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Yilmaz D, Egorova AD, Schalij MJ, van Erven L. Implantable cardioverter-defibrillators and the older patient: the Dutch clinical practice. Eur J Cardiovasc Nurs 2022; 21:169-173. [DOI: 10.1093/eurjcn/zvab100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 05/25/2021] [Indexed: 11/12/2022]
Abstract
Abstract
Background and objective
Balance between benefit and burden of implantable cardioverter-defibrillator (ICD) therapy is more debatable in older patients, compared to younger patients. Of around 6000 yearly implanted ICDs in the Netherlands, 1:4 is received by patients ≥75 years. We aimed to evaluate the current clinical practice in the Netherlands for ICD implants and generator replacements, with a special focus on the older ICD patients.
Research design and methods
Cardiologists from all Dutch ICD implanting centres (n = 28) were interviewed. Questions aimed to evaluate outpatient care, pre-operative patient assessment, end-of-life-care counselling, evaluation of social and cognitive wellbeing, clinical evaluation of all patients prior to ICD replacement, and the consideration of the option to downgrade or not replace a device.
Results
Implanting cardiologists from all 28 implanting centres were approached for an interview. Response rate was 86%. Management appeared diverse. An age ≥80 years was consistently reported as incentive for more extensive patient evaluation. Patients were invited for counselling prior to device replacements in only the minority (46%) of hospitals. Downgrade or non-replacement was performed in rare cases. End-of-life care discussions were not standard procedure in 67% of the hospitals. Evaluation of social and cognitive wellbeing of patients was based solely on the general clinical impression of the physician in 83%, or not at all assessed in 8% of the centres.
Discussion and implication
A structured framework for care and evaluation of cognitive and/or physical limitations is currently absent in most hospitals. At time of ICD (re-)evaluation, several factors may be considered before deciding on (continuation of) ICD therapy: patient preferences and comorbidity, the need for pacemaker therapy, primary vs. secondary prevention, procedural risks, and patient preferences.
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Affiliation(s)
- Dilek Yilmaz
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Anastasia D Egorova
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Martin J Schalij
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Lieselot van Erven
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
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Poupin P, Bouleti C, Degand B, Paccalin M, Le Gal F, Bureau ML, Alos B, Roumegou P, Christiaens L, Ingrand P, Garcia R. Prognostic value of Charlson Comorbidity Index in the elderly with a cardioverter defibrillator implantation. Int J Cardiol 2020; 314:64-69. [PMID: 32291172 DOI: 10.1016/j.ijcard.2020.03.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Elderly patients are often underrepresented in implantable cardioverter defibrillator (ICD) trials, and ICD implantation in patients ≥75 years consequently remains controversial. We aimed to evaluate mortality, appropriate ICD therapy rates and survival gain in an elderly population after risk stratification according to the Charlson Comorbidity Index (CCI). METHODS This monocentric retrospective study included elderly ICD patients ≥75 years. They were subdivided according to their CCI score into 3 categories (0-1, 2-3 or ≥4 points). Elderly patients were matched 1:2 with younger control ICD patients on gender, type of prevention (primary or secondary) and type of device (associated cardiac resynchronization therapy or not). RESULTS Between January 2009 and July 2017, 121 elderly patients (mean age 78 ± 3; 83% male) matched with 242 controls (mean age 66 ± 5) were included. At 5 year follow-up after ICD implantation, overall survival was 78%, 57%, and 29% (P = 0.002) in the elderly with a CCI score of 0-1, 2-3 and ≥4 respectively, and 72% in controls. There was no significant difference regarding ICD appropriate therapy between the 3 subgroups despite a trend towards lower rates of therapy in CCI ≥ 4 points patients (34.2%, 39.7% and 22.8% respectively; P = 0.45). Median potential survival gain after an appropriate therapy was >5, 4.7 and 1.4 years, with a CCI score of 0-1, 2-3 and ≥4 respectively (P = 0.01). CONCLUSION Elderly patients with CCI score ≥ 4 had the lowest survival after ICD implantation and little survival gain in case of appropriate defibrillator therapy. More than age alone, the burden of comorbidities assessed by the CCI could be helpful to better select elderly patients for ICD implantation.
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Affiliation(s)
- Pierre Poupin
- CHU Poitiers, Unité Médico-Chirurgicale Pôle Montmorillon, 2 rue de la Milétrie, F-86021 Poitiers, France
| | - Claire Bouleti
- CHU Poitiers, Service de Cardiologie, 2 rue de la Milétrie, F-86021 Poitiers, France; Univ Poitiers, Faculté de Médecine et Pharmacie, F-86021 Poitiers, France; INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, F-86021 Poitiers, France
| | - Bruno Degand
- CHU Poitiers, Service de Cardiologie, 2 rue de la Milétrie, F-86021 Poitiers, France.
| | - Marc Paccalin
- Univ Poitiers, Faculté de Médecine et Pharmacie, F-86021 Poitiers, France; CHU Poitiers, Service de Gériatrie, 2 rue de la Milétrie, F-86021 Poitiers, France.
| | - François Le Gal
- CHU Poitiers, Service de Cardiologie, 2 rue de la Milétrie, F-86021 Poitiers, France.
| | - Marie-Laure Bureau
- CHU Poitiers, Service de Cardiologie, 2 rue de la Milétrie, F-86021 Poitiers, France; Univ Poitiers, Faculté de Médecine et Pharmacie, F-86021 Poitiers, France.
| | - Benjamin Alos
- CHU Poitiers, Service de Cardiologie, 2 rue de la Milétrie, F-86021 Poitiers, France; Univ Poitiers, Faculté de Médecine et Pharmacie, F-86021 Poitiers, France; INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, F-86021 Poitiers, France
| | - Pierre Roumegou
- CHU Poitiers, Service de Cardiologie, 2 rue de la Milétrie, F-86021 Poitiers, France.
| | - Luc Christiaens
- CHU Poitiers, Service de Cardiologie, 2 rue de la Milétrie, F-86021 Poitiers, France; Univ Poitiers, Faculté de Médecine et Pharmacie, F-86021 Poitiers, France; INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, F-86021 Poitiers, France.
| | - Pierre Ingrand
- Univ Poitiers, Faculté de Médecine et Pharmacie, F-86021 Poitiers, France; Epidemiology and Biostatistics, INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, F-86021 Poitiers, France.
| | - Rodrigue Garcia
- CHU Poitiers, Service de Cardiologie, 2 rue de la Milétrie, F-86021 Poitiers, France; Univ Poitiers, Faculté de Médecine et Pharmacie, F-86021 Poitiers, France; INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, F-86021 Poitiers, France.
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Zamani M, Wininger M. Letter by Zamani and Wininger Regarding Article, “Efficacy of Pharmacologic and Cardiac Implantable Electronic Device Therapies in Patients With Heart Failure and Reduced Ejection Fraction: A Systematic Review and Network Meta-Analysis”. Circ Arrhythm Electrophysiol 2019; 12:e007667. [DOI: 10.1161/circep.119.007667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mark Zamani
- Cooperative Studies Program, Department of Veterans Affairs, West Haven, CT (M.Z., M.W.)
- Department of Statistics, Florida State University, Tallahassee (M.Z.)
| | - Michael Wininger
- Department of Statistics, Florida State University, Tallahassee (M.Z.)
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