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Cortés M, Palfy JA, Lopez M, Martínez J, Rivero AL, Devesa A, Franco-Peláez JA, Briongos S, Taibo-Urquia M, Benezet J, Rubio JM. Comparison of pharmacological treatment alone vs. treatment combined with implantable cardioverter defibrillator therapy in patients older than 75 years. ESC Heart Fail 2018; 5:884-891. [PMID: 29936703 PMCID: PMC6165960 DOI: 10.1002/ehf2.12310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/06/2018] [Indexed: 12/21/2022] Open
Abstract
Aims Implantable cardioverter defibrillator (ICD) reduces mortality in selected patients. However, its role in patients older than 75 years is not well established. Methods and results We performed a retrospective, non‐randomized study using a historical cohort from a single centre. Between January 2008 and July 2014, we assessed patients aged ≥75 years with left ventricular ejection fraction ≤ 35%, identifying 385 patients with a Class I or IIa recommendation for ICD implantation. At the decision of the patient or attending cardiologists, 92 patients received an ICD. To avoid potential confounding factors, we used propensity‐score matching. Finally, 126 patients were included (63 with ICD). The mean age was 79.1 ± 3.1 years (86.5% male). As compared with the medical therapy group, the ICD patients had a lower percentage of chronic obstructive pulmonary disease (19.0% vs. 38.1%, P < 0.05) and more frequent use of beta‐blockers (BBs) (85.7 vs. 70.0%, P < 0.05). Other treatments were otherwise similar in both groups. There were no differences related to age, aetiology, or other co‐morbidities. During follow‐up (39.2 ± 22.4 months), total mortality was 46.0% and cardiovascular events (death or hospitalization) occurred in 66.7% of the patients. A multivariate analysis revealed that only BB therapy was shown to be an independent protective variable with respect to mortality [hazard ratio 0.4 (0.2–0.7)]. ICD therapy did not reduce overall mortality or the rate of cardiovascular events. Conclusions According to our results, the use of ICD, as compared with medical therapy, in patients older than 75 years did not demonstrate any benefit. Well‐designed randomized controlled studies in patients older than 75 years are needed to ascertain the value of ICD therapy.
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Affiliation(s)
- Marcelino Cortés
- Department of Cardiology, Hospital Universitario Fundación Jiménez Díaz-quirónsalud, Universidad Autónoma de Madrid, Avenida Reyes Católicos 2, Madrid, 28040, Spain
| | - Julia Anna Palfy
- Department of Cardiology, Hospital Alvarez Buylla, Mieres, Asturias, Spain
| | - Marta Lopez
- Department of Cardiology, Hospital Universitario Fundación Jiménez Díaz-quirónsalud, Universidad Autónoma de Madrid, Avenida Reyes Católicos 2, Madrid, 28040, Spain
| | - Juan Martínez
- Department of Cardiology, Hospital Universitario Fundación Jiménez Díaz-quirónsalud, Universidad Autónoma de Madrid, Avenida Reyes Católicos 2, Madrid, 28040, Spain
| | - Ana Lucia Rivero
- Department of Cardiology, Hospital Universitario Fundación Jiménez Díaz-quirónsalud, Universidad Autónoma de Madrid, Avenida Reyes Católicos 2, Madrid, 28040, Spain
| | - Ana Devesa
- Department of Cardiology, Hospital Universitario Fundación Jiménez Díaz-quirónsalud, Universidad Autónoma de Madrid, Avenida Reyes Católicos 2, Madrid, 28040, Spain
| | - Juan Antonio Franco-Peláez
- Department of Cardiology, Hospital Universitario Fundación Jiménez Díaz-quirónsalud, Universidad Autónoma de Madrid, Avenida Reyes Católicos 2, Madrid, 28040, Spain
| | - Sem Briongos
- Department of Cardiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Mikel Taibo-Urquia
- Department of Cardiology, Hospital Universitario Fundación Jiménez Díaz-quirónsalud, Universidad Autónoma de Madrid, Avenida Reyes Católicos 2, Madrid, 28040, Spain
| | - Juan Benezet
- Department of Cardiology, Hospital Universitario Fundación Jiménez Díaz-quirónsalud, Universidad Autónoma de Madrid, Avenida Reyes Católicos 2, Madrid, 28040, Spain
| | - Jose-Manuel Rubio
- Department of Cardiology, Hospital Universitario Fundación Jiménez Díaz-quirónsalud, Universidad Autónoma de Madrid, Avenida Reyes Católicos 2, Madrid, 28040, Spain
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Daniels JD, Saunders J, Parvathaneni S, Byrd A, Joglar JA, Obel O. Electrocardiographic findings, device therapies, and comorbidities in octogenarian implantable defibrillator recipients. J Cardiovasc Electrophysiol 2009; 21:236-41. [PMID: 19804546 DOI: 10.1111/j.1540-8167.2009.01614.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The use of implantable cardioverter-defibrillators (ICDs) in octogenarians is poorly defined. OBJECTIVE To assess baseline electrocardiographic (ECG) findings, arrhythmia episodes, and development of severe nonarrhythmic illness or death in patients aged >or=80 years at ICD implantation, and to compare them with younger patients. METHODS Medical records and device interrogations for 199 patients >or=70 years old who underwent ICD implantation were reviewed. Patients were divided into 3 groups based on age at the time of implant: age 70-74 (group 1; 88 patients), age 75-79 (group 2; 67 patients), and age >or=80 (group 3; 44 patients). RESULTS ECGs: Octogenarians were more likely to have sinus bradycardia (SB) (P = 0.047) and left bundle branch block (LBBB) (P = 0.043) compared to younger patients. There was no difference among groups in the proportion of patients with atrial fibrillation or any degree of AV block. THERAPIES: There was no difference between age groups in any therapy (P = 0.78), appropriate therapy (P = 0.54), or inappropriate therapy (P = 0.21) per patient-year. There was no difference between groups in time-to-first therapy of any type (P = 0.71). NONARRHYTHMIC DEATH/MORBIDITY: There was no difference between groups in time to death or serious illness. CONCLUSION Our study is the first to evaluate in detail the therapies received by octogenarians after ICD placement. The higher incidence of SB and LBBB might influence the number of pacing sites in octogenarian patients. Very elderly patients have similar rates of arrhythmic episodes and development of severe comorbidities as septuagenarians, and they should not be denied ICD implantation based solely on age.
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Affiliation(s)
- James D Daniels
- The North Texas VA Health Sciences Center, Dallas, Texas, USA.
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Al-Khatib SM, Sanders GD, Carlson M, Cicic A, Curtis A, Fonarow GC, Groeneveld PW, Hayes D, Heidenreich P, Mark D, Peterson E, Prystowsky EN, Sager P, Salive ME, Thomas K, Yancy CW, Zareba W, Zipes D. Preventing tomorrow's sudden cardiac death today: dissemination of effective therapies for sudden cardiac death prevention. Am Heart J 2008; 156:613-22. [PMID: 18926144 DOI: 10.1016/j.ahj.2008.05.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Accepted: 05/23/2008] [Indexed: 10/21/2022]
Abstract
Because the burden of sudden cardiac death (SCD) is substantial, it is important to use all guideline-driven therapies to prevent SCD. Among those therapies is the implantable cardioverter defibrillator (ICD). When indicated, ICD use is beneficial and cost-effective. Unfortunately, studies suggest that most patients who have indications for this therapy for primary or secondary prevention of SCD are not receiving it. To explore potential reasons for this underuse and to propose potential facilitators for ICD dissemination, the Duke Center for the Prevention of SCD at the Duke Clinical Research Institute (Durham, NC) organized a think tank meeting of experts on this issue. The meeting took place on December 12 and 13, 2007, and it included representatives of clinical cardiology, cardiac electrophysiology, general internal medicine, economics, health policy, the US Food and Drug Administration, the Centers for Medicare and Medicaid Services, the Agency for Health care Research and Quality, and the device and pharmaceutical industry. Although the meeting was funded by industry participants, this article summarizing the presentations and discussions that occurred at the meeting presents the expert opinion of the authors.
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Pellegrini CN, Lee K, Olgin JE, Turakhia MP, Tseng ZH, Lee R, Badhwar N, Lee B, Varosy PD. Impact of advanced age on survival in patients with implantable cardioverter defibrillators. Europace 2008; 10:1296-301. [PMID: 18818212 DOI: 10.1093/europace/eun253] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS Given the selectivity of clinical trial patients and meager representation of elderly in the major implantable cardioverter defibrillator (ICD) randomized trials (<25%), whether such data apply to elderly patients overall is unclear. The purpose of our study is to understand the influence of age on mortality after ICD implantation. METHODS AND RESULTS We performed a retrospective cohort study of 502 consecutive patients receiving ICDs from 1993 to 2003 at a single university hospital. The primary predictor was patient age, categorized as <65, 65-75, and >75 years at ICD implantation. The primary outcome was time to death. Mean follow-up was 4 years. Median survival after ICD implantation was 5.3 years among subjects >75 years, less than half that of the youngest group. After adjusting for potential confounders, compared with subjects <65 years of age, patients >75 years [hazard ratio (HR), 4.7; 95% confidence interval (CI), 2.8-7.9; P < 0.001] and those 65-75 years (HR, 2.8; 95% CI, 1.7-4.8; P < 0.001) were at greater risk of death. Increased age was associated with higher total, cardiac, and non-cardiac mortality (all P <or= 0.001). CONCLUSION Age at ICD implantation is strongly and independently associated with mortality. Age should be considered among potential co-morbidities in anticipating survival of the elderly patient prior to ICD implantation.
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Affiliation(s)
- Cara N Pellegrini
- Department of Medicine, Division of Cardiology, Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
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Duray G, Richter S, Manegold J, Israel CW, Grönefeld G, Hohnloser SH. Efficacy and Safety of ICD Therapy in a Population of Elderly Patients Treated with Optimal Background Medication. J Interv Card Electrophysiol 2006; 14:169-73. [PMID: 16421693 DOI: 10.1007/s10840-006-5200-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2005] [Accepted: 09/26/2005] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Implantable cardioverter-defibrillator (ICD) therapy has been shown to improve survival in patients with structural heart disease and at high risk for life threatening ventricular arrhythmias. Whether elderly patients benefit from device therapy in a similar way as younger patients is largely unknown. METHODS We retrospectively analyzed data from 375 consecutive ICD recipients with structural heart disease. Patients were divided into two groups, younger than 70 years at time of ICD implantation (group 1) or 70 years or older (group 2). Main outcome measures were time to death from any cause and time from first appropriate ICD therapy to death. RESULTS Group 1 and 2 patients were comparable with respect to clinical presentation and average follow-up duration. In the elderly patient group, 78% received an ICD for secondary prevention versus 63% in group 1 (p = 0.007). During a mean follow-up period of 26.5 +/- 18.1 months, there was no significant difference in overall mortality among the two groups: 47 patients died, 34 (12.5%) of group 1 versus 13 (12.7%) of group 2. The average time to death was 28.4 +/- 16.7 vs 30.4 +/- 22.1 months after device implantation, respectively (p = ns). There was no difference in time from device implantation to first adequate ICD therapy and time from first appropriate ICD therapy to death among the two groups (p = ns). Device associated complications were comparable in both groups. CONCLUSIONS Elderly ICD recipients had comparable survival rates and appropriate use of the ICD compared to younger individuals.
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Affiliation(s)
- Gabor Duray
- Department of Cardiology, Division of Clinical Electrophysiology, J. W. Goethe University, Frankfurt a. M., Germany
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Voigt A, Ezzeddine R, Barrington W, Obiaha-Ngwu O, Ganz LI, London B, Saba S. Utilization of implantable cardioverter-defibrillators in survivors of cardiac arrest in the United States from 1996 to 2001. J Am Coll Cardiol 2004; 44:855-8. [PMID: 15312871 DOI: 10.1016/j.jacc.2004.05.053] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2004] [Revised: 04/23/2004] [Accepted: 05/03/2004] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We analyzed the incidence of implantable cardioverter-defibrillator (ICD) therapy in survivors of cardiac arrest (CA) in the U.S. from 1996 through 2001. BACKGROUND Cardiac arrest is a class I indication for ICD therapy. The current patterns of ICD utilization in survivors of CA have not been fully examined. METHODS We searched a representative sample of all hospital discharges for patients admitted with the primary diagnosis of CA who survived to hospital discharge. Patients with a concomitant diagnosis of acute myocardial infarction or previous ICD in situ were excluded. RESULTS From 1996 to 2001, 113,262 patients were admitted for CA. Of those, 63,745 (56.3%) did not survive to hospital discharge. Of the remaining 49,517 patients, 30.7% received an ICD before discharge, with a gradual increase in implantation rates from 1996 (23.6%) to 2001 (46.3%). Using logistic regression for the years 2000 and 2001, patients who were discharged without an ICD were older (odds ratio [OR] 0.93 for every 10-year increase in age, p < 0.001), more likely to be African American (OR 0.19, p < 0.001), and more likely to be admitted to a smaller hospital (OR 2.24 for each additional 100 beds, p < 0.001). These predictors were independent of other co-morbid illnesses. CONCLUSIONS Although they are increasing, the rates of ICD therapy after CA remain very low. There are gross discrepancies by race. At a time when newer indications for ICD implantation are emerging, efforts should be focused on identifying the causes of this underutilization and discrepancies in survivors of CA.
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Affiliation(s)
- Andrew Voigt
- Cardiovascular Institute, University of Pittsburgh, Pennsylvania, USA
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Noseworthy PA, Lashevsky I, Dorian P, Greene M, Cvitkovic S, Newman D. Feasibility of Implantable Cardioverter Defibrillator Use in Elderly Patients:. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:373-8. [PMID: 15009867 DOI: 10.1111/j.1540-8159.2004.00445.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This article addresses the feasibility and safety of ICD therapy in patients >80 years of age. Recent trials have expanded the indication for ICD implantation to include an increasing number and variety of patients. The feasibility of ICD implantation in elderly patients has not been adequately studied. A prospectively collected single center ICD database was analyzed to assess the safety and feasibility of ICD implantation in elderly patients. Patients were divided based on age into two groups (group 1: 70-79 years of age, n = 183; group 2: >or=80 years of age, n = 29). The two groups were similar in gender distribution, NYHA class, and indication for implantation. The actuarial survival was not significantly different between groups 1 and 2 (P > 0.05; primary endpoint), with a 1-year survival of 91% and 93% in groups 1 and 2, respectively, (P = NS). The complication rates at the time of ICD implantation were similar in groups 1 and 2 (6.6% and 13.1%, respectively, P = 0.16). Age alone may not be sufficient criteria to exclude ICD implantation. The current consensus guidelines for ICD implantation appear to be generalizable to treating octogenarians who are otherwise medically fit.
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Affiliation(s)
- Peter A Noseworthy
- Arrhythmia Service, Saint Michael's Hospital, University of Toronto, Toronto, Canada
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Shinde AA, Juneman EB, Mitchell B, Pierce MK, Gaballa MA, Goldman S, Thai H. Shocks from pacemaker cardioverter defibrillators increase with amiodarone in patients at high risk for sudden cardiac death. Cardiology 2003; 100:143-8. [PMID: 14631135 DOI: 10.1159/000073932] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2003] [Accepted: 07/31/2003] [Indexed: 11/19/2022]
Abstract
The efficacy of amiodarone used in combination with a pacemaker cardioverter defibrillator (PCD) to decrease episodes of ventricular tachycardia and subsequent PCD shocks is not clear. We examined a retrospective registry of 82 patients with PCD implantation to define the efficacy of amiodarone treatment. We compared patients treated with amiodarone (for 24 consecutive months without interruption) versus no amiodarone. In patients treated with amiodarone there was a 3-fold increase (p = 0.02) in PCD shocks; in patients not on beta-blockers, amiodarone resulted in a 6-fold increase (p < 0.05) in PCD shocks. Patients with a left ventricular ejection fraction >30% on amiodarone and patients <72 years old had increases (p < 0.05) in PCD shocks. In conclusion, patients treated with amiodarone had more PCD shocks than those not treated. These findings are unexpected and merit a prospective study.
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MESH Headings
- Aged
- Amiodarone/adverse effects
- Amiodarone/therapeutic use
- Case-Control Studies
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Dose-Response Relationship, Drug
- Drug Administration Schedule
- Humans
- Logistic Models
- Male
- Middle Aged
- Multivariate Analysis
- Pacemaker, Artificial
- Probability
- Reference Values
- Registries
- Retrospective Studies
- Risk Assessment
- Severity of Illness Index
- Shock, Cardiogenic/epidemiology
- Shock, Cardiogenic/etiology
- Survival Analysis
- Tachycardia, Ventricular/diagnosis
- Tachycardia, Ventricular/mortality
- Tachycardia, Ventricular/therapy
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Affiliation(s)
- Abhijit A Shinde
- Section of Cardiology, Department of Medicine, Southern Arizona VA Health Care System and Sarver Heart Center, University of Arizona, Tucson, AZ 85723, USA
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