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In this study of a public healthcare system covering an entire nation, increasing time from a first heart failure hospitalization (HFH) to CRT implantation was associated with progressively worse outcomes, with each year amounting to a 21% higher mortality and a 34% higher risk of HFH. The optimum timing of CRT implantation is unknown. Total mortality (HR: 1.67), HFH (HR: 2.63), and total mortality or HFH (HR: 1.92) (all P < 0.001) were highest in patients undergoing CRT ≥2 years after the first HFH. Over 4.54 (2.80–6.71) years, the time in years from the first HFH to CRT implantation was associated with a higher risk of total mortality (1.15 95% CI 1.14–1.16, HFH (HR: 1.26 95% CI 1.24–1.28), and the combined endpoint of total mortality or HFH (HR: 1.19 95% CI 1.27–1.20) than CRT in patients with no previous HFHs, after co-variate adjustment. From 2010 to 2019, 64 968 patients underwent CRT implantation, 57% in the absence of a previous HFH, 12.9% during the first HFH, and 30.1% after ≥1 HFH. A database covering the population of England (56.3 million in 2019) was used to quantify clinical outcomes after CRT implantation in relation to first HFHs.

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