Primary prevention implantable cardioverter-defibrillator and cardiac resynchronization therapy-defibrillator in elderly patients: results of a Spanish multicentre study

Implantable cardiac defibrillator outcomes in octogenarians

Background

Implantable cardiac defibrillators (ICDs) are essential for preventing sudden cardiac death. Despite inclusion in national guidelines, older adults are often underrepresented in trials. Evaluating ICD use in the aging population, particularly with advancements in heart failure treatment, is crucial.

Objective

This study examines outcomes in octogenarians undergoing ICD implantation for primary and secondary prevention, focusing on ICD therapies and mortality timing.

Methods

A retrospective observational study at a single Canadian academic center included patients ≥80 years old at ICD implantation, excluding those with <30 days follow-up. Data on demographics, comorbidities, mortality, and ICD therapies were collected from electronic medical records. Clinical frailty was assessed using the Dalhousie Clinical Frailty Scale.

Results

We identified 143 patients (mean age 82.6 ± 2.2 years, 14% female) from May 2015 to October 2023. ICDs were implanted for primary prevention in 63 patients (44%) and secondary prevention in 80 patients (56%). Thirty-seven patients were excluded due to insufficient follow-up. ICD therapies occurred in 30 patients (25%) through anti-tachycardia pacing (ATP) and in 19 patients (18%) through shocks. The mean time to first ATP was 16.9 ± 21.0 months, and to first shock, 21.2 ± 23.6 months. Among 66 patients with mortality data, 19 (24%) died at 31.3 ± 30.4 months. Patients with non-ischemic cardiomyopathy experienced earlier shocks (7.7 vs. 32.2 months, p < 0.05).

Conclusion

Elderly patients undergoing ICD implantation have multiple comorbidities and competing causes of mortality. Device use is overall infrequent but occurs well before observed mortality. Prospective clinical trials are needed to determine ICD benefits in this age cohort.

Risk factors for non-benefit of implantable cardioverter defibrillator therapy

Studies have demonstrated overall prognostic benefits of ICD implantation in patients at increased risk of sudden cardiac death. However, results are inconsistent in certain subgroups. This study aims to evaluate the prognostic implications of comorbidities on ICD outcomes and compare trends in patient selection and outcomes over a decade-long inclusion period. This study analysed 422 patients undergoing ICD implantation between 2011 and 2020. The study endpoint "no-benefit" was characterized by death from any cause occurring without prior appropriate ICD therapy. Benefit of ICD implantation was defined as either receiving appropriate ICD therapy before death or surviving until the end of the observation period. During a mean follow-up of 4.2 ± 3.0 years, no-benefit of ICD implantation was observed in 84 patients (20%). Independent risk factors for no-benefit were age ≥ 68 years (HR 4.599, p < 0.001), anemia (HR 2.549, p < 0.001), peripheral artery disease (HR 2.066, p = 0.007), and chronic obstructive pulmonary disease (HR 1.939, p = 0.014). Subgroup analysis by age < 68 years and ≥ 68 years demonstrated that the risk of no-benefit increases with age and comorbidities. When comparing patients with ICD implantation in 2011-2015 with those in 2016-2020, there were no significant differences in one-, two- and three-year-no-benefit rates. Different comorbidities were associated with no-benefit in the early and late implantation groups. Risk factors such as older age and specific comorbidities are associated with a higher likelihood of no-benefit from ICD implantation. A careful patient selection and consideration of individual risk factors besides advanced age is important.

Long-term outcome of cardiac resynchronization therapy patients in the elderly

Heart failure (HF) is a leading cause of mortality and hospitalization in the elderly. However, data are scarce about their response to device treatment such as cardiac resynchronization therapy (CRT). We aimed to evaluate the age-related differences in the effectiveness of CRT, procedure-related complications, and long-term outcome. Between 2000 and 2020, 2656 patients undergoing CRT implantation were registered and analyzed retrospectively. Patients were divided into 3 groups according to their age: group I, < 65; group II, 65-75; and group III, > 75 years. The primary endpoint was the echocardiographic response defined as a relative increase > 15% in left ventricular ejection fraction (LVEF) within 6 months, and the secondary endpoint was the composite of all-cause mortality, heart transplantation, or left ventricular assist device implantation. Procedure-related complications were also assessed. After implantation, LVEF showed significant improvement both in the total cohort [28% (IQR 24/33) vs. 35% (IQR 28/40); p < 0.01)] and in each subgroup (27% vs. 34%; p < 0.01, 29% vs. 35%; p < 0.01, 30% vs. 35%; p < 0.01). Response rate was similar in the 3 groups (64% vs. 62% vs. 56%; p = 0.41). During the follow-up, 1574 (59%) patients died. Kaplan-Meier curves revealed a significantly lower survival rate in the older groups (log-rank p < 0.001). The cumulative complication rates were similar among the three age groups (27% vs. 28% vs. 24%; p = 0.15). Our results demonstrate that CRT is as effective and safe therapy in the elderly as for young ones. The present data suggest that patients with appropriate indications benefit from CRT in the long term, regardless of age.

Hospital utilisation and the costs associated with complications of ICD implantation in a contemporary primary prevention cohort

Introduction

Implantation of an implantable cardioverter defibrillator (ICD) is standard care for primary prevention of sudden cardiac death. However, ICD-related complications are increasing as the population of ICD recipients grows.

Methods

ICD-related complications in a national DO-IT Registry cohort of 1442 primary prevention ICD patients were assessed in terms of additional use of hospital care resources and costs.

Results

During a median follow-up of 28.7 months (IQR 25.2–33.7) one or more complications occurred in 13.5% of patients. A complication resulted in a surgical intervention in 53% of cases and required on average 3.65 additional hospital days. The additional hospital costs were €6,876 per complication or €8,110 per patient, to which clinical re-interventions and additional hospital days contributed most. Per category of complications, infections required most hospital utilisation and were most expensive at an average of €22,892. The mean costs were €5,800 for lead-related complications, €2,291 for pocket-related complications and €5,619 for complications due to other causes. We estimate that the total yearly incidence-based costs in the Netherlands for hospital management of ICD-related complications following ICD implantation for primary prevention are €2.7 million.

Conclusion

Complications following ICD implantation are related to a substantial additional need for hospital resources. When performing cost-effectiveness analyses of ICD implantation, including the costs associated with complications, one should be aware that real-world complication rates may deviate from trial data. Considering the economic implications, strategies to reduce the incidence of complications are encouraged.

Sacubitril/valsartan reduces indications for arrhythmic primary prevention in heart failure with reduced ejection fraction: insights from DISCOVER-ARNI, a multicenter Italian register

Aims

This sub-study deriving from a multicentre Italian register [Deformation Imaging by Strain in Chronic Heart Failure Over Sacubitril-Valsartan: A Multicenter Echocardiographic Registry (DISCOVER)-ARNI] investigated whether sacubitril/valsartan in addition to optimal medical therapy (OMT) could reduce the rate of implantable cardioverter-defibrillator (ICD) indications for primary prevention in heart failure with reduced ejection fraction (HFrEF) according to European guidelines indications, and its potential predictors.

Methods and results

In this observational study, consecutive patients with HFrEF eligible for sacubitril/valsartan from 13 Italian centres were included. Lack of follow-up or speckle tracking data represented exclusion criteria. Demographic, clinical, biochemical, and echocardiographic data were collected at baseline and after 6 months from sacubitril/valsartan initiation. Of 351 patients, 225 (64%) were ICD carriers and 126 (36%) were not ICD carriers (of whom 13 had no indication) at baseline. After 6 months of sacubitril/valsartan, among 113 non-ICD carriers despite having baseline left ventricular (LV) ejection fraction (EF) ≤ 35% and New York Heart Association (NYHA) class = II-III, 69 (60%) did not show ICD indications; 44 (40%) still fulfilled ICD criteria. Age, atrial fibrillation, mitral regurgitation > moderate, left atrial volume index (LAVi), and LV global longitudinal strain (GLS) significantly varied between the groups. With receiver operating characteristic curves, age ≥ 75 years, LAVi ≥ 42 mL/m2 and LV GLS ≥-8.3% were associated with ICD indications persistence (area under the curve = 0.65, 0.68, 0.68, respectively). With univariate and multivariate analysis, only LV GLS emerged as significant predictor of ICD indications at follow-up in different predictive models.

Conclusions

Sacubitril/valsartan may provide early improvement of NYHA class and LVEF, reducing the possible number of implanted ICD for primary prevention in HFrEF. Baseline reduced LV GLS was a strong marker of ICD indication despite OMT. Early therapy with sacubitril/valsartan may save infective/haemorrhagic risks and unnecessary costs deriving from ICDs.

Dutch Outcome in Implantable Cardioverter-Defibrillator Therapy: Implantable Cardioverter-Defibrillator-Related Complications in a Contemporary Primary Prevention Cohort

Background

One third of primary prevention implantable cardioverter‐defibrillator patients receive appropriate therapy, but all remain at risk of defibrillator complications. Information on these complications in contemporary cohorts is limited. This study assessed complications and their risk factors after defibrillator implantation in a Dutch nationwide prospective registry cohort and forecasts the potential reduction in complications under distinct scenarios of updated indication criteria.

Methods and Results

Complications in a prospective multicenter registry cohort of 1442 primary implantable cardioverter‐defibrillator implant patients were classified as major or minor. The potential for reducing complications was derived from a newly developed prediction model of appropriate therapy to identify patients with a low probability of benefitting from the implantable cardioverter‐defibrillator. During a follow‐up of 2.2 years (interquartile range, 2.0–2.6 years), 228 complications occurred in 195 patients (13.6%), with 113 patients (7.8%) experiencing at least one major complication. Most common ones were lead related (n=93) and infection (n=18). Minor complications occurred in 6.8% of patients, with lead‐related (n=47) and pocket‐related (n=40) complications as the most prevailing ones. A surgical reintervention or additional hospitalization was required in 53% or 61% of complications, respectively. Complications were strongly associated with device type. Application of stricter implant indication results in a comparable proportional reduction of (major) complications.

Conclusions

One in 13 patients experiences at least one major implantable cardioverter‐defibrillator–related complication, and many patients undergo a surgical reintervention. Complications are related to defibrillator implantations, and these should be discussed with the patient. Stricter implant indication criteria and careful selection of device type implanted may have significant clinical and financial benefits.

Distribution and impact of age in patients with implantable cardioverter-defibrillators regarding early complications and 1-year clinical outcome: results from the German Device Registry

BACKGROUND

Patients receiving implantable-cardioverter-defibrillators (ICD) in clinical practice are often older or younger than in clinical trials. Whether older patients benefit from ICD-therapy in a similar way as younger patients is under debate. The objective of this study was to provide real-world data regarding outcomes with respect to age in a large cohort in the German Device Registry.

METHODS

Within the registry data from 50 German centers were collected between January 2007 and February 2014.

RESULTS

Our analysis included 3239 ICD patients representing a group of young (28%; group I: < 58 years), intermediate aged (50%; group II: 58-74 years), and elderly patients (22%; group III: 75-92 years). Intergroup comparison of all groups was performed followed by individual comparison vs. group II serving as age-reference group. Procedure-related complications did not differ between all groups. Analysis of the primary endpoint, 1-year all-cause mortality, revealed an increased mortality in the elderly and a decreased mortality in the young cohort vs. the reference group II (group I 2.1%, group II 6.2%, group III 13.2%; p < 0.001). While all-cause rehospitalizations did not differ, we observed a difference in reported device revisions showing more device revisions required in younger patients (group I 8.9%, group II 6.8%, group III 4.0%; p = 0.001).

CONCLUSIONS

One-year mortality was doubled in elderly ICD patients probably due to non-cardiac causes. These results further underpin the need for re-evaluating the primary prevention ICD indication in octo- and nonagenarians. Young patients show lower mortality rates but seem to bear higher risk of device-related complications, which highlights the need for improved measures to reduce device-related complications in the young.

Prophylactic implantable cardioverter-defibrillator in the very elderly

Aims

Current guidelines do not propose any age cut-off for the primary prevention implantable cardioverter-defibrillator (ICD). However, the risk/benefit balance in the very elderly population has not been well studied.

Methods and results

In a multicentre French study assessing patients implanted with an ICD for primary prevention, outcomes among patients aged ≥80 years were compared with <80 years old controls matched for sex and underlying heart disease (ischaemic and dilated cardiomyopathy). A total of 300 ICD recipients were enrolled in this specific analysis, including 150 patients ≥80 years (mean age 81.9 ± 2.0 years; 86.7% males) and 150 controls (mean age 61.8 ± 10.8 years). Among older patients, 92 (75.6%) had no more than one associated comorbidity. Most subjects in the elderly group got an ICD as part of a cardiac resynchronization therapy procedure (74% vs. 46%, P < 0.0001). After a mean follow-up of 3.0 ± 2 years, 53 patients (35%) in the elderly group died, including 38.2% from non cardiovascular causes of death. Similar proportion of patients received ≥1 appropriate therapy (19.4% vs. 21.6%; P = 0.65) in the elderly group and controls, respectively. There was a trend towards more early perioperative events (P = 0.10) in the elderly, with no significant increase in late complications (P = 0.73).

Conclusion

Primary prevention ICD recipients ≥80 years in the real world had relatively low associated comorbidity. Rates of appropriate therapies and device-related complications were similar, compared with younger subjects. Nevertheless, the inherent limitations in interpreting observational data on this particular competing risk situation call for randomized controlled trials to provide definitive answers. Meanwhile, a careful multidisciplinary evaluation is needed to guide patient selection for ICD implantation in the elderly population.

Comparison of pharmacological treatment alone vs. treatment combined with implantable cardioverter defibrillator therapy in patients older than 75 years

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.

Prophylactic implantable cardioverter defibrillator in heart failure: the growing evidence for all or Primum non nocere for some?

Heart failure (HF) is a common health problem and has reached epidemic in many western countries. Despite the current era of HF treatment, the risk of sudden cardiac death (SCD) in HF remains significant. Implantable cardioverter defibrillator (ICD) support has been shown to reduce the risk of SCD in patients with HF and impaired left ventricular function. Prophylactic ICD implantation in HF patients seems a logical step to reduce mortality through a reduction in SCD. However, ICD implantation is an invasive procedure, and both short- and long-term complications can occur. This needs to be carefully considered when evaluating the risk-benefit ratio of ICD implantation for individual patients. As the severity of HF increases, the proportion of SCD compared with HF-related deaths decreases. The challenge lies in identifying patients with HF who are at significant risk of SCD and who would most benefit from an ICD in addition to other anti-arrhythmic strategies. This review offers insight on the applicability and practicability of ICD for this growing population.

Inappropriate implantable cardioverter defibrillator shocks-incidence, effect, and implications for driver licensing

Purpose

Patients with implantable cardioverter defibrillators (ICDs) have an ongoing risk of sudden incapacitation that may cause traffic accidents. However, there are limited data on the magnitude of this risk after inappropriate ICD therapies. We studied the rate of syncope associated with inappropriate ICD therapies to provide a scientific basis for formulating driving restrictions.

Methods

Inappropriate ICD therapy event data between 1997 and 2014 from 50 Japanese institutions were analyzed retrospectively. The annual risk of harm (RH) to others posed by a driver with an ICD was calculated for private driving habits. We used a commonly employed annual RH to others of 5 in 100,000 (0.005%) as an acceptable risk threshold.

Results

Of the 4089 patients, 772 inappropriate ICD therapies occurred in 417 patients (age 61 ± 15 years, 74% male, and 65% secondary prevention). Patients experiencing inappropriate therapies had a mean number of 1.8 ± 1.5 therapy episodes during a median follow-up period of 3.9 years. No significant differences were found in the age, sex, or number of inappropriate therapies between patients receiving ICDs for primary or secondary prevention. Only three patients (0.7%) experienced syncope associated with inappropriate therapies. The maximum annual RH to others after the first therapy in primary and secondary prevention patients was calculated to be 0.11 in 100,000 and 0.12 in 100,000, respectively.

Conclusions

We found that the annual RH from driving was far below the commonly cited acceptable risk threshold. Our data provide useful information to supplement current recommendations on driving restrictions in ICD patients with private driving habits.

Electronic supplementary material

The online version of this article (doi:10.1007/s10840-017-0272-4) contains supplementary material, which is available to authorized users.

[ICD in elderly patients]

Treatment with an implantable cardioverter-defibrillator (ICD) represents a prognostic but not symptomatic therapy. It should therefore be restricted to patients where an improvement of prognosis is possible and reasonable. ICD implantation should only be performed in patients with a life expectancy of at least 1 year at reasonable quality of life. The decision in which patient improvement of prognosis is no longer a desirable target is problematic, both medically and ethically. It is not entirely clear in which elderly patient an ICD therapy can convey prognostic benefit despite comorbidity and competitive life-threatening diseases, as it is unclear how old age should be defined. In primary prophylaxis of sudden cardiac death, data on a prognostic benefit of the ICD in elderly patients are less clear than in secondary prophylaxis since short-term mortality due to other causes is higher in the elderly. However, elderly ICD patients have a similar rate of appropriate ICD therapy as younger patients. Complications at ICD implantation or long-term lead failure do not occur more frequently in elderly patients and therefore do not represent a reason to withhold ICD implantation in elderly patients or to set an age limit above which ICD implantation should no longer be performed. The ICD indication in elderly patients should be individualized depending on remaining life expectancy, comorbidity, "biological age" and patient preferences which play a particularly important role in elderly patients. Aspects of a potential improvement in quality of life by the ICD which may also serve as a system for antibradycardiac or resynchronization treatment should be included into considerations. Deactivation of at least shock therapy should be discussed in elderly patients fitted with an ICD if the subject is brought up by the patient or if clinical deterioration suggests the need to talk about a "do not resuscitate" order. This talk should be performed before death is imminent and before an electrical storm in terminal illness leads to multiple shocks by the active device.

Increasing age does not affect time to appropriate therapy in primary prevention ICD/CRT-D: a competing risks analysis

Aims

To evaluate the impact of age on the clinical outcomes in a primary prevention implantable cardioverter defibrillator (ICD)/cardiac resynchronization therapy defibrillator (CRT-D) population.

Methods and Results

A retrospective, multicentre analysis of patients aged 60 years and over with primary prevention ICD/CRT-D devices implanted between 1 January 2006 and 1 November 2014 was performed. Survival to follow-up with no therapy (T1), death prior to follow-up with no therapy (T2), delivery of appropriate therapy with survival to follow-up (T3), and delivery of appropriate therapy with death prior to follow-up (T4) were measured. In total, 424 patients were eligible for inclusion in the analysis, mean follow-up of 32.6 months during which time 44 patients (10.1%) received appropriate therapy. The sub-hazard ratio (SHR) for the cumulative incidence of appropriate therapy (T3) according to age at implant was 1.00 (P = 0.851; 95% CI 0.96–1.04). The SHR for cumulative incidence of death (T2) according to age at implant was 1.06 (P < 0.001; 95% CI 1.03–1.01). Age at implant, ischaemic aetiology, baseline haemoglobin, and the presence of diabetes mellitus were predictors of all-cause mortality.

Conclusion

Age has no impact on the time to appropriate therapy, but risk of death prior to therapy increases by 6% for every year increment. As the ICD population ages, the proportion who die without receiving appropriate therapy increases due to competing risks. Characterizing competing risks predictive of death independent of ICD indication would focus therapy on those with potential to benefit and reduce unnecessary exposure to ICD-related morbidity.

Complications and 1-year benefit of cardiac resynchronization therapy in patients over 75 years of age - Insights from the German Device Registry

OBJECTIVE

Evidence on cardiac resynchronization therapy (CRT) in older patients is scarce and conflicting. Nevertheless, CRT in the elderly is of major practical relevance as heart failure prevalence increases with age.

METHODS

The German Device Registry (DEVICE) is a nationwide, prospective registry with a longitudinal follow-up design investigating device implantations in 60 German centres. The present analysis of DEVICE focussed on perioperative complication rates and 1-year outcome of patients ≥75years (n=320) compared to younger patients (n=879) receiving a CRT device.

RESULTS

Comorbidities were more common in older patients (chronic kidney disease (CKD): 27.5% vs. 21.5%, p=0.029; atrial fibrillation (AF): 26.9% vs. 15.6%, p<0.001). Despite higher NYHA classes in the older age group, ejection fractions were comparable (27.2±7.1% ≥75years, 26.2±7.1% <75years, p=0.06). Perioperative complications and mortality rates did not show significant difference between groups. After new device implantation, absolute 1-year mortality was higher in older patients (11.0% ≥75years, 6.4% <75years, p=0.014), with a significantly lower proportion of cardiac deaths in the older group (p=0.05). Patients ≥75years being alive after 1year had lower response rates, with chronic kidney disease (OR 0.46, p<0.05) and smaller QRS complexes (OR 0.31, p<0.01) being particular risk factors for missing improvement of heart failure symptoms. As expected severe heart failure (NYHA IV) was a strong independent predictor of death (HR 1.95, p=0.01), whereas AF as underlying rhythm could be worked out as predictor for mortality especially in the younger patients (HR 2.31, p=0.002).

CONCLUSIONS

Patients ≥75years of age receiving a CRT device do not have a higher perioperative mortality and complication rate although comorbidities (CKD and AF) occur more frequently. The absolute 1-year mortality is higher; nevertheless, the proportion of cardiac deaths is even lower in the older patients reflecting a benefit of CRT in this group.

Heart Failure in Older Adults

Heart failure (HF) is a leading cause of morbidity, hospitalization, and mortality in older adults and a growing public health problem placing a huge financial burden on the health care system. Many challenges exist in the assessment and management of HF in geriatric patients, who often have coexisting multimorbidity, polypharmacy, cognitive impairment, and frailty. These complex "geriatric domains" greatly affect physical and functional status as well as long-term clinical outcomes. Geriatric patients have been under-represented in major HF clinical trials. Nonetheless, available data suggest that guideline-based medical and device therapies improve morbidity and mortality. Nonpharmacologic strategies, such as exercise training and dietary interventions, are an active area of research. Targeted geriatric evaluation, including functional and cognitive assessment, can improve risk stratification and guide management in older patients with HF. Clinical trials that enroll older patients with multiple morbidities and HF and evaluate functional status and quality of life in addition to mortality and cardiovascular morbidity should be encouraged to guide management of this age group.