Feasibility of Implantable Cardioverter Defibrillator Use in Elderly Patients:

Outcomes Following Implantable Cardioverter-Defibrillator Insertion in Patients 80 Years of Age or Older: A Statewide Population Cohort Study

BACKGROUND

Patients ≥ 80 years of age are underrepresented in major implantable cardioverter-defibrillator (ICD) trials, and real-world data are lacking. In this study, we sought to assess ICD utilisation, outcomes, and their predictors, in an unselected statewide population including patients ≥ 80 years old.

METHODS

We extracted details of ICDs implanted from 2009 to 2018 in New South Wales (NSW), Australia from the Centre for Health Record Linkage administrative data sets. Analysis was stratified into age groups of < 60 years, 60-79 years, and ≥ 80 years.

RESULTS

A total of 9304 patients (mean age 66.1 ± 13.1 years; 12.1% ≥ 80 years) had de novo ICD placement at an average rate of 1163 ± 122 patients per annum, with more implants in men in all age groups. After adjusting for NSW population size by sex, age group, and calendar year, mean implantation rates were 5.5 ± 0.6, 63.2 ± 8.6, and 52.7 ± 10.8 per 100,000 persons per annum in patients aged < 60 years, 60-79 years, and ≥ 80 years, respectively. In-hospital mortality was 0.4% and did not differ among age groups. However, 1-year mortality was 2.1%, 5.9%, and 10.7%, in those < 60 years, 60-79 years, and ≥ 80 years of age, respectively (P < 0.001), with hazard ratios for those aged ≥ 80 years of 4.3 (95% confidence interval [CI] 3.1-6.0) and those aged 60-79 years of 2.6 (95% CI 1.9-3.5) relative to those aged < 60 years (both P < 0.001) after adjusting for ICD indications, sex, implantation year, referral source, and comorbidities. In those aged ≥ 80 years, age > 83 years, congestive cardiac failure, chronic renal failure, neurodegenerative disease, and a higher Charlson comorbidity index score were each independent predictors of 1-year mortality.

CONCLUSIONS

ICD use in patients aged ≥ 80 years and 60-79 years was 10-fold that in patients aged < 60 years, and perioperative outcomes were good in all ages, but there was substantially increased 1-year mortality in those aged ≥ 80 years. Careful selection based on age and comorbidity may further reduce 1-year mortality in patients ≥ 80 years old receiving ICDs.

Laser lead extraction in octo- and nonagenarians. A subgroup analysis from the GALLERY registry

INTRODUCTION

In an aging population with cardiac implantable electronic devices, an increasing number of octo- and even nonagenarians present for lead extraction procedures. Those patients are considered at increased risk for surgical procedures including lead extraction. Here, we investigated safety and efficacy of transvenous lead extraction in a large patient cohort of octo- and nonagenarians.

METHODS AND RESULTS

A subgroup analysis of all patients aged ≥80 years (n = 499) in the German Laser Lead Extraction Registry (GALLERY) was performed. Outcomes were compared to the nonoctogenarians from the registry. Primary extraction method was Laser lead extraction, with additional use of mechanical rotational sheaths or femoral snares, if necessary. An analysis of patient- and device characteristics, as well as an assessment of predictors for adverse events via multivariate analyses was conducted. Mean patients age was 84.3 ± 3.7 years in the octogenarians group and 64.1 ± 12.4 years in the nonoctogenarians group. The median lead dwell time was 118.0 months (78; 167) and 92.0 months [60; 133], p < .001 in the octogenarians and nonoctogenarians group, respectively. Clinical procedural success rate was achieved in 97.6% of the cases in octogenarians and 97.9% in nonoctogenarians (p = .70). Overall complication rate was 4.4% in octogenarians and 4.3% in nonoctogenarians (0.91). In octogenarians procedure-related mortality was 0.8% and all-cause in-hospital mortality was 5.4%, while in nonoctogenarians, procedure related and all-cause in-hospital mortality were 0.5% and 3.1%, respectively. A body mass index (BMI) <20 kg/m2 , was the only statistically significant predictor for procedure-related complications in octogenarians, while systemic infection, BMI ≤20 kg/m2 , procedural complications and chronic kidney disease were predictors for in-hospital mortality.

CONCLUSIONS

Laser lead extraction in octo- and nonagenarians is safe and effective. BMI ≤20 kg/m2 was the only statistically significant predictor for procedural complications. According to our data, advanced age should not be considered as contraindication for laser lead extraction.

Can Frailty Be a Predictor of ICD Shock after the Implantation of a Cardioverter Defibrillator in Elderly Patients?

INTRODUCTION

The aim of the study was to assess the prevalence of frailty among elderly patients who had an implanted cardioverter defibrillator, as well as the influence of frailty on the main endpoints during the follow-up.

METHODS

The study included 103 patients > 60 years of age (85M, aged 71.56-8.17 years). All of the patients had an implanted single or dual-chamber cardioverter-defibrillator. In the research, there was a 12-month follow-up. The occurrence of frailty syndrome was assessed using the Tilburg Frailty Indicator scale (TFI).

RESULTS

Frailty syndrome was diagnosed in 75.73% of the patients that were included in the study. The mean values of the TFI were 6.55 ± 2.67, in the physical domain 4.06 ± 1.79, in the psychological domain 2.06 ± 1.10, and in the social domain 0.44 ± 0.55. During the follow-up period, 27.2% of patients had a defibrillator cardioverter electric shock, which occurred statistically more often in patients with diagnosed frailty syndrome (34.6%) compared to the robust patients (4%); p = 0.0062. In the logistic regression, frailty (OR: 1.203, 95% CI:1.0126-1.4298; p < 0.030) was an independent predictor of a defibrillator cardioverter electric shock. Similarly, in the logistic regression, frailty (OR: 1.3623, 95% CI:1.0290-1.8035; p = 0.019) was also an independent predictor for inadequate electric shocks.

CONCLUSION

About three-quarters of the elderly patients that had qualified for ICD implantation were affected by frailty syndrome. In the frailty subgroup, adequate and inadequate shocks occurred more often compared to the robust patients.

Safety and efficacy of transvenous lead extraction in octogenarians using powered extraction sheaths

BACKGROUND

In the aging population equipped with cardiac implantable electronic devices, an increasing number of octogenarians require lead extractions. This patient population is often considered as a high-risk group for surgical procedures. We, therefore, investigated the safety and efficacy of transvenous lead extraction in octogenarians using powered extraction sheaths.

METHODS

Between January 2013 and March 2017, 403 patients underwent lead extraction at two high-volume lead extraction centers. A total of 71 octogenarians were treated with laser lead extraction and were included in this analysis. Primary extraction method was laser lead extraction, with additional use of mechanical rotational sheaths or femoral snares, if necessary. Patient-based and procedural data were collected and analyzed retrospectively.

RESULTS

Mean age was 83.5 ± 3.3 years, 64.7% were males. A total of 152 leads were extracted. The mean lead dwell time of treated leads was 10.2 ± 5.2 years. Complete procedural success rate was 92.9%, while clinical success was achieved in 98.6%. Failure of extraction occurred in one patient (1.4%). In six (7.7%) patients, additional mechanical rotational sheaths or femoral snares were used. Overall complication rate was 4.2%, including one (1.4%) major (RA perforation) and two (2.8%) minor complications. No procedure-related mortality was observed in any of the patients.

CONCLUSION

Transvenous lead extraction in octogenarians with old leads is safe and effective when performed in experienced centers. Patient's age should therefore not be considered as contraindication for lead extraction using powered extraction sheaths.

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.

[Electrophysiologic procedure complications in the elderly]

Published registries give limited information on age-dependent complication rates. There are several reasons for this, including limited numbers of patients in subgroups (e.g., contractility management), experience-dependent procedures (e.g., catheter ablation), or in changing indications (e.g., resynchronization). Finally, severely ill and very old patients with limited prognosis are often excluded from electrophysiologic procedures. Therefore, published data are difficult to interpret. Meta-analyses of randomized trials give more precise information on included patient cohorts, but do not necessarily reflect daily practice because elderly patients are often excluded from trials. Therefore, the individual risk of elderly patients has to be estimated on an individual case basis. In summary, the age of patients is not relevant regarding possible complications; thus, there is no age limit for electrophysiologic interventions. Therefore, there is no alternative to the individual estimation of procedural risks of interventions of an informed patient by an experienced cardiologist.

[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.

Position paper for management of elderly patients with pacemakers and implantable cardiac defibrillators: Groupe de Rythmologie et Stimulation Cardiaque de la Société Française de Cardiologie and Société Française de Gériatrie et Gérontologie

Despite the increasingly high rate of implantation of pacemakers (PMs) and implantable cardioverter defibrillators (ICDs) in elderly patients, data supporting their clinical and cost-effectiveness in this age stratum are ambiguous and contradictory. We reviewed the data regarding the applicability, safety and effectiveness of conventional pacing, ICDs and cardiac resynchronization therapy (CRT) in elderly patients. Although periprocedural risk may be slightly higher in the elderly, the implantation procedure for PMs and ICDs is still relatively safe in this age group. In older patients with sinus node disease, the general consensus is that DDD pacing with the programming of an algorithm to minimize ventricular pacing is preferred. In very old patients presenting with intermittent or suspected atrioventricular block, VVI pacing may be appropriate. In terms of correcting potentially life-threatening arrhythmias, the effectiveness of ICD therapy is similar in older and younger individuals. However, the assumption of persistent ICD benefit in the elderly population is questionable, as any advantageous effect of the device on arrhythmic death may be attenuated by higher total non-arrhythmic mortality. While septuagenarians and octogenarians have higher annual all-cause mortality rates, ICD therapy may remain effective in selected patients at high risk of arrhythmic death and with minimum comorbidities despite advanced age. ICD implantation among the elderly, as a group, may not be cost-effective, but the procedure may reach cost-effectiveness in those expected to live more than 5-7years after implantation. Elderly patients usually experience significant functional improvement after CRT, similar to that observed in middle-aged patients. Management of CRT non-responders remains globally the same, while considering a less aggressive approach in terms of reinterventions (revision of left ventricular [LV] lead placement, addition of a right ventricular or LV lead, LV endocardial pacing configuration). Overall, physiological age, general status and comorbidities rather than chronological age per se should be the decisive factors in making a decision about device implantation selection for survival and well-being benefit in elderly patients.

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

AIMS

Currently, there continues to be a lack of evidence regarding outcomes associated with device-based therapy for ventricular arrhythmias in elderly patients, even more in primary-prevention indications. We aimed to describe the follow-up in terms of efficacy and safety of implantable cardioverter-defibrillator (ICD) therapy in a large cohort of elderly patients.

METHODS AND RESULTS

Retrospective multicentre study performed in 15 Spanish hospitals. Consecutive patients referred for ICD implantation before 2011 were included. One hundred and sixty-two of 1174 patients (13.8%) ≥75 years were considered as 'elderly'. When compared with those patients <75, this subgroup presented more co-morbid conditions, including hypertension, chronic obstructive pulmonary disease , and renal failure, and more previous hospitalizations due to heart failure (HF). During a mean follow-up of 104.4 ± 3.3 months, 162 patients (14%) died, 120 in the younger age (12.4%), and 42 (24.4%) in the elderly. Kaplan-Meier analysis showed an increased probability of death with increasing age (17, 24, 28, and 69% at 12, 24, 48, and 60 months of follow-up in the elderly group). There was neither difference regarding the rate of appropriate nor inappropriate ICD intervention.

CONCLUSION

In a real-world scenario, elderly patients comprise ∼15% of ICD implantations for primary prevention of sudden cardiac death (SCD). Although the rate of appropriate therapy is similar between groups, the benefit of ICD is attenuated for a major increase in mortality risk among those patients ≥75 years at the moment of device implantation.

Implantable cardioverter-defibrillators in the elderly: rationale and specific age-related considerations

Despite the increasingly high rate of implantation of cardioverter-defibrillators (ICD) in elderly patients, data supporting their clinical and cost-effectiveness in this age stratum are ambiguous and contradictory. We comprehensively reviewed the state-of-the-art data regarding the applicability, safety, clinical- and cost-effectiveness of the ICD in elderly patients, and analysed which patients in this age stratum are more likely to get a survival benefit from this therapy. Although peri-procedural risk may be slightly higher in the elderly, this procedure is still relatively safe in this age group. In terms of correcting potentially life-threatening arrhythmias, the effectiveness of ICD therapy is comparable in older and younger individuals. However, the assumption of persistent ICD benefit in the elderly population is questionable, as any advantage of the device on arrhythmic death may be largely attenuated by a higher total non-arrhythmic mortality. While septuagenarians and octogenarians have higher annual all-cause mortality rates, ICD therapy may remain effective in highly selected patients at high risk of arrhythmic death and with minimum comorbidities despite advanced age. ICD intervention among the elderly, as a group, may not be cost-effective, but the procedure may reach cost-effectiveness in those expected to live >5-7 years after implantation. Biological age rather than chronological age per se should be the decisive factor in making a decision on ICD selection for survival benefit.

Ventricular arrhythmias: device therapy and ablation

There are few randomized, well-controlled studies to guide decision making with respect to the treatment of ventricular arrhythmias in the elderly treated with either device implantation or catheter ablation. Although some data are conflicting, the elderly appear to have a greater degree of risk related to treatment compared with younger ones; however, this increased risk is in part a consequence of age itself and comorbid conditions. Conversely, in terms of benefit, although the data may again be mixed, there is ample information indicating that age should not contraindicate aggressive treatment when accepted indications for intervention exist.

Influence of age on perioperative complications among patients undergoing implantable cardioverter-defibrillators for primary prevention in the United States

BACKGROUND- The majority of current implantable cardioverter-defibrillator (ICD) recipients are significantly older than those in the ICD trials. Data on periprocedural complications among the elderly are insufficient. We evaluated the influence of age on perioperative complications among primary prevention ICD recipients in the United States. METHODS AND RESULTS- Using the National Cardiovascular Data's ICD Registry, we identified 150 264 primary prevention patients who received ICDs from January 2006 to December 2008. The primary end point was any adverse event or in-hospital mortality. Secondary end points included major adverse events, minor adverse events, and length of stay. Of 150 264 patients, 61% (n=91 863) were 65 years and older. A higher proportion of patients ≥65 years had diabetes, congestive heart failure, atrial fibrillation, renal disease, and coronary artery disease. Approximately 3.4% of the entire cohort had any complication, including death, after ICD implant. Any adverse event or death occurred in 2.8% of patients under 65 years old; 3.1% of 65- to 69-year-olds; 3.5% of 70- to 74-year-olds; 3.9% of 75- to 79-year-olds, 4.5% of 80- to 84-year-olds; and 4.5% of patients 85 years and older. After adjustment for clinical covariates, multivariate analysis found an increased odds of any adverse event or death among 75- to 79-year-olds (1.14 [95% confidence interval, 1.03 to 1.25], 80-to 84-year-olds (1.22 [95% confidence interval, 1.10 to 1.36], and patients 85 years and older (1.15 [95% confidence interval, 1.01 to 1.32], compared with patients under 65 years old. CONCLUSIONS- Older patients had a modestly increased-but acceptably safe-risk of periprocedural complications and in-hospital mortality, driven mostly by increased comorbidity.

Safety and effectiveness of primary prevention cardioverter defibrillators in octogenarians

BACKGROUND

Implantable cardioverter-defibrillators (ICDs) reduce the rate of sudden cardiac death (SCD) in patients with cardiomyopathy and reduced left ventricular systolic function. It is unclear if this benefit extends to the very elderly patient population.

METHODS

Patients who underwent initial ICD implantation at age 80 or older between January 1995 and April 2010 for primary SCD prevention were identified. Clinical data were collected from the medical record, including periprocedural complications, device type, and therapies delivered.

RESULTS

Three-hundred eighty patients were identified; 84 patients met eligibility criteria. The mean age was 82.68 years; mean follow-up was 34 months. Mean left ventricular ejection fraction was 28.1%. Mortality during follow-up was 17.9%. One- and 5-year survival estimates were 100% and 60%, respectively. Periprocedural complications occurred in 9.4% of patients; serious complications occurred in 4.8% with no periprocedural deaths. Device therapies occurred in 11.9% (n = 10) of patients (9.5% appropriate, n = 8; 2.4% inappropriate, n = 2). Cardiac resynchronization therapy-defibrillator (CRT-D) implantation was associated with prolonged median survival and decreased risk of death (hazard ratio 0.212; 95% confidence interval 0.048-.942, P = 0.042) compared to ICD alone.

CONCLUSIONS

Implantation of primary prevention ICDs in patients 80 years of age or older was associated with a low risk of serious complications and a 5-year survival estimate of 60%. Inappropriate therapies after implantation were uncommon. CRT-D implantation was associated with a decreased risk of death compared to ICD alone. These data suggest that, in selected patients in this age group, ICD implantation is safe and effective.

Device therapy in patients with heart failure and advanced age: too much too late?

Expanding indications for implantable cardiac rhythm devices coupled with the aging of the population have led to a progressive rise in the number of elderly patients referred for device implantation. However, the value of implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) in elderly patients remains unproven, in part because few patients over 75 years of age were enrolled in the major device trials. In this article, we summarize the current evidence base regarding the use of device therapy in elderly heart failure patients. We review the efficacy, complications, indications, cost, and current controversies surrounding the use of ICDs and CRT in the geriatric age group. We conclude that reduced benefit coupled with higher complication rates and associated higher costs make it unlikely that the net clinical benefit of an ICD is favorable in most patients over 75 to 80 years of age. Conversely, preliminary data indicate that elderly patients undergoing CRT experience improved quality of life at acceptable cost, suggesting that CRT may be an attractive therapeutic option in appropriately selected patients of advanced age.

Cost-effectiveness of implantable cardioverter defibrillators in patients >or=65 years of age

BACKGROUND

More than 80% of sudden cardiac deaths (SCDs) occur in patients >or=65 years old; the cost-effectiveness of implantable cardioverter defibrillator (ICD) therapy in older patients remains unclear. We sought to examine the cost-effectiveness of ICD therapy in at-risk patients >or=65 years old.

METHODS

We developed a Markov model to evaluate lifetime costs and benefits of ICD therapy compared with optimal medical therapy in patients >or=65 years of age with left ventricular dysfunction. Data were derived from the literature and existing clinical trials of primary prevention of SCD. Outcome measures included life years, quality-adjusted life years, costs, and incremental cost-effectiveness.

RESULTS

Benefits and costs of ICD therapy in older individuals varied widely by clinical-trial population. In the 5 trials considered, for patients >or=65 years of age, ICDs demonstrated a life expectancy benefit compared with control therapy (incremental cost-effectiveness ratios ranging from $37,031-$138,458 per quality-adjusted life year). For 75-year-old patients, the findings were qualitatively similar, although cost-effectiveness was reduced in all trial populations. In sensitivity analyses, cost-effectiveness of ICD therapy in older individuals depended upon the trial population, quality of life, device cost, and frequency of generator replacement. Sensitivity analyses on other variables did not change the results substantially.

CONCLUSIONS

The cost-effectiveness of ICD therapy for primary prevention in older patients varies widely among trials. Given an aging US population and the high risk of SCD in these individuals, further studies of ICD therapy and their cost-effectiveness-specifically in older patients-are needed.

Evidence-based management of heart failure in clinical practice: a review of device-based therapy use

BACKGROUND

Heart failure is a growing health issue and is associated with significant mortality risk. Device therapy is efficacious in preventing sudden death in patients with heart failure; however, this evidence comes from rigorous clinical trials. It is unclear how device therapy is utilized in 'real-world' practice. The primary objective was to characterize patterns of device use in patients with heart failure at risk of sudden death and to identify barriers to guideline-driven prescription of implantable cardioverter-defibrillators.

METHODS

We report a cross-sectional study of patients attending general cardiology clinic over a 3-month period.

RESULTS

Of 1003 consecutive patients attending the cardiology clinic, 176 had heart failure. Of these, 66 were potentially eligible for device therapy, but only 16 of these had actually undergone device implantation. Potentially eligible non-recipients were older (P < 0.001), more likely to have ischaemic cardiomyopathy (P= 0.002), less likely to be prescribed spironolactone (P= 0.005) or warfarin (P= 0.02), and less likely to have a widened QRS > 120 ms (P= 0.005). There was a high prevalence of underuse of evidence-based pharmacotherapies among patients with heart failure.

CONCLUSION

There is substantial underuse of device therapy in patients with heart failure. Strikingly, whereas patients with symptoms of heart failure were more likely to receive a device, those being managed for ischaemic heart disease were not. There is also a high prevalence of failure to prescribe evidence-based pharmacotherapy in a tertiary hospital general cardiology clinic. This may be explained in part by the lack of a patient database to record treatment contraindications and to alert clinicians to possible gaps in patient therapy.

Electrocardiographic findings, device therapies, and comorbidities in octogenarian implantable defibrillator recipients

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.

Preventing tomorrow's sudden cardiac death today: dissemination of effective therapies for sudden cardiac death prevention

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.

A comprehensive approach to management of ventricular arrhythmias

This review presents five cases that highlight the complexity of taking care of patients with ventricular arrhythmias. Three of the cases discuss management of patients with nonsustained ventricular tachycardia in the setting of structural heart disease: dilated cardiomyopathy, hypertrophic cardiomyopathy, and after myocardial infarction. A fourth case asks whether data from implantable cardioverter defibrillator (ICD) trials can be extrapolated to older patients, and the fifth case discusses management of recurrent ventricular arrhythmias in a patient with an ICD.

Outcomes of elderly heart failure recipients of ICD and CRT

Implantable cardioverter defibrillator (ICD) therapy has been established as a highly effective method for primary and secondary prevention of sudden cardiac death in heart failure patients. In addition, cardiac resynchronization therapy (CRT) with and without defibrillator back-up improves symptoms, exercise capacity and prognosis in selected patients with advanced heart failure and intraventricular conduction delay. Unfortunately, mean patient age in ICD- and CRT-intervention trials was only 60 to 65 years with few patients being older than 75 years. None of these trials separately studied an elderly heart failure population. This review summarizes the available scientific evidence for the use of ICDs and CRT devices in elderly heart failure patients based on subgroup analyses of prospective randomized ICD- and CRT-intervention trials, and based on published cohort studies.

Implantable cardioverter-defibrillators should be used routinely in the elderly

Implantable cardioverter-defibrillators (ICDs) reduce mortality in selected high-risk populations by reducing the risk of sudden death. No clinical trial examining ICD efficacy has focused specifically on benefits and risks in the elderly, but all trials have included substantial numbers of older patients. The author addresses several issues: Is the risk of sudden death different for the elderly than in younger patients? Is ICD implantation feasible in the elderly? Is there evidence that ICD use in the elderly improves survival? The author's research indicates that while total mortality is higher for the elderly, there does not appear to be a specific predilection for arrhythmic death. Recent reports indicate that while ICDs can be implanted in a Medicare population, ICD implantation is associated with significant mortality (0.9%), as well as periprocedural complications (10.8%). In spite of the risks, both secondary and primary prevention trials demonstrate that the survival benefit associated with ICD use in the study populations was at least as great for elderly patients as for younger persons. Thus, published data support judicious ICD use in elderly patients at high risk for sudden death.

Role of the implantable defibrillator among elderly patients with a history of life-threatening ventricular arrhythmias

AIMS

The implantable defibrillator (ICD) reduces arrhythmic and all-cause mortality in patients with a history of life-threatening ventricular arrhythmias. However, its effectiveness in elderly patients is uncertain, given their competing risk of non-arrhythmic death.

METHODS AND RESULTS

Individual patient data from all three secondary prevention trials comparing the ICD to amiodarone were pooled. Patients were divided into two groups based on age < 75 and > or = 75 years. Patient characteristics were reported and the effect of the ICD on all-cause mortality and arrhythmic death was determined for each group. The effect of age on these outcomes was determined by evaluating the interaction term (age-treatment). A total of 1866 patients were included in this analysis. Their mean age was 63.7 +/- 10.4 years (intra-quartile range 58-71 years). There were 252 patients > or = 75 years old (13.5% of total). Patients > or = 75 years old had a similar left ventricular (LV) ejection fraction (EF)(32.6 +/- 13.7 vs. 33.8 +/- 14.9%, P = 0.20) and baseline prevalence of NYHA class 3 or 4 heart (12.3 vs. 11.8%, P = 0.38) failure as younger patients, but were less likely to have ventricular fibrillation as their presenting arrhythmia (39 vs. 53%, P = 0.0001). Over a mean follow-up of 2.3 years, older patients were more likely to die of non-arrhythmic death (8.74% per year vs. 3.96% per year, P = 0.001) and arrhythmic death (6.73% per year vs. 3.84% per year, P = 0.03). The ICD significantly reduced all-cause and arrhythmic death in patients < 75 years old (all-cause death HR = 0.69, 95% CI: 0.56-0.85, P < 0.0001; arrhythmic death HR = 0.44, 95% CI: 0.32-0.62, P < 0.0001), but not in patients > or = 75 years old (all-cause death HR = 1.06, 95% CI: 0.69-1.64, P = 0.79; arrhythmic death HR = 0.90, 95% CI: 0.42-1.95, P = 0.79). The interaction between age > or = 75 and ICD use was of borderline significance in each case (P = 0.09 and P = 0.11, respectively).

CONCLUSION

Elderly patients with a history of life-threatening ventricular arrhythmias have a high incidence of non-arrhythmic death. In these patients, the ICD may not afford the same survival advantage over amiodarone that is seen in younger patients. ICD therapy should not be withheld based on age alone; however, physicians should carefully consider the risk of non-arrhythmic death among elderly patients when selecting the appropriate therapy for an individual.

Complications of Pacemakers and Defibrillators in the Elderly

Within the United States, the elderly population is projected to increase 126% by 2050, making those over the age of 65 the most rapidly growing segment in the population. Permanent pacemakers and defibrillators are important therapies with expanding indications for their use, and older persons constitute the majority of recipients of these devices. Recognizing complications associated with these cardiac devices is essential in caring for patients with them. Complications can be related to the implantation procedure and are most commonly lead dislodgement, pneumothorax, lead perforation, hematoma, and infection. Intrinsic device programming can also result in complications such as pacemaker syndrome, pacemaker-mediated tachycardia, and inappropriate shocks. Extrinsic factors, such as electromagnetic interference and physically manipulating the device, can also result in problems. Recent work suggests that older age, by itself, is not associated with a significant increase in the complication rates from these devices and should not preclude their use.

Outcomes of Elderly Recipients of Implantable Cardioverter Defibrillators

AIMS OF THE STUDY

To examine the patterns of use, complication rates, and survival in elderly recipients of implantable cardioverter defibrillators (ICD).

METHODS AND RESULTS

We followed 500 consecutive patients included in the Marburg Defibrillator database for 48+/-39 months. There were 40 patients (8%) >/= 75 and 460 (92%) < 75 years of age at the time of implant. The 5-year Kaplan-Meier estimate for appropriate treatment of VT or VF by ICD was 49% among patients < 75- versus 57% among patients >/= 75-years-old (P = 0.17). The 5-year sudden death rate was similarly low in both groups of patients (2% versus 3%). The 5-year overall mortality rate was significantly higher in patients >/= 75 than in patients < 75 years of age (55% versus 21%, P = 0.001), due to a higher mortality from heart failure (HF). All procedure-related, lead-related, and pulse generator-related complications were similar in both patient groups (23% versus 25%).

CONCLUSIONS

ICD therapy was equally effective in patients >/= 75 and patients < 75 years of age in the prevention of sudden cardiac death. While the complication rates were similar in both age groups, the long-term mortality was considerably higher in elderly patients, due to a higher mortality from HF. The current ICD therapy guidelines appear applicable to elderly patients who are otherwise medically stable and without advanced HF.

Implantable cardioverter-defibrillators for secondary prevention: is it worth it in the elderly?

Aging is associated with structural alterations in the heart that predispose the elderly to life-threatening ventricular arrhythmias. The majority of sudden cardiac deaths occur in people aged 65 and older. As the proportion of elderly in our population continues to grow, a greater number of elderly patients with malignant ventricular arrhythmias will require appropriate medical management. Clinical outcome trials have demonstrated that implantable cardioverter-defibrillators (ICDs) improve overall survival compared with pharmacologic therapy when used for the secondary prevention of cardiac arrest. Despite proven efficacy, physicians may be reluctant to implant a defibrillator in an older patient. This review summarizes the data pertaining to the use of defibrillators for secondary prevention in the elderly. ICD use for secondary prevention reduces all-cause mortality and appears to be economically advantageous in an older patient population. Currently, there is no convincing data to suggest that ICD therapy should be withheld from a patient based on age alone.

Arrhythmia Therapy in the Elderly

As with other illnesses, the risks and benefits of diagnostic studies and treatments for arrhythmias are altered by age. In the elderly, the risks of treatment are often greater; drug metabolism varies and mechanical approaches (ablation procedures and insertion of electrical devices) are associated with greater complication rates. This paper reviews recommendations for diagnosis and treatment of arrhythmias in the elderly. (c) 2000 by CVRR, Inc.