding a defibrillator to the CRTP device is substantial and will act as a barrier to wide scale penetration. Annualized sudden death rates are very low in certain primary prevention populations. Consequently, the potential for overtreatment is very large and the negative costs of ICD therapy are distributed equally among those patients who will have a life saving benefit and those who were "destined" never to require the therapy. The perception that these costs are acceptable if lives are saved is commonly cited as justification for expensive therapy on a population scale, but there is an important and practical difference between costs per unit life saved and costs among patients who really never needed the device. Until the a priori predictors of volumetric response to CRT are better understood, the use of CRTD in class IV patients should be discouraged since ICD therapy is unlikely to extend life in volumetric non-responders. Similarly, the use of CRTD in patients who are "destined" for significant volumetric response is probably unwise since their risk of sudden death is minimized due to favorable substrate modification. Clinical trials comparing conventional ICDs, CRTP and CRTD are necessary to rationalize use of expensive hardware resources among different patient populations. Additionally, the importance of patient preference regarding end of life care should receive greater emphasis. While CRTP may be considered palliative in terminal heart failure, the decision to offer CRTD must include a discussion with the patient regarding mode of death and the potential for the defibrillator to replace a sudden and peaceful death with a prolonged death from progressive pump failure.