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Robinson I, Daly-Grafstein D, Khan M, Krahn AD, Hawkins NM, Brubacher JR, Staples JA. Distinguishing Primary Prevention From Secondary Prevention Implantable Cardioverter Defibrillators Using Administrative Health and Cardiac Device Registry Data. CJC Open 2024; 6:876-883. [PMID: 39026626 PMCID: PMC11252512 DOI: 10.1016/j.cjco.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/28/2024] [Indexed: 07/20/2024] Open
Abstract
Background Administrative health data and cardiac device registries can be used to empirically evaluate outcomes and costs after implantable cardioverter defibrillator (ICD) implantation. These datasets often have incomplete information on the indication for implantation (primary vs secondary prevention of sudden cardiac death). Methods We used 16 years of population-based cardiac device registry and administrative health data from British Columbia, Canada, to derive and internally validate statistical models that predict the likely indication for ICD implantation. We used chart review data as the reference standard for ICD indication in the Cardiac Device Registry database (CDR; 2004-2012 [Cardiac Services BC]) and nonmissing indication as the reference standard in the Heart Information System registry database (HEARTis; 2013-2019 [Cardiac Services BC]). We created 3 logistic regression prediction models in each database: one using only registry data, one using only administrative data, and one using both registry and administrative data. We assessed the predictive performance of each model using standard metrics after optimism correction with 200 bootstrap resamples. Results Models that used registry data alone demonstrated excellent predictive performance (sensitivity ≥ 89%; specificity ≥ 87%). Models that used only administrative data performed well (sensitivity ≥ 84%; specificity ≥ 70%). Models that used both registry and administrative data showed modest gains over those that used registry data alone (sensitivity ≥ 90%; specificity ≥ 89%). Conclusions Administrative health data and cardiac device registry data can distinguish secondary prevention ICDs from primary prevention ICDs with acceptable sensitivity and specificity. Imputation of missing ICD indication might make these data resources more useful for research and health system monitoring.
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Affiliation(s)
- Isaac Robinson
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Daniel Daly-Grafstein
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mayesha Khan
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew D. Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nathaniel M. Hawkins
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey R. Brubacher
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - John A. Staples
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, British Columbia, Canada
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2
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Kuhrt N, Stevenson LW, Akhabue E, Visaria A, Lee E, Bates B, Gandhi P, Setoguchi S. Is it time to consider a "time-out" before primary prevention implantable cardioverter-defibrillator placement in currently or recently hospitalized older patients with heart failure? Heart Rhythm 2024:S1547-5271(24)02562-1. [PMID: 38750911 DOI: 10.1016/j.hrthm.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 05/05/2024] [Accepted: 05/08/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Trajectories of mortality after primary prevention implantable cardioverter-defibrillator (ICD) placement for older patients with heart failure during or soon after acute hospitalization have not been assessed. OBJECTIVE The purpose of this study was to compare trajectories of mortality after primary prevention ICD placement during or soon after acute cardiac or non-cardiac hospitalization. METHODS We identified older patients with heart failure undergoing primary prevention ICD placement using 20% Medicare data (2008-2018). Placement settings were as follows: (1) Current-H-during current hospitalization, (2) Recent-H-within 90 days of hospitalization, or (3) Chronic stable. Hospitalization was categorized as cardiac vs non-cardiac. Interval mortality rates and hazard ratios (HRs) using Cox regression were estimated at 0-30, 31-90, and 91-365 days after ICD placement. RESULTS Of the 61,710 patients (mean age 76 years; 35% female; 85% white), 19% (11,947), 25% (15,147), and 56% (34,616) had ICDs in Current-H, Recent-H, and Chronic stable settings. Mortality rates (per 100 person-years) were highest during 0-30 days, with 38 (34-42) and 22 (19-24) for Current-H and Recent-H, which declined to 21 (20-22) and 16 (15-17) during 91-365 days, respectively. Compared to Chronic stable, HRs were highest during 0-30 days post-ICD placement (5.5 [4.5-6.8] for Current-H and 3.4 [2.8-4.2] for Recent-H) and decreased during 91-365 days (2.0 [1.8-2.1] for Current-H and 1.6 [1.5-1.7] for Recent-H). HR pattens were similar for cardiac and non-cardiac hospitalizations. CONCLUSION Primary prevention ICD placement during or soon after hospitalization for any reason was associated with worse mortality with diminishing risks after 90 days. Hospitalization likely identifies a sicker population in whom early mortality with or without ICD may be higher. Our results support careful consideration regarding ICD placement during the 90 days after hospitalization.
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Affiliation(s)
- Nathaniel Kuhrt
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; Rutgers New Jersey Medical School, Newark, New Jersey
| | - Lynne Warner Stevenson
- Division of Advanced Heart Failure and Transplant Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ehimare Akhabue
- Department of Cardiology, Zucker School of Medicine at Hofstra / Northwell, Hempstead, New York; Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Aayush Visaria
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Eileen Lee
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut; Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Benjamin Bates
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Center for Pharmacoepidemiology and Treatment Science, Rutgers Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey
| | - Poonam Gandhi
- Center for Pharmacoepidemiology and Treatment Science, Rutgers Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey
| | - Soko Setoguchi
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Center for Pharmacoepidemiology and Treatment Science, Rutgers Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey.
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Aryana A, Kenigsberg D, Greenberg S, d'Avila A, Natale A. To The Editor- Ask not if, but which ablation procedures may be performed in the ambulatory surgical center! Heart Rhythm 2024:S1547-5271(24)02543-8. [PMID: 38718941 DOI: 10.1016/j.hrthm.2024.04.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 06/02/2024]
Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California.
| | | | - Scott Greenberg
- Woodlands North Houston Heart Center-Baylor St. Luke's, The Woodlands, Texas
| | - André d'Avila
- The Harvard Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
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4
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Faridi KF, Ong EL, Zimmerman S, Varosy PD, Friedman DJ, Hsu JC, Kusumoto F, Mortazavi BJ, Minges KE, Pereira L, Lakkireddy D, Koutras C, Denton B, Mobayed J, Curtis JP, Freeman JV. Predicting Major Adverse Events in Patients Undergoing Transcatheter Left Atrial Appendage Occlusion. Circ Arrhythm Electrophysiol 2024; 17:e012424. [PMID: 38390713 PMCID: PMC11021146 DOI: 10.1161/circep.123.012424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/31/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND The National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry (LAAO) includes the vast majority of transcatheter LAAO procedures performed in the United States. The objective of this study was to develop a model predicting adverse events among patients undergoing LAAO with Watchman FLX. METHODS Data from 41 001 LAAO procedures with Watchman FLX from July 2020 to September 2021 were used to develop and validate a model predicting in-hospital major adverse events. Randomly selected development (70%, n=28 530) and validation (30%, n=12 471) cohorts were analyzed with 1000 bootstrapped samples, using forward stepwise logistic regression to create the final model. A simplified bedside risk score was also developed using this model. RESULTS Increased age, female sex, low preprocedure hemoglobin, no prior attempt at atrial fibrillation termination, and increased fall risk most strongly predicted in-hospital major adverse events and were included in the final model along with other clinically relevant variables. The median in-hospital risk-standardized adverse event rate was 1.50% (range, 1.03%-2.84%; interquartile range, 1.42%-1.64%). The model demonstrated moderate discrimination (development C-index, 0.67 [95% CI, 0.65-0.70] and validation C-index, 0.66 [95% CI, 0.62-0.70]) with good calibration. The simplified risk score was well calibrated with risk of in-hospital major adverse events ranging from 0.26% to 3.90% for a score of 0 to 8, respectively. CONCLUSIONS A transcatheter LAAO risk model using National Cardiovascular Data Registry and LAAO Registry data can predict in-hospital major adverse events, demonstrated consistency across hospitals and can be used for quality improvement efforts. A simple bedside risk score was similarly predictive and may inform shared decision-making.
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Affiliation(s)
- Kamil F. Faridi
- Section of Cardiovascular Medicine, Dept of Medicine, Yale School of Medicine
- Ctr for Outcomes Rsrch & Evaluation, Yale New Haven Health, New Haven, CT
| | - Emily L. Ong
- Section of Cardiovascular Medicine, Dept of Medicine, Yale School of Medicine
| | - Sarah Zimmerman
- Ctr for Outcomes Rsrch & Evaluation, Yale New Haven Health, New Haven, CT
| | - Paul D. Varosy
- Cardiology Section, VA Eastern Colorado Hlth Care System, Aurora, CO
| | | | - Jonathan C. Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Univ of California San Diego Health System, La Jolla, CA
| | - Fred Kusumoto
- Dept of Cardiovascular Disease, Mayo Clinic, Jacksonville, FL
| | - Bobak J. Mortazavi
- Dept of Computer Science & Engineering, Texas A&M Univ, College Station, TX
| | - Karl E. Minges
- Ctr for Outcomes Rsrch & Evaluation, Yale New Haven Health, New Haven, CT
| | - Lucy Pereira
- Ctr for Outcomes Rsrch & Evaluation, Yale New Haven Health, New Haven, CT
| | | | | | - Beth Denton
- American College of Cardiology, Washington, DC
| | | | - Jeptha P. Curtis
- Section of Cardiovascular Medicine, Dept of Medicine, Yale School of Medicine
- Ctr for Outcomes Rsrch & Evaluation, Yale New Haven Health, New Haven, CT
| | - James V. Freeman
- Section of Cardiovascular Medicine, Dept of Medicine, Yale School of Medicine
- Ctr for Outcomes Rsrch & Evaluation, Yale New Haven Health, New Haven, CT
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Debray TPA, Collins GS, Riley RD, Snell KIE, Van Calster B, Reitsma JB, Moons KGM. Transparent reporting of multivariable prediction models developed or validated using clustered data: TRIPOD-Cluster checklist. BMJ 2023; 380:e071018. [PMID: 36750242 PMCID: PMC9903175 DOI: 10.1136/bmj-2022-071018] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 02/09/2023]
Affiliation(s)
- Thomas P A Debray
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Richard D Riley
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Kym I E Snell
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Ben Van Calster
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Johannes B Reitsma
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | - Karel G M Moons
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
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6
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Campos MPC, Bernardes LFG, de Melo JPC, dos Santos LC, Teixeira CHR, Pavão MLRC, Arfelli E, Scorzoni A, Rassi A, Marin-Neto JA, Schmidt A. Defibrillation Threshold Testing and Long-term Follow-up in Chagas Disease. Arq Bras Cardiol 2022; 119:923-928. [PMID: 36228277 PMCID: PMC9814814 DOI: 10.36660/abc.20210770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 06/15/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Sudden cardiac death is the most common cause of death in chronic Chagas cardiomyopathy (CCC). Because most CCC patients who are candidates for implantable cardioverter-defibrillators (ICD) meet criteria for high defibrillation threshold values, a defibrillator threshold test (DTT) is suggested. OBJECTIVES We investigated the use of DTT in CCC patients, focusing on deaths related to ICD and arrhythmic events, as well as treatment during long-term follow-up. METHODS We retrospectively evaluated 133 CCC patients who received an ICD mainly for secondary prevention. Demographic, clinical, laboratory data, Rassi score, and DTT data were collected, with p < 0.05 considered significant. RESULTS The mean patient age was 61 (SD, 13) years and 72% were men. The baseline left ventricular ejection fraction was 40 (SD, 15%) and the mean Rassi score was 10 (SD, 4). No deaths occurred during DTT and no ICD failures were documented. There was a relationship between higher baseline Rassi scores and higher DTT scores (ANOVA = 0.007). The mean time to first shock was 474 (SD, 628) days, although shock was only necessary for 28 (35%) patients with ventricular tachycardia, since most cases resolved spontaneously or through antitachycardia pacing. After a mean clinical follow-up of 1728 (SD, 1189) days, 43 deaths occurred, mainly related to progressive heart failure and sepsis. CONCLUSIONS A routine DTT may not be necessary for CCC patients who receive an ICD for secondary prevention. High DTT values seem to be unusual and may be related to high Rassi scores.
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Affiliation(s)
- Marco Paulo Cunha Campos
- Faculdade de Medicina de Ribeirão PretoUniversidade de São PauloRibeirão PretoSPBrasil Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo , Ribeirão Preto , SP – Brasil
| | - Luiz Fernando Gouveia Bernardes
- Faculdade de Medicina de Ribeirão PretoUniversidade de São PauloRibeirão PretoSPBrasil Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo , Ribeirão Preto , SP – Brasil
| | - João Paulo Chaves de Melo
- Faculdade de Medicina de Ribeirão PretoUniversidade de São PauloRibeirão PretoSPBrasil Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo , Ribeirão Preto , SP – Brasil
| | - Lucas Corsino dos Santos
- Faculdade de Medicina de Ribeirão PretoUniversidade de São PauloRibeirão PretoSPBrasil Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo , Ribeirão Preto , SP – Brasil
| | - Cristiano Honório Ribeiro Teixeira
- Faculdade de Medicina de Ribeirão PretoUniversidade de São PauloRibeirão PretoSPBrasil Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo , Ribeirão Preto , SP – Brasil
| | - Maria Licia Ribeiro Cury Pavão
- Faculdade de Medicina de Ribeirão PretoUniversidade de São PauloRibeirão PretoSPBrasil Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo , Ribeirão Preto , SP – Brasil
| | - Elerson Arfelli
- Faculdade de Medicina de Ribeirão PretoUniversidade de São PauloRibeirão PretoSPBrasil Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo , Ribeirão Preto , SP – Brasil
| | - Adilson Scorzoni
- Faculdade de Medicina de Ribeirão PretoUniversidade de São PauloRibeirão PretoSPBrasil Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo , Ribeirão Preto , SP – Brasil
| | - Anis Rassi
- Anis Rassi Heart HospitalGoiâniaGOBrasil Anis Rassi Heart Hospital , Goiânia , GO – Brasil
| | - José A. Marin-Neto
- Faculdade de Medicina de Ribeirão PretoUniversidade de São PauloRibeirão PretoSPBrasil Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo , Ribeirão Preto , SP – Brasil
| | - André Schmidt
- Faculdade de Medicina de Ribeirão PretoUniversidade de São PauloRibeirão PretoSPBrasil Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo , Ribeirão Preto , SP – Brasil
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7
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Ngo L, Ali A, Ganesan A, Woodman R, Krumholz HM, Adams R, Ranasinghe I. Institutional Variation in 30‐Day Complications Following Catheter Ablation of Atrial Fibrillation. J Am Heart Assoc 2022; 11:e022009. [PMID: 35156395 PMCID: PMC9245833 DOI: 10.1161/jaha.121.022009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Complications are a measure of procedural quality, yet variation in complication rates following catheter ablation of atrial fibrillation (AF) among hospitals has not been systematically examined. We examined institutional variation in the risk‐standardized 30‐day complication rates (RSCRs) following AF ablation which may suggest variation in care quality. Methods and Results This cohort study included all patients >18 years old undergoing AF ablations from 2012 to 2017 in Australia and New Zealand. The primary outcome was procedure‐related complications occurring during the hospital stay and within 30 days of hospital discharge. We estimated the hospital‐specific risk‐standardized complication rates using a hierarchical generalized linear model. A total of 25 237 patients (mean age, 62.5±11.4 years; 30.2% women; median length of stay 1 day [interquartile range, 1–2 days]) were included. Overall, a complication occurred in 1400 (5.55%) patients (4.34% in hospital, 1.46% following discharge, and 0.25% experienced both). Bleeding (3.31%), pericardial effusion (0.74%), and infection (0.44%) were the most common complications while stroke/transient ischemic attack (0.24%), cardiorespiratory failure and shock (0.19%), and death (0.08%) occurred less frequently. Among 46 hospitals that performed ≥25 ablations during the study period, the crude complication rate varied from 0.00% to 21.43% (median, 5.74%). After adjustment for differences in patient and procedural characteristics, the median risk‐standardized complication rate was 5.50% (range, 2.89%–10.31%), with 10 hospitals being significantly different from the national average. Conclusions Procedure‐related complications occur in 5.55% of patients undergoing AF ablations, although the risk of complications varies 3‐fold among hospitals, which suggests potential disparities in care quality and the need for efforts to standardize AF ablation practices among hospitals.
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Affiliation(s)
- Linh Ngo
- School of Clinical Medicine The University of Queensland Australia
- Department of Cardiology The Prince Charles Hospital Queensland Australia
- Cardiovascular CentreE Hospital Hanoi Vietnam
| | - Anna Ali
- Discipline of Medicine Faculty of Health and Medical Sciences The University of Adelaide South Australia Australia
| | - Anand Ganesan
- Department of Cardiovascular Medicine Flinders Medical Centre South Australia Australia
- College of Medicine and Public Health Flinders University South Australia Australia
| | - Richard Woodman
- Flinders Centre for Epidemiology and Biostatistics College of Medicine and Public Health Flinders University South Australia Australia
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine Department of Medicine Yale School of Medicine New Haven CT
- Center for Outcomes Research and Evaluation Yale New Haven Hospital New Haven CT
- Department of Health Policy and Management Yale School of Public Health New Haven CT
| | - Robert Adams
- Discipline of Medicine Faculty of Health and Medical Sciences The University of Adelaide South Australia Australia
- College of Medicine and Public Health Flinders University South Australia Australia
- Respiratory and Sleep Services Southern Adelaide Local Health Network South Australia Australia
| | - Isuru Ranasinghe
- School of Clinical Medicine The University of Queensland Australia
- Department of Cardiology The Prince Charles Hospital Queensland Australia
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8
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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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9
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Burri H, Starck C, Auricchio A, Biffi M, Burri M, D'Avila A, Deharo JC, Glikson M, Israel C, Lau CP, Leclercq C, Love CJ, Nielsen JC, Vernooy K, Dagres N, Boveda S, Butter C, Marijon E, Braunschweig F, Mairesse GH, Gleva M, Defaye P, Zanon F, Lopez-Cabanillas N, Guerra JM, Vassilikos VP, Martins Oliveira M. EHRA expert consensus statement and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter-defibrillators: endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin-American Heart Rhythm Society (LAHRS). Europace 2021; 23:983-1008. [PMID: 33878762 DOI: 10.1093/europace/euaa367] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.
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Affiliation(s)
- Haran Burri
- Department of Cardiology, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Augustenburger Pl. 1, 13353 Berlin, Germany.,German Center of Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Steinbeis University Berlin, Institute (STI) of Cardiovascular Perfusion, Berlin, Germany
| | - Angelo Auricchio
- Fondazione Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland
| | - Mauro Biffi
- Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Università di Bologna, Bologna, Italy
| | - Mafalda Burri
- Division of Scientific Information, University of Geneva, Rue Michel Servet 1, 1211 Geneva, Switzerland
| | - Andre D'Avila
- Serviço de Arritmia Cardíaca-Hospital SOS Cardio, 2 Florianópolis, SC, Brazil.,Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | | | - Carsten Israel
- Department of Cardiology, Bethel-Clinic Bielefeld, Burgsteig 13, 33617, Bielefeld, Germany
| | - Chu-Pak Lau
- Division of Cardiology, University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | | | - Charles J Love
- Johns Hopkins Hospital and School of Medicine, Baltimore, MD, USA
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 161, 8200 Aarhus, Denmark
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | | | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Serge Boveda
- Heart Rhythm Department, Clinique Pasteur, 31076 Toulouse, France
| | - Christian Butter
- Department of Cardiology, Heart Center Brandenburg, Chefarzt, Abteilung Kardiologie, Berlin, Germany
| | - Eloi Marijon
- University of Paris, Head of Cardiac Electrophysiology Section, European Georges Pompidou Hospital, 20 Rue Leblanc, 75908 Paris Cedex 15, France
| | | | - Georges H Mairesse
- Department of Cardiology-Electrophysiology, Cliniques du Sud Luxembourg-Vivalia, rue des Deportes 137, BE-6700 Arlon, Belgium
| | - Marye Gleva
- Washington University in St Louis, St Louis, MO, USA
| | - Pascal Defaye
- CHU Grenoble Alpes, Unite de Rythmologie, Service De Cardiologie, CS10135, 38043 Grenoble Cedex 09, France
| | - Francesco Zanon
- Arrhythmia and Electrophysiology Unit, Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | | | - Jose M Guerra
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Universidad Autonoma de Barcelona, CIBERCV, Barcelona, Spain
| | - Vassilios P Vassilikos
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.,3rd Cardiology Department, Hippokrateio General Hospital, Thessaloniki, Greece
| | - Mario Martins Oliveira
- Department of Cardiology, Hospital Santa Marta, Rua Santa Marta, 1167-024 Lisbon, Portugal
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10
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Fudim M, Ali-Ahmed F, Parzynski CS, Ambrosy AP, Friedman DJ, Pokorney SD, Curtis JP, Fonarow GC, Masoudi FA, Hernandez AF, Al-Khatib SM. Periprocedural Risk and Survival Associated With Implantable Cardioverter-Defibrillator Placement in Older Patients With Advanced Heart Failure. JAMA Cardiol 2021; 5:643-651. [PMID: 32211811 DOI: 10.1001/jamacardio.2020.0391] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Little is known about the utilization rates and outcomes of implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy defibrillator (CRT-D) placement among patients with advanced heart failure (HF). Objective To examine utilization rates, patient characteristics, and outcomes of ICD and CRT-D placements among patients with advanced HF. Design, Setting, and Participants This cohort study was a post hoc analysis of 81 492 Medicare fee-for-service beneficiaries enrolled in the National Cardiovascular Data Registry ICD Registry between January 2010 and December 2014. Inclusion criteria were patients who had received an HF diagnosis, had a left ventricular ejection fraction of 35% or lower, and showed evidence of advanced HF, which was defined as New York Heart Association (NYHA) class IV symptoms, inotrope use within the last 60 days, left ventricular assist device in situ, or orthotopic heart transplant listing. The comparator group included patients with NYHA class II and no HF hospitalization within the last 12 months, no left ventricular assist device, no orthotopic heart transplant listing, and no current or recent inotrope use. All eligible patients underwent first-time ICD or CRT-D placement for primary prevention of sudden cardiac death. Data were analyzed from January 2010 to December 2014. Main Outcomes and Measures All-cause mortality and periprocedural complications. Results Of 81 492 Medicare patients, 3343 had advanced HF (4.1%) and 19 424 were in the comparator group (23.8%). Among the advanced HF population, the mean (SD) age of patients was 74 (9) years, and patients were predominantly white individuals (81.5%) and men (71.1%). The all-cause mortality rate at 30 days was 3.1% (95% CI, 2.6%-3.8%) in the advanced HF group vs 0.5% (0.4%-0.6%) in the comparator group (P < .001). In the advanced HF population, the aggregate in-hospital periprocedural complication rate was 3.74% (95% CI, 3.12%-4.44%) vs 1.10% (95% CI, 0.95%-1.25%) in the comparator group (P < .001). Most adverse events in this group were in-hospital fatality (1.82%; 95% CI, 1.40%-2.34%) and resuscitated cardiac arrest (1.05%; 95% CI, 0.73%-1.45%). Patients with NYHA class IV (hazard ratio, 1.40; 95% CI, 1.02-1.93; P = .04), ischemic heart disease (hazard ratio, 1.24; 95% CI, 1.04-1.48; P = .02), or diabetes (hazard ratio, 1.17; 95% CI, 1.04-1.33; P = .01) had a higher risk of death. Conclusions and Relevance Among patients undergoing ICD or CRT-D placement for primary prevention of sudden cardiac death, only a small proportion had advanced HF. These patients experienced clinically important periprocedural complication rates associated with in-hospital death and cardiac arrest relative to patients with nonadvanced HF.
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Affiliation(s)
- Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Fatima Ali-Ahmed
- Duke Clinical Research Institute, Durham, North Carolina.,Beaumont Health, Dearborn, Michigan
| | - Craig S Parzynski
- Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew P Ambrosy
- Department of Cardiology, The Permanente Medical Group, San Francisco, California.,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Daniel J Friedman
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Sean D Pokorney
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, Connecticut
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at UCLA (University of California, Los Angeles).,Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, University of California, Los Angeles.,Section Editor
| | - Frederick A Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Adrian F Hernandez
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina.,Associate Editor
| | - Sana M Al-Khatib
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
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11
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Hess PL, Matlock DD, Al-Khatib SM. Decision-making regarding primary prevention implantable cardioverter-defibrillators among older adults. Clin Cardiol 2019; 43:187-195. [PMID: 31867773 PMCID: PMC7021655 DOI: 10.1002/clc.23315] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/26/2019] [Accepted: 11/26/2019] [Indexed: 11/12/2022] Open
Abstract
Most implantable cardioverter defibrillators (ICDs) are implanted for the purpose of primary prevention of sudden cardiac death among older patients with heart failure with reduced ejection fraction. Shared decision‐making prior to device implantation is guideline‐recommended and payer‐mandated. This article summarizes patient and provider attitudes toward device placement, device efficacy and effectiveness, potential periprocedural complications, long‐term events such as shocks, quality of life, costs, and shared decision‐making principles and recommendations. Most patients eligible for an ICD anticipate more than 10 years of survival. Physicians are less likely to offer an ICD to patients ≥80 years of age given a perceived lack of benefit. There is a dearth of data from randomized clinical trials addressing device efficacy among older patients; there is a need for more research in this area. However, currently available data support the use of ICDs irrespective of age provided life expectancy exceeds 1 year. Advanced age is independently associated with complications at the time of device placement but not the risk of device infection. The risk of inappropriate shock may be comparable or lower than that of younger patients. While quality of life is generally not adversely impacted by an ICD, a subset of patients experience post‐traumatic stress disorder. ICDs are cost‐effective from societal and health care sector perspectives; however, out‐of‐pocket costs vary according to insurance type and level. Shared decision‐making encounters may be incremental and iterative in nature. Providers are encouraged to partner with their patients, providing them counsel tailored to their values, preferences, and clinical presentation inclusive of age.
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Affiliation(s)
- Paul L Hess
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado.,Cardiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Daniel D Matlock
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado.,Cardiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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12
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Wong JA, Devereaux PJ. Cardiac Device Implantation Complications: A Gap in the Quality of Care? Ann Intern Med 2019; 171:368-369. [PMID: 31357214 DOI: 10.7326/m19-1895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jorge A Wong
- McMaster University, Hamilton, Ontario, Canada (J.A.W., P.D.)
| | - P J Devereaux
- McMaster University, Hamilton, Ontario, Canada (J.A.W., P.D.)
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13
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Ranasinghe I, Labrosciano C, Horton D, Ganesan A, Curtis JP, Krumholz HM, McGavigan A, Hossain S, Air T, Hariharaputhiran S. Institutional Variation in Quality of Cardiovascular Implantable Electronic Device Implantation: A Cohort Study. Ann Intern Med 2019; 171:309-317. [PMID: 31357210 DOI: 10.7326/m18-2810] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cardiovascular implantable electronic devices (CIEDs) are associated with procedure-related complications, yet little is known about variation in complication rates among institutions that may suggest disparities in care quality. OBJECTIVE To assess institutional variation in risk-standardized complication rates (RSCRs) for CIED. DESIGN Cohort study. SETTING 174 hospitals in Australia and New Zealand, 98 of which implanted at least 25 CIEDs during the study period. PARTICIPANTS 81 304 patients older than 18 years (mean, 74.7 years [SD, 12.4]; 37.9% female) who received a new CIED (65 711 permanent pacemakers [PPMs] and 15 593 implantable cardioverter-defibrillators [ICDs]) in 2010 to 2015. MEASUREMENTS RSCRs and frequencies of major device-related complications during hospitalization or within 90 days of discharge. RESULTS Of the cohort, 6664 patients (8.2%) had a major complication. Although complication rates were higher for ICDs than PPMs (10.04% vs. 7.76%), 76.5% of all complications were attributable to PPMs (5098 vs. 1566 for ICDs). Among hospitals that implanted at least 25 CIEDs, the median RSCR was 8.1%; however, rates varied from 5.3% to 14.3%, with 22 hospitals identified as having RSCRs that differed significantly from the national average. Similar variation was observed when RSCRs for PPM implantation (n = 96 hospitals) (median RSCR, 7.6% [range, 5.4% to 12.9%]) were considered separately from those for ICD placement (n = 68 hospitals) (median RSCR, 9.7% [range, 6.2% to 16.9%]) and persisted when only elective procedures were assessed (n = 88 hospitals) (median RSCR, 7.4% [range, 4.7% to 13.0%]). LIMITATION Possible unmeasured confounding from the use of administrative data. CONCLUSION CIED complications are common and vary among hospitals, suggesting institutional variation in CIED care quality. Concerted clinical and policy interventions are needed to address CIED-related complications. These efforts should preferentially target PPMs, because most CIED complications are attributable to these devices. PRIMARY FUNDING SOURCE The Hospitals Contribution Fund Research Foundation.
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Affiliation(s)
- Isuru Ranasinghe
- Basil Hetzel Institute for Translational Research, University of Adelaide, and Central Adelaide Local Health Network, Adelaide, South Australia, Australia (I.R.)
| | | | - Dennis Horton
- Basil Hetzel Institute for Translational Research, University of Adelaide, and Data to Decisions Cooperative Research Centre, Adelaide, South Australia, Australia (D.H.)
| | - Anand Ganesan
- Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia (A.G., A.M.)
| | - Jeptha P Curtis
- Yale-New Haven Hospital and Yale School of Medicine, New Haven, Connecticut (J.P.C.)
| | - Harlan M Krumholz
- Yale-New Haven Hospital, Yale School of Medicine, and Yale University, New Haven, Connecticut (H.M.K.)
| | - Andrew McGavigan
- Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia (A.G., A.M.)
| | - Sadia Hossain
- Basil Hetzel Institute for Translational Research and University of Adelaide, Adelaide, South Australia, Australia (S.H., S.H.)
| | - Tracy Air
- University of Adelaide, Adelaide, South Australia, Australia (C.L., T.A.)
| | - Saranya Hariharaputhiran
- Basil Hetzel Institute for Translational Research and University of Adelaide, Adelaide, South Australia, Australia (S.H., S.H.)
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14
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Wasfy JH, Kennedy KF, Masoudi FA, Ferris TG, Arnold SV, Kini V, Peterson P, Curtis JP, Amin AP, Bradley SM, French WJ, Messenger J, Ho PM, Spertus JA. Predicting Length of Stay and the Need for Postacute Care After Acute Myocardial Infarction to Improve Healthcare Efficiency. Circ Cardiovasc Qual Outcomes 2019; 11:e004635. [PMID: 30354547 DOI: 10.1161/circoutcomes.118.004635] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background To improve value in the care of patients with acute myocardial infarction (MI), payment models increasingly hold providers accountable for costs. As such, providers need tools to predict length of stay (LOS) during hospitalization and the likelihood of needing postacute care facilities after discharge for acute MI patients. We developed models to estimate risk for prolonged LOS and postacute care for acute MI patients at time of hospital admission to facilitate coordinated care planning. Methods and Results We identified patients in the National Cardiovascular Data Registry ACTION registry (Acute Coronary Treatment and Intervention Outcomes Network) who were discharged alive after hospitalization for acute MI between July 1, 2008 and March 31, 2017. Within a 70% random sample (Training cohort) we developed hierarchical, proportional odds models to predict LOS and hierarchical logistic regression models to predict discharge to postacute care. Models were validated in the remaining 30%. Of 633 737 patients in the Training cohort, 16.8% had a prolonged LOS (≥7 days) and 7.8% were discharged to a postacute facility (extended care, a transitional care unit, or rehabilitation). Model discrimination was moderate in the validation dataset for predicting LOS (C statistic=0.640) and strong for predicting discharge to postacute care (C statistic=0.827). For both models, discrimination was similar in ST-segment-elevation MI and non-ST-segment-elevation MI subgroups and calibration was excellent. Conclusions These models developed in a national registry can be used at the time of initial hospitalization to predict LOS and discharge to postacute facilities. Prospective testing of these models is needed to establish how they can improve care coordination and lower costs.
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Affiliation(s)
- Jason H Wasfy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.H.W.)
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO (K.F.K., S.V.A., J.A.S.)
| | - Frederick A Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora (F.A.M., V.K., P.P., J.M., P.M.H.)
| | - Timothy G Ferris
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (T.G.F.)
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO (K.F.K., S.V.A., J.A.S.)
| | - Vinay Kini
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora (F.A.M., V.K., P.P., J.M., P.M.H.)
| | - Pamela Peterson
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora (F.A.M., V.K., P.P., J.M., P.M.H.)
| | | | - Amit P Amin
- Washington University School of Medicine, St Louis, MO (A.P.A.)
| | | | | | - John Messenger
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora (F.A.M., V.K., P.P., J.M., P.M.H.)
| | - P Michael Ho
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora (F.A.M., V.K., P.P., J.M., P.M.H.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO (K.F.K., S.V.A., J.A.S.)
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15
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Wynants L, Kent DM, Timmerman D, Lundquist CM, Van Calster B. Untapped potential of multicenter studies: a review of cardiovascular risk prediction models revealed inappropriate analyses and wide variation in reporting. Diagn Progn Res 2019; 3:6. [PMID: 31093576 PMCID: PMC6460661 DOI: 10.1186/s41512-019-0046-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 01/03/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Clinical prediction models are often constructed using multicenter databases. Such a data structure poses additional challenges for statistical analysis (clustered data) but offers opportunities for model generalizability to a broad range of centers. The purpose of this study was to describe properties, analysis, and reporting of multicenter studies in the Tufts PACE Clinical Prediction Model Registry and to illustrate consequences of common design and analyses choices. METHODS Fifty randomly selected studies that are included in the Tufts registry as multicenter and published after 2000 underwent full-text screening. Simulated examples illustrate some key concepts relevant to multicenter prediction research. RESULTS Multicenter studies differed widely in the number of participating centers (range 2 to 5473). Thirty-nine of 50 studies ignored the multicenter nature of data in the statistical analysis. In the others, clustering was resolved by developing the model on only one center, using mixed effects or stratified regression, or by using center-level characteristics as predictors. Twenty-three of 50 studies did not describe the clinical settings or type of centers from which data was obtained. Four of 50 studies discussed neither generalizability nor external validity of the developed model. CONCLUSIONS Regression methods and validation strategies tailored to multicenter studies are underutilized. Reporting on generalizability and potential external validity of the model lacks transparency. Hence, multicenter prediction research has untapped potential. REGISTRATION This review was not registered.
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Affiliation(s)
- L. Wynants
- Department of Development and Regeneration, KU Leuven, Herestraat 49, box 7003, 3000 Leuven, Belgium
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht University, PO Box 9600, 6200 MD Maastricht, The Netherlands
| | - D. M. Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 63, Boston, MA 02111 USA
| | - D. Timmerman
- Department of Development and Regeneration, KU Leuven, Herestraat 49, box 7003, 3000 Leuven, Belgium
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - C. M. Lundquist
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 63, Boston, MA 02111 USA
| | - B. Van Calster
- Department of Development and Regeneration, KU Leuven, Herestraat 49, box 7003, 3000 Leuven, Belgium
- Department of Biomedical Data Sciences, Leiden University Medical Center, PO Box 9600, Leiden, 2300RC The Netherlands
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16
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Karnik AA, Helm RH, Monahan KM. Mechanisms and management of inappropriate therapy in subcutaneous implantable cardioverter defibrillators. J Cardiovasc Electrophysiol 2019; 30:402-409. [DOI: 10.1111/jce.13831] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 12/03/2018] [Accepted: 12/18/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Ankur A. Karnik
- Electrophysiology and Arrhythmia Service, Cardiology Division, Department of Medicine, Boston Medical CenterBoston Massachusetts
| | - Robert H. Helm
- Electrophysiology and Arrhythmia Service, Cardiology Division, Department of Medicine, Boston Medical CenterBoston Massachusetts
| | - Kevin M. Monahan
- Electrophysiology and Arrhythmia Service, Cardiology Division, Department of Medicine, Boston Medical CenterBoston Massachusetts
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17
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Padala SK, Gunda S, Li S, Sharma PS, Koneru JN, Varosy PD, Ellenbogen KA. A risk score model for predicting intraprocedural cardiac injury during implantable cardioverter defibrillator implantation: Insights from the National Cardiovascular Data Registry. J Cardiovasc Electrophysiol 2019; 30:212-220. [PMID: 30575180 DOI: 10.1111/jce.13823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/29/2018] [Accepted: 11/12/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Individual risk factors of intraprocedural cardiac injury (cardiac perforation and tamponade) during implantable cardioverter defibrillator (ICD) placement have been documented. However, the prognostic impact of their coexistence has not been explored. OBJECTIVE To develop a risk score model to identify patients at risk for intraprocedural cardiac injury. METHODS We identified 438 679 patients from National Cardiovascular Data Registry (NCDR)-ICD who underwent de novo ICD implantation between 2010 and 2015, split randomly into a derivation cohort (n = 220 000) and a validation cohort (n = 218 679). The generalized estimating equations (GEEs) analysis with quasilikelihood under the independence model criterion goodness-of-fit statistics were used to identify the predictors of intraprocedural cardiac injury and a risk scoring model was developed. Model discrimination was assessed by receiver-operator characteristic curve and C-statistic. RESULTS The risk of intraprocedural cardiac injury in the overall cohort was 0.13%. GEE analysis yielded seven variables (points in parentheses) that were strongly associated with intraprocedural cardiac injury: age, greater than 75 years (1), female gender (1), body mass index, less than 18.5 kg/m 2 (1), hypertension (1), chronic lung disease (1), left bundle branch block (1), and continued warfarin use (1). Only prior history of coronary artery bypass grafting (CABG) (-1) was associated with reduced risk. A risk scoring system was developed that had good discrimination with a C-statistic of 0.72. The risk of intraprocedural cardiac injury increased with the increase in risk score from low risk (0.03%) to high risk (1.37%). CONCLUSION A practical risk score model can stratify patients into high- and low-risk groups for cardiac perforation or tamponade before undergoing ICD implantation.
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Affiliation(s)
- Santosh K Padala
- Divison of Cardiology, Department of Electrophysiology, Virginia Commonwealth University, Richmond, Virginia
| | - Sampath Gunda
- Divison of Cardiology, Department of Electrophysiology, Virginia Commonwealth University, Richmond, Virginia
| | - Shelby Li
- Department of Cardiac Rhythm and Heart Failure, Medtronic PLC, Minneapolis, Minnesota
| | - Parikshit S Sharma
- Divison of Cardiology, Department of Electrophysiology, Rush University Medical Center, Chicago, Illinois
| | - Jayanthi N Koneru
- Divison of Cardiology, Department of Electrophysiology, Virginia Commonwealth University, Richmond, Virginia
| | - Paul D Varosy
- Division of Cardiology, Department of Electrophysiology, VA Eastern Colorado Health Care System, University of Colorado, Denver, Colorado
| | - Kenneth A Ellenbogen
- Divison of Cardiology, Department of Electrophysiology, Virginia Commonwealth University, Richmond, Virginia
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18
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Ambrosy AP, Parzynski CS, Friedman DJ, Fudim M, Hernandez AF, Fonarow GC, Masoudi FA, Al-Khatib SM. Is Time From Last Hospitalization for Heart Failure to Placement of a Primary Prevention Implantable Cardioverter-Defibrillator Associated With Patient Outcomes? Circulation 2018; 138:2787-2797. [PMID: 30565983 PMCID: PMC6931009 DOI: 10.1161/circulationaha.118.035627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/14/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Landmark studies have demonstrated the safety and efficacy of implantable cardioverter-defibrillators (ICDs) in selected stable ambulatory patients with heart failure (HF) with a reduced ejection fraction receiving optimal medical therapy. It is not known whether a recent hospitalization for HF before ICD placement is associated with subsequent outcomes. METHODS A post hoc analysis was performed of Medicare beneficiaries enrolled in the National Cardiovascular Data Registry's ICD Registry with a known diagnosis of HF and an ejection fraction ≤35% underdoing a new ICD placement for primary prevention. Patients were grouped based on the timing of ICD placement from the last hospitalization for HF. The association between timing of ICD placement and outcomes was assessed by using multivariable logistic regression models. RESULTS The final analytic cohort included 81 180 patients undergoing initial ICD placement for primary prevention who were currently hospitalized for HF (n=11 563, 14%), hospitalized for HF within 3 months (n=6252, 8%), or hospitalized for HF >3 months previously or had no previous hospitalizations for HF (n=63 365, 78%). Patients currently or recently hospitalized for HF had a higher unadjusted composite periprocedural complication rate (2.60% versus 1.71% versus 1.25%, P<0.001). After adjusting for potential confounders, patients currently hospitalized for HF were at higher risk for death (odds ratio, 2.25; 95% CI, 2.02-2.52; P <0.001) and all-cause readmission (odds ratio, 1.89; 95% CI, 1.79-1.99; P <0.001) at 90 days. CONCLUSION Older patients currently or recently hospitalized for HF undergoing initial ICD placement for primary prevention experienced a higher rate of periprocedural complications and were at increased risk of death in comparison with those receiving an ICD without recent HF hospitalization. Additional prospective, real-world, pragmatic, comparative effectiveness studies should be conducted to define the optimal timing of ICD placement.
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Affiliation(s)
- Andrew P. Ambrosy
- Division of Cardiology, The Permanente Medical Group, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Craig S. Parzynski
- Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel J. Friedman
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Adrian F. Hernandez
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Gregg C. Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, University of California, Los Angeles, CA, USA
| | - Frederick A. Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sana M. Al-Khatib
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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19
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Heidenreich PA. US Department of Justice Investigations of Implantable Cardioverter-Defibrillators and Quality Improvement in Health Care. JAMA 2018; 320:40-42. [PMID: 29971380 DOI: 10.1001/jama.2018.8514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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20
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Quality and Safety in Health Care, Part XLIII: Selected Outcome Studies From the Implantable Cardioverter Defibrillator Registry. Clin Nucl Med 2018; 44:30-31. [PMID: 29762241 DOI: 10.1097/rlu.0000000000002135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To compare outcome results from different institutions in a registry, it is necessary to have a way to take into account differences in the risk characteristics of the patients. This model has been constructed for the Implantable Cardioverter Defibrillator (ICD) Registry, and the most important variables have been identified. In another study, it has also been found that many of these patients have comorbidities, and the mortality rate 60 months after a replacement ICD was 41.2%. In a third study, it was determined that for individuals at least 65 years of age, 60 months after ICD placement, 50.9% of the recipients used hospice services or were dead.
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21
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Nishimura M, Sab S, Birgersdotter-Green U, Krummen D, Schricker A, Raissi F, Hoffmayer KS, Feld GK, Hsu JC. Reasons for and predictors of acute hospitalization versus elective outpatient implantable cardioverter-defibrillator implantation and subsequent differential clinical outcomes. J Interv Card Electrophysiol 2017; 50:85-93. [PMID: 28844089 DOI: 10.1007/s10840-017-0283-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 08/15/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Implantable cardioverter-defibrillator (ICD) implantation is often an elective outpatient procedure, but previous studies have shown that approximately 30% are performed during acute hospitalizations. PURPOSE This study aims to identify predictors of acute hospitalization versus elective outpatient ICD implantation and evaluate differential clinical outcomes. METHODS We studied 327 first-time ICD recipients between 2011 and 2015. All patients receiving a primary prevention ICD were optimized on guideline directed medical therapy (GDMT) prior to consideration for device implantation. Using multivariate logistic regression, we examined predictors of ICD implantation during acute hospitalization. Cox proportional hazard regression was used adjusting for patient characteristics to examine associations with clinical outcomes including complications, device therapy, heart failure re-admission, and death. RESULTS Of all patients, 132 (40.3%) underwent ICD implantation during acute hospitalization, most frequently performed for secondary prevention (n = 76, 57.6%). The most common reason for acute hospitalization ICD implantation in primary prevention patients was an indication for pacing (n = 20, 35.7%). In multivariable adjusted models, secondary prevention indication, non-single chamber device, NYHA class IV symptoms, lower diastolic blood pressure, higher BUN, and lower hemoglobin were significant predictors of ICD implantation during an acute hospitalization. In univariate analysis, acute hospitalization ICD implantation was associated with a higher risk of heart failure re-admission (HR = 1.6, 95% CI 1.1-2.4) and mortality (HR = 3.0, 95% CI 1.1-8.0) but no difference in risk of ICD therapy (HR = 1.4, 95% CI 0.9-2.3) or adverse events (HR = 1.1, 95% CI 0.6-2.1). After multivariable adjustment for potential confounders, all outcomes were no different between acute hospitalization versus elective outpatient ICD recipients. CONCLUSIONS Among first-time ICD recipients, specific clinical characteristics predicted acute hospitalization ICD implantation. After adjustment for potential confounders, acute hospitalization ICD implantation was not associated with increased risk of morbidity or mortality.
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Affiliation(s)
- Marin Nishimura
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, 9452 Medical Center Dr, 3rd Fl, Rm 3E-417, La Jolla, CA, 92037, USA
| | - Shiv Sab
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, 9452 Medical Center Dr, 3rd Fl, Rm 3E-417, La Jolla, CA, 92037, USA
| | - Ulrika Birgersdotter-Green
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, 9452 Medical Center Dr, 3rd Fl, Rm 3E-417, La Jolla, CA, 92037, USA
| | - David Krummen
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, 9452 Medical Center Dr, 3rd Fl, Rm 3E-417, La Jolla, CA, 92037, USA
| | - Amir Schricker
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, 9452 Medical Center Dr, 3rd Fl, Rm 3E-417, La Jolla, CA, 92037, USA
| | - Farshad Raissi
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, 9452 Medical Center Dr, 3rd Fl, Rm 3E-417, La Jolla, CA, 92037, USA
| | - Kurt S Hoffmayer
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, 9452 Medical Center Dr, 3rd Fl, Rm 3E-417, La Jolla, CA, 92037, USA
| | - Gregory K Feld
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, 9452 Medical Center Dr, 3rd Fl, Rm 3E-417, La Jolla, CA, 92037, USA
| | - Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, 9452 Medical Center Dr, 3rd Fl, Rm 3E-417, La Jolla, CA, 92037, USA.
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22
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Hawkins NM, Grubisic M, Andrade JG, Huang F, Ding L, Gao M, Bashir J. Long-term complications, reoperations and survival following cardioverter-defibrillator implant. Heart 2017; 104:237-243. [PMID: 28747313 DOI: 10.1136/heartjnl-2017-311638] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/26/2017] [Accepted: 06/28/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Implantable cardioverter-defibrillators (ICDs) reduce risk of death in select populations, but are also associated with harms. We aimed to characterise long-term complications and reoperation rate. METHODS We assessed the rate, cumulative incidence and predictors of long-term reoperation and survival using a prospective, multicentre registry serving British Columbia in Canada, a universal single payer healthcare system with 4.5 million residents. 3410 patients (mean 63.3 years, 81.7% male) with new primary (n=1854) or secondary prevention (n=1556) ICD implant from 2003 to 2012 were followed for a median of 34 months (single chamber n=1069, dual chamber n=1905, biventricular n=436). Independent predictors of adverse outcomes were defined using Cox regression models. RESULTS The overall reoperation rate was 12.0% per patient-year, and less for single vs dual vs biventricular ICDs (9.1% vs 12.5% vs 17.8% per patient-year, respectively). The Kaplan-Meier complication estimates (excluding generator end of life) at 1, 3 and 5 years were respectively: single chamber 10.2%, 16.2% and 21.6%; dual 11.7%, 19.1% and 27.4% and biventricular 15.9%, 22.2% and 24.7%. Cardiac resynchronisation therapy had the highest rate of early lead complications, but lower long-term need for upgrade. Device complexity, age and atrial fibrillation were key determinants of complications. Overall mortality at 1, 3 and 5 years was 5.4%, 17.4% and 32.7%, respectively. In younger patients, observed 5-year survival approached the expected survival in the general population (relative survival ratio=0.96 (0.90-0.98)). With increasing age, observed survival steadily declined relative to expected. CONCLUSIONS In a prospective registry capturing all procedures, complication and reoperation rates following de novo ICD implantation were high. Shared decision making must carefully consider these factors.
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Affiliation(s)
| | - Maja Grubisic
- BC Centre for Improved Cardiovascular Health, Vancouver, Canada
| | - Jason G Andrade
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Flora Huang
- University of British Columbia, Vancouver, Canada
| | - Lillian Ding
- Cardiac Services of British Columbia, Vancouver, Canada
| | - Min Gao
- BC Centre for Improved Cardiovascular Health, Vancouver, Canada
| | - Jamil Bashir
- Division of Cardiovascular Surgery, University of British Columbia, Vancouver, Canada
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23
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Karnik AA, Helm RH, Monahan KM. Oversensing of atrial fibrillatory waves in a subcutaneous implantable cardioverter-defibrillator. HeartRhythm Case Rep 2017; 3:e1-e6. [PMID: 28491810 PMCID: PMC5419807 DOI: 10.1016/j.hrcr.2016.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- Ankur A. Karnik
- Address reprint requests and correspondence: Dr Ankur A. Karnik, Electrophysiology and Arrhythmia Service, Cardiology Division, Department of Medicine, Boston Medical Center and the Boston University School of Medicine, 88 E Newton St, Boston, MA 02118.Electrophysiology and Arrhythmia Service, Cardiology Division, Department of Medicine, Boston Medical Center, Boston University School of Medicine88 E Newton StBostonMA02118
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24
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Turakhia MP, Zweibel S, Swain AL, Mollenkopf SA, Reynolds MR. Healthcare Utilization and Expenditures Associated With Appropriate and Inappropriate Implantable Defibrillator Shocks. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.115.002210. [DOI: 10.1161/circoutcomes.115.002210] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 12/20/2016] [Indexed: 11/16/2022]
Abstract
Background—
In patients with implantable cardioverter–defibrillators, healthcare utilization (HCU) and expenditures related to shocks have not been quantified.
Methods and Results—
We performed a retrospective cohort study of patients with implantable cardioverter–defibrillators identified from commercial and Medicare supplemental claims databases linked to adjudicated shock events from remote monitoring data. A shock event was defined as ≥1 spontaneous shocks delivered by an implanted device. Shock-related HCU was ascertained from inpatient and outpatient claims within 7 days following a shock event. Shock events were adjudicated and classified as inappropriate or appropriate, and HCU and expenditures, stratified by shock type, were quantified. Of 10 266 linked patients, 963 (9.4%) patients (61.3±13.6 years; 81% male) had 1885 shock events (56% appropriate, 38% inappropriate, and 6% indeterminate). Of these events, 867 (46%) had shock-related HCU (14% inpatient and 32% outpatient). After shocks, inpatient cardiovascular procedures were common, including echocardiography (59%), electrophysiology study or ablation (34%), stress testing (16%), and lead revision (11%). Cardiac catheterization was common (71% and 51%), but percutaneous coronary intervention was low (6.5% and 5.0%) after appropriate and inappropriate shocks. Expenditures related to appropriate and inappropriate shocks were not significantly different.
Conclusions—
After implantable cardioverter–defibrillator shock, related HCU was common, with 1 in 3 shock events followed by outpatient HCU and 1 in 7 followed by hospitalization. Use of invasive cardiovascular procedures was substantial, even after inappropriate shocks, which comprised 38% of all shocks. Implantable cardioverter–defibrillator shocks seem to trigger a cascade of health care. Strategies to reduce shocks could result in cost savings.
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Affiliation(s)
- Mintu P. Turakhia
- From the Center for Digital Health, Stanford University School of Medicine, Stanford, CA (M.P.T.); the Division of Cardiac Electrophysiology, Hartford Healthcare Heart and Vascular Institute, Hartford, CT (S.Z.); the Department of Economics, Reimbursement, and Evidence, Medtronic plc, Mounds View, MN (A.L.S., S.A.M.); and Baim Institute for Clinical Research, Boston, MA (M.R.R.)
| | - Steven Zweibel
- From the Center for Digital Health, Stanford University School of Medicine, Stanford, CA (M.P.T.); the Division of Cardiac Electrophysiology, Hartford Healthcare Heart and Vascular Institute, Hartford, CT (S.Z.); the Department of Economics, Reimbursement, and Evidence, Medtronic plc, Mounds View, MN (A.L.S., S.A.M.); and Baim Institute for Clinical Research, Boston, MA (M.R.R.)
| | - Andrea L. Swain
- From the Center for Digital Health, Stanford University School of Medicine, Stanford, CA (M.P.T.); the Division of Cardiac Electrophysiology, Hartford Healthcare Heart and Vascular Institute, Hartford, CT (S.Z.); the Department of Economics, Reimbursement, and Evidence, Medtronic plc, Mounds View, MN (A.L.S., S.A.M.); and Baim Institute for Clinical Research, Boston, MA (M.R.R.)
| | - Sarah A. Mollenkopf
- From the Center for Digital Health, Stanford University School of Medicine, Stanford, CA (M.P.T.); the Division of Cardiac Electrophysiology, Hartford Healthcare Heart and Vascular Institute, Hartford, CT (S.Z.); the Department of Economics, Reimbursement, and Evidence, Medtronic plc, Mounds View, MN (A.L.S., S.A.M.); and Baim Institute for Clinical Research, Boston, MA (M.R.R.)
| | - Matthew R. Reynolds
- From the Center for Digital Health, Stanford University School of Medicine, Stanford, CA (M.P.T.); the Division of Cardiac Electrophysiology, Hartford Healthcare Heart and Vascular Institute, Hartford, CT (S.Z.); the Department of Economics, Reimbursement, and Evidence, Medtronic plc, Mounds View, MN (A.L.S., S.A.M.); and Baim Institute for Clinical Research, Boston, MA (M.R.R.)
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25
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Ruwald AC, Vinther M, Gislason GH, Johansen JB, Nielsen JC, Petersen HH, Riahi S, Jons C. The impact of co-morbidity burden on appropriate implantable cardioverter defibrillator therapy and all-cause mortality: insight from Danish nationwide clinical registers. Eur J Heart Fail 2016; 19:377-386. [PMID: 27905161 DOI: 10.1002/ejhf.685] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/14/2016] [Accepted: 10/07/2016] [Indexed: 11/06/2022] Open
Abstract
AIMS In a nationwide cohort of primary (PP-ICD) and secondary prevention (SP-ICD) implantable cardioverter defibrillator (ICD) patients, we aimed to investigate the association between co-morbidity burden and risk of appropriate ICD therapy and mortality. METHODS AND RESULTS We identified all patients >18 years, implanted with first-time PP-ICD (n = 1873) or SP-ICD (n = 2461) in Denmark from 2007 to 2012. Co-morbidity was identified in administrative registers of hospitalization and drug prescription from pharmacies. Co-morbidity burden was defined as the number of pre-existing non-ICD indication-related co-morbidities including atrial fibrillation, diabetes, chronic obstructive pulmonary disease, chronic renal disease, liver disease, cancer, chronic psychiatric disease, and peripheral and/or cerebrovascular disease, and divided into four groups (co-morbidity burden 0, 1, 2, and ≥3). Through Cox models, we assessed the impact of co-morbidity burden on appropriate ICD therapy and mortality. Increasing co-morbidity burden was not associated with increased risk of appropriate therapy, irrespective of implant indication [all hazard ratios (HRs) 1.0-1.4, P = NS]. Using no co-morbidities as reference, increasing co-morbidity burden was associated with increased mortality risk in PP-ICD patients (co-morbidity burden 1, HR 2.1; comorbidity burden 2, HR 3.7; co-morbidity burden ≥3, HR 6.6) (all P < 0.001) and SP-ICD patients (co-morbidity burden 1, HR 2.2; co-morbidity burden 2, HR 3.8; co-morbidity burden ≥3, HR 5.8). With increasing co-morbidity burden, an increasing frequency of patients died without having utilized their device, with 72% PP-ICD and 45% SP-ICD patients with co-morbidity burden ≥3 dying without prior appropriate ICD therapy. CONCLUSION Increasing co-morbidity burden was not associated with increased risk of appropriate ICD therapy. With increasing co-morbidity burden, mortality increased, and a higher proportion of patients died, without ever having utilized their device.
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Affiliation(s)
| | - Michael Vinther
- Department of Cardiology, Herlev-Gentofte University Hospitals, Copenhagen, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Herlev-Gentofte University Hospitals, Copenhagen, Denmark.,National Institute of Public Health, Copenhagen, Denmark.,Department of Cardiology, University of Southern Denmark, Odense, Denmark.,The Danish Heart Foundation
| | | | | | | | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Christian Jons
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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26
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Friedman DJ, Al-Khatib SM. Measuring quality in electrophysiology. J Interv Card Electrophysiol 2016; 47:5-10. [PMID: 26936264 DOI: 10.1007/s10840-016-0118-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 02/22/2016] [Indexed: 10/22/2022]
Abstract
The evolving healthcare environment demands optimally measured quality of care. Performance measures are increasingly being used for quality improvement, public reporting, and reimbursement determinations. The National Quality Forum has created rigorous criteria for the evaluation of potential performance measures across medical fields. The Heart Rhythm Society has championed the development of four separate electrophysiology (EP)-specific performance measures: implantable cardioverter defibrillator complication rate, cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation, infection within 180 days of a cardiac implantable electronic device implantation, replacement, or revision, and in-person evaluation following a cardiac implantable electronic device implantation. National registries serve a key role in developing performance measures and facilitating quality improvement, particularly as they provide improved granularity and accuracy of data compared with administrative claims data. All performance measures demand continued reassessment as technology and performance gaps change and as unintended consequences may arise.
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Affiliation(s)
- Daniel J Friedman
- Duke Clinical Research Institute, PO Box 17969, Durham, NC, 27715, USA
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, PO Box 17969, Durham, NC, 27715, USA.
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27
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Implantable Cardioverter-Defibrillators at End of Battery Life. J Am Coll Cardiol 2016; 67:435-444. [DOI: 10.1016/j.jacc.2015.11.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 11/02/2015] [Accepted: 11/11/2015] [Indexed: 11/23/2022]
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28
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Ascoeta MS, Marijon E, Defaye P, Klug D, Beganton F, Perier MC, Gras D, Algalarrondo V, Deharo JC, Leclercq C, Fauchier L, Babuty D, Bordachar P, Sadoul N, Boveda S, Piot O. Impact of early complications on outcomes in patients with implantable cardioverter-defibrillator for primary prevention. Heart Rhythm 2016; 13:1045-1051. [PMID: 26749313 DOI: 10.1016/j.hrthm.2015.12.046] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The lifesaving benefit of implantable cardioverter-defibrillators (ICDs) has been demonstrated. Their use has increased considerably in the past decade, but related complications have become a major concern. OBJECTIVE The purpose of this study was to assess the incidence and effect on outcomes of early (≤30 days) complications after ICD implantation for primary prevention in a large French population. METHODS We analyzed data from 5539 patients from the multicenter French DAI-PP (Défibrillateur Automatique Implantable-Prévention Primaire) registry (2002-2012) who had coronary artery disease or dilated cardiomyopathy and were implanted with an ICD for primary prevention. RESULTS Overall, early complications occurred in 707 patients (13.5%), mainly related to lead dislodgment or hematoma (57%). Independent factors associated with occurrence of early complications were severe renal impairment (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.17-2.37, P = .02), age ≥75 years (OR 1.01, 95% CI 1.00-1.02, P = .03), cardiac resynchronization therapy (OR 1.58, 95% CI 1.16-2.17, P = .01), and anticoagulant therapy (OR 1.28, 95% CI 1.02-1.61, P = .03). During a mean ± SD follow-up of 3.1 ± 2.3 years, 824 (15.8%) patients experienced ≥1 late complication (>30 days), and 782 (14.9%) patients died. After adjustment, early complications remained associated with occurrence of late complications (OR 2.15, 95% CI 1.73-2.66, P < .0001) and mortality (OR 1.70, 95% CI 1.34-2.17, P = .003). CONCLUSION Early complications are common after ICD implantation for primary prevention, occurring in 1 in 7 patients, and are associated with an increased risk of late complications and overall mortality. Further studies are needed to investigate the underlying mechanisms of such associations.
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Affiliation(s)
| | - Eloi Marijon
- European Georges Pompidou Hospital and Paris Descartes University, Paris, France
| | | | | | - Frankie Beganton
- Paris Cardiovascular Research Center, Inserm U(††#), Paris, France
| | | | - Daniel Gras
- Nouvelles Cliniques Nantaises, Nantes, France
| | | | | | | | | | | | | | | | | | - Olivier Piot
- Centre Cardiologique du Nord, Saint Denis, France.
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- European Georges Pompidou Hospital and Paris Descartes University, Paris, France
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29
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Affiliation(s)
- Janet M McComb
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK
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30
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Implantable cardioverter-defibrillator harm in young patients with inherited arrhythmia syndromes: A systematic review and meta-analysis of inappropriate shocks and complications. Heart Rhythm 2015; 13:443-54. [PMID: 26385533 DOI: 10.1016/j.hrthm.2015.09.010] [Citation(s) in RCA: 178] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Implantable cardioverter-defibrillators (ICDs) are implanted with the intention to prolong life in selected patients with inherited arrhythmia syndromes, but ICD implantation is also associated with inappropriate shocks and complications. OBJECTIVE We aimed to quantify the rate of inappropriate shocks and other ICD-related complications to be able to weigh benefit and harm in these patients. METHODS We performed a systematic review and meta-analysis of inappropriate shock and/or other ICD-related complication rates, including ICD-related mortality, in patients with inherited arrhythmia syndromes, that is, arrhythmogenic right ventricular cardiomyopathy/dysplasia, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, hypertrophic cardiomyopathy, dilated cardiomyopathy due to a mutation in the lamin A/C gene, long QT syndrome, and short QT syndrome. We searched MEDLINE and EMBASE from inception to May 30, 2014. RESULTS Of 2471 unique citations, 63 studies comprising 4916 patients with inherited arrhythmia syndromes (mean age of 39 ± 15 years) were included. Inappropriate shocks occurred in 20% of patients (crude annual rate of 4.7% per year), with a significantly higher rate in studies published before 2008 (6.1% per year vs 4.1% per year). Moreover, 22% experienced ICD-related complications (4.4% per year) and there was a 0.5% ICD-related mortality (0.08% per year). CONCLUSION ICD implantation carries a significant risk of inappropriate shocks and inhospital and postdischarge complications in relatively young patients with inherited arrhythmia syndromes. These data can be used to better inform patients and physicians about the expected risk of adverse ICD events and thereby facilitate shared decision making.
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32
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Kramer DB, Matlock DD, Buxton AE, Goldstein NE, Goodwin C, Green AR, Kirkpatrick JN, Knoepke C, Lampert R, Mueller PS, Reynolds MR, Spertus JA, Stevenson LW, Mitchell SL. Implantable Cardioverter-Defibrillator Use in Older Adults: Proceedings of a Hartford Change AGEnts Symposium. Circ Cardiovasc Qual Outcomes 2015; 8:437-46. [PMID: 26038525 DOI: 10.1161/circoutcomes.114.001660] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel B Kramer
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.).
| | - Daniel D Matlock
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Alfred E Buxton
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Nathan E Goldstein
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Carol Goodwin
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Ariel R Green
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - James N Kirkpatrick
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Christopher Knoepke
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Rachel Lampert
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Paul S Mueller
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Matthew R Reynolds
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - John A Spertus
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Lynne W Stevenson
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Susan L Mitchell
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
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Ezzat VA, Lee V, Ahsan S, Chow AW, Segal O, Rowland E, Lowe MD, Lambiase PD. A systematic review of ICD complications in randomised controlled trials versus registries: is our 'real-world' data an underestimation? Open Heart 2015; 2:e000198. [PMID: 25745566 PMCID: PMC4346580 DOI: 10.1136/openhrt-2014-000198] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 12/15/2014] [Accepted: 01/12/2015] [Indexed: 01/01/2023] Open
Abstract
Implantable cardioverter defibrillator (ICD) implantation carries a significant risk of complications, however published estimates appear inconsistent. We aimed to present a contemporary systematic review using meta-analysis methods of ICD complications in randomised controlled trials (RCTs) and compare it to recent data from the largest international ICD registry, the US National Cardiovascular Data Registry (NCDR). PubMed was searched for any RCTs involving ICD implantation published 1999–2013; 18 were identified for analysis including 6433 patients, mean follow-up 3 months–5.6 years. Exclusion criteria were studies of children, hypertrophic cardiomyopathy, congenital heart disease, resynchronisation therapy and generator changes. Total pooled complication rate from the RCTs (excluding inappropriate shocks) was 9.1%, including displacement 3.1%, pneumothorax 1.1% and haematoma 1.2%. Infection rate was 1.5%.There were no predictors of complications but longer follow-up showed a trend to higher complication rates (p=0.07). In contrast, data from the NCDR ICD, reporting on 356 515 implants (2006–2010) showed a statistically significant threefold lower total major complication rate of 3.08% with lead displacement 1.02%, haematoma 0.86% and pneumothorax 0.44%. The overall ICD complication rate in our meta-analysis is 9.1% over 16 months. The ICD complication reported in the NCDR ICD registry is significantly lower despite a similar population. This may reflect under-reporting of complications in registries. Reporting of ICD complications in RCTs and registries is very variable and there is a need to standardise classification of complications internationally.
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Datino T, Miracle Blanco Á, Núñez García A, González-Torrecilla E, Atienza Fernández F, Arenal Maíz Á, Hernández-Hernández J, Ávila Alonso P, Eidelman G, Fernández-Avilés F. Safety of Outpatient Implantation of the Implantable Cardioverter-defibrillator. ACTA ACUST UNITED AC 2014; 68:579-84. [PMID: 25435093 DOI: 10.1016/j.rec.2014.07.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 07/03/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND OBJECTIVES Strategies are needed to reduce health care costs and improve patient care. The objective of our study was to analyze the safety of outpatient implantation of cardioverter-defibrillators. METHODS A retrospective study was conducted in 401 consecutive patients who received an implantable cardioverter-defibrillator between 2007 and 2012. The rate of intervention-related complications was compared between 232 patients (58%) whose implantation was performed in the outpatient setting and 169 patients (42%) whose intervention was performed in the inpatient setting. RESULTS The mean age (standard deviation) of the patients was 62 (14) years; 336 (84%) were male. Outpatients had lower left ventricular ejection fraction and a higher percentage had an indication for primary prevention of sudden death, compared to inpatients. Only 21 outpatients (9%) required subsequent hospitalization. The rate of complications until the third month postimplantation was similar for outpatients (6.0%) and inpatients (5.3%); P = .763. In multivariate analysis, only previous anticoagulant therapy was related to the presence of complications (odds ratio = 3.2; 95% confidence interval, 1.4-7.4; P < .01), mainly due to an increased rate of pocket hematomas. Each outpatient implantation saved approximately €735. CONCLUSIONS Outpatient implantation of implantable cardioverter-defibrillators is safe and reduces costs. Close observation is recommended for patients receiving chronic anticoagulation therapy due to an increased risk of complications.
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Affiliation(s)
- Tomás Datino
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Ángel Miracle Blanco
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Alberto Núñez García
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Esteban González-Torrecilla
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Felipe Atienza Fernández
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ángel Arenal Maíz
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jesús Hernández-Hernández
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Pablo Ávila Alonso
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gabriel Eidelman
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Francisco Fernández-Avilés
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Abstract
In the current health care system, high costs without proportional improvements in quality or outcome have prompted widespread calls for change in how we deliver and pay for care. Value-based health care delivery models have been proposed. Multiple impediments exist to achieving value, including misaligned patient and provider incentives, information asymmetries, convoluted and opaque cost structures, and cultural attitudes toward cancer treatment. Radiation oncology as a specialty has recently become a focus of the value discussion. Escalating costs secondary to rapidly evolving technologies, safety breaches, and variable, nonstandardized structures and processes of delivering care have garnered attention. In response, we present a framework for the value discussion in radiation oncology and identify approaches for attaining value, including economic and structural models, process improvements, outcome measurement, and cost assessment.
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Affiliation(s)
- Sewit Teckie
- Sewit Teckie, Memorial Sloan-Kettering Cancer Center, New York, NY; and Susan A. McCloskey and Michael L. Steinberg, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Susan A McCloskey
- Sewit Teckie, Memorial Sloan-Kettering Cancer Center, New York, NY; and Susan A. McCloskey and Michael L. Steinberg, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Michael L Steinberg
- Sewit Teckie, Memorial Sloan-Kettering Cancer Center, New York, NY; and Susan A. McCloskey and Michael L. Steinberg, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
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Hess PL, Hellkamp AS, Peterson ED, Sanders GD, Al-Khalidi HR, Curtis LH, Hammill BG, Pun PH, Curtis JP, Anstrom KJ, Hammill SC, Al-Khatib SM. Survival after primary prevention implantable cardioverter-defibrillator placement among patients with chronic kidney disease. Circ Arrhythm Electrophysiol 2014; 7:793-9. [PMID: 25038119 DOI: 10.1161/circep.114.001455] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Guidelines recommend that implantable cardioverter-defibrillator (ICD) candidates have an estimated longevity of ≥1 year. Longevity can be affected by chronic kidney disease (CKD). METHODS AND RESULTS Using the National Cardiovascular Data Registry ICD registry linked with the Social Security Death Master File, we assessed the rate of death after primary prevention ICD placement between January 1, 2006, and December 31, 2007, according to CKD stage. Using Cox models, we identified factors associated with death among patients with CKD. Compared with patients without CKD (n=26,056), those with CKD (n=21,226) were older, less commonly men, more often white, and more frequently had comorbid illness. Compared with patients without CKD, patients with a glomerular filtration rate 30 to 60, glomerular filtration rate <30, and end-stage renal disease on dialysis had a higher risk of death after ICD placement (hazard ratio, 2.08; 95% confidence interval, 1.99-2.18; P<0.0001; hazard ratio, 4.20; 95% confidence interval, 3.92-4.50; P<0.0001; and hazard ratio, 4.80; 95% confidence interval, 4.46-5.17; P<0.0001, respectively). Corresponding 1-year death rates were 4.4%, 9.1%, 20.2%, and 22.4%. Among patients with CKD, factors associated with increased risk of death included CKD severity, age >65 years, heart failure symptoms, diabetes mellitus, lung disease, serum sodium <140 mEq/L, atrial fibrillation or flutter, and a lower ejection fraction. CONCLUSIONS The risk of death after primary prevention ICD placement is proportional to CKD severity. Among patients with CKD, several factors are prognostically significant and could inform clinical decision making on primary prevention ICD candidacy.
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Affiliation(s)
- Paul L Hess
- From the Duke Clinical Research Institute, Durham, NC (P.L.H., A.S.H., E.D.P., G.D.S., H.R.A.-K., L.H.C., B.G.H., P.H.P., K.J.A., S.M.A.-K.); Department of Medicine, Duke University Medical Center, Durham, NC (P.L.H., A.S.H., E.D.P., P.H.P., S.M.A.-K.); Department of Medicine, Yale University, New Haven, CT (J.P.C.); and Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN (S.C.H.).
| | - Anne S Hellkamp
- From the Duke Clinical Research Institute, Durham, NC (P.L.H., A.S.H., E.D.P., G.D.S., H.R.A.-K., L.H.C., B.G.H., P.H.P., K.J.A., S.M.A.-K.); Department of Medicine, Duke University Medical Center, Durham, NC (P.L.H., A.S.H., E.D.P., P.H.P., S.M.A.-K.); Department of Medicine, Yale University, New Haven, CT (J.P.C.); and Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN (S.C.H.)
| | - Eric D Peterson
- From the Duke Clinical Research Institute, Durham, NC (P.L.H., A.S.H., E.D.P., G.D.S., H.R.A.-K., L.H.C., B.G.H., P.H.P., K.J.A., S.M.A.-K.); Department of Medicine, Duke University Medical Center, Durham, NC (P.L.H., A.S.H., E.D.P., P.H.P., S.M.A.-K.); Department of Medicine, Yale University, New Haven, CT (J.P.C.); and Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN (S.C.H.)
| | - Gillian D Sanders
- From the Duke Clinical Research Institute, Durham, NC (P.L.H., A.S.H., E.D.P., G.D.S., H.R.A.-K., L.H.C., B.G.H., P.H.P., K.J.A., S.M.A.-K.); Department of Medicine, Duke University Medical Center, Durham, NC (P.L.H., A.S.H., E.D.P., P.H.P., S.M.A.-K.); Department of Medicine, Yale University, New Haven, CT (J.P.C.); and Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN (S.C.H.)
| | - Hussein R Al-Khalidi
- From the Duke Clinical Research Institute, Durham, NC (P.L.H., A.S.H., E.D.P., G.D.S., H.R.A.-K., L.H.C., B.G.H., P.H.P., K.J.A., S.M.A.-K.); Department of Medicine, Duke University Medical Center, Durham, NC (P.L.H., A.S.H., E.D.P., P.H.P., S.M.A.-K.); Department of Medicine, Yale University, New Haven, CT (J.P.C.); and Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN (S.C.H.)
| | - Lesley H Curtis
- From the Duke Clinical Research Institute, Durham, NC (P.L.H., A.S.H., E.D.P., G.D.S., H.R.A.-K., L.H.C., B.G.H., P.H.P., K.J.A., S.M.A.-K.); Department of Medicine, Duke University Medical Center, Durham, NC (P.L.H., A.S.H., E.D.P., P.H.P., S.M.A.-K.); Department of Medicine, Yale University, New Haven, CT (J.P.C.); and Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN (S.C.H.)
| | - Bradley G Hammill
- From the Duke Clinical Research Institute, Durham, NC (P.L.H., A.S.H., E.D.P., G.D.S., H.R.A.-K., L.H.C., B.G.H., P.H.P., K.J.A., S.M.A.-K.); Department of Medicine, Duke University Medical Center, Durham, NC (P.L.H., A.S.H., E.D.P., P.H.P., S.M.A.-K.); Department of Medicine, Yale University, New Haven, CT (J.P.C.); and Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN (S.C.H.)
| | - Patrick H Pun
- From the Duke Clinical Research Institute, Durham, NC (P.L.H., A.S.H., E.D.P., G.D.S., H.R.A.-K., L.H.C., B.G.H., P.H.P., K.J.A., S.M.A.-K.); Department of Medicine, Duke University Medical Center, Durham, NC (P.L.H., A.S.H., E.D.P., P.H.P., S.M.A.-K.); Department of Medicine, Yale University, New Haven, CT (J.P.C.); and Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN (S.C.H.)
| | - Jeptha P Curtis
- From the Duke Clinical Research Institute, Durham, NC (P.L.H., A.S.H., E.D.P., G.D.S., H.R.A.-K., L.H.C., B.G.H., P.H.P., K.J.A., S.M.A.-K.); Department of Medicine, Duke University Medical Center, Durham, NC (P.L.H., A.S.H., E.D.P., P.H.P., S.M.A.-K.); Department of Medicine, Yale University, New Haven, CT (J.P.C.); and Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN (S.C.H.)
| | - Kevin J Anstrom
- From the Duke Clinical Research Institute, Durham, NC (P.L.H., A.S.H., E.D.P., G.D.S., H.R.A.-K., L.H.C., B.G.H., P.H.P., K.J.A., S.M.A.-K.); Department of Medicine, Duke University Medical Center, Durham, NC (P.L.H., A.S.H., E.D.P., P.H.P., S.M.A.-K.); Department of Medicine, Yale University, New Haven, CT (J.P.C.); and Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN (S.C.H.)
| | - Stephen C Hammill
- From the Duke Clinical Research Institute, Durham, NC (P.L.H., A.S.H., E.D.P., G.D.S., H.R.A.-K., L.H.C., B.G.H., P.H.P., K.J.A., S.M.A.-K.); Department of Medicine, Duke University Medical Center, Durham, NC (P.L.H., A.S.H., E.D.P., P.H.P., S.M.A.-K.); Department of Medicine, Yale University, New Haven, CT (J.P.C.); and Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN (S.C.H.)
| | - Sana M Al-Khatib
- From the Duke Clinical Research Institute, Durham, NC (P.L.H., A.S.H., E.D.P., G.D.S., H.R.A.-K., L.H.C., B.G.H., P.H.P., K.J.A., S.M.A.-K.); Department of Medicine, Duke University Medical Center, Durham, NC (P.L.H., A.S.H., E.D.P., P.H.P., S.M.A.-K.); Department of Medicine, Yale University, New Haven, CT (J.P.C.); and Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN (S.C.H.)
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Marcus GM, Dewland TA. The Calculated Risk of Defibrillator Implantation. J Am Coll Cardiol 2014; 63:797-8. [DOI: 10.1016/j.jacc.2013.10.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 10/28/2013] [Indexed: 11/30/2022]
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