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Backman WD, DiCaro MV, Zuo X, Peralta A, Orkaby AR. Aligning goals with care: Advance directives in older adults with implantable cardioverter-defibrillators. Pacing Clin Electrophysiol 2024; 47:697-701. [PMID: 38597183 DOI: 10.1111/pace.14983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/19/2024] [Accepted: 03/22/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Patients ≥80 with implantable cardioverter-defibrillators (ICDs) have high rates of hospitalization and mortality, yet few have documented advance directives. We sought to determine the prevalence of advance directives in adults ≥80 years with ICDs, focusing on those with frailty and cognitive impairment. METHODS Prospective cohort study (July 2016-May 2019) in an electrophysiology clinic. Presence of advance directives (health care proxies [HCP] and living wills [LW], or medical orders for life-sustaining treatment [MOLST]) was determined by medical record review. Frailty and cognitive impairment were screened using 4-m gait speed and Mini-Cog. RESULTS 77 Veterans were evaluated. Mean age 84 years, 100% male, 70% frail. Overall, 52 (68%) had an HCP and 37 (48%) had a LW/MOLST. Of 67 with cognitive testing, 36% were impaired. HCP documentation was similar among frail and non-frail (69% vs. 65%). LW/MOLST was more prevalent among frail versus non-frail (52% vs. 39%). There was no difference in HCP documentation by cognitive status (67%). A LW/MOLST was more frequent for cognitively impaired versus non-impaired (50% vs. 42%). Among 19 Veterans who were frail and cognitively impaired, 14 (74%) had an HCP and 11 (58%) had a LW/MOLST. CONCLUSIONS Most Veterans had a documented advance directive, but a significant minority did not. Simple frailty and cognitive screening tools can rapidly identify patients for whom discussion of advance directives is especially important.
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Affiliation(s)
- Warren D Backman
- New England Geriatric Research Education and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Section of Geriatrics, Division of Palliative Care & Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael V DiCaro
- New England Geriatric Research Education and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Department of Internal Medicine, Kirk Kerkorian School of Medicine, University of Nevada, Las Vegas, Nevada, USA
| | - Xintong Zuo
- Hospital Medicine, Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Adelqui Peralta
- Department of Cardiology, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - Ariela R Orkaby
- New England Geriatric Research Education and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Background Inherited cardiomyopathies (ICs) are relatively rare. General cardiologists have little experience in diagnosing and managing these conditions. International societies have recognized the need for dedicated IC clinics. However, only few reports on such clinics are available. Methods and Results Clinical data of patients referred to our clinic during its first 2 years for a personal or family history of (possible) IC were analyzed. A total of 207 patients from 196 families were seen; 13% of probands had their diagnosis changed. Diagnosis was most commonly altered in patients referred for possible arrhythmogenic dominant right ventricular cardiomyopathy (62.5%). A total of 90% of probands had genetic testing, of whom 27.3% harbored a likely pathogenic or pathogenic variant. Of patients with confirmed hypertrophic cardiomyopathy, 31 (28.7%) were treated for left ventricular outflow tract obstruction, including septal reduction in 13. Patients with either hypertrophic cardiomyopathy or left ventricular noncompaction and a history of atrial fibrillation were started on oral anticoagulation. Oral anticoagulation was also discussed with all patients with hypertrophic cardiomyopathy and apical aneurysm. Patients with a definite diagnosis of arrhythmogenic dominant right ventricular cardiomyopathy were started on β‐blockers and given restrictive exercise prescriptions. A total of 17 patients with hypertrophic cardiomyopathy and 5 patients with likely pathogenic or likely variants in arrhythmogenic genes received primary prevention implantable cardioverter‐defibrillators. No implantable cardioverter‐defibrillators were warranted for arrhythmogenic dominant right ventricular cardiomyopathy. A total of 76 family members from 24 families had cascade screening, 32 of whom carried the familial variant. A total of 21 members from 13 gene‐elusive families were evaluated by clinical screening, 3 of whom had positive screening. Conclusions Specialized IC clinics may improve diagnosis, management, and outcomes of patients with (possible) IC and their family members.
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Affiliation(s)
- Emily Smith
- Hartford HealthCare, Heart and Vascular Institute Hartford CT
| | - Paul D Thompson
- Hartford HealthCare, Heart and Vascular Institute Hartford CT.,Department of Medicine University of Connecticut Farmington CT
| | | | - Adaya Weissler-Snir
- Hartford HealthCare, Heart and Vascular Institute Hartford CT.,Department of Medicine University of Connecticut Farmington CT
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Peterson PN, Greenlee RT, Go AS, Magid DJ, Cassidy-Bushrow A, Garcia-Montilla R, Glenn KA, Gurwitz JH, Hammill SC, Hayes J, Kadish A, Reynolds K, Sharma P, Smith DH, Varosy PD, Vidaillet H, Zeng CX, Normand SLT, Masoudi FA. Comparison of Inappropriate Shocks and Other Health Outcomes Between Single- and Dual-Chamber Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Cardiac Death: Results From the Cardiovascular Research Network Longitudinal Study of Implantable Cardioverter-Defibrillators. J Am Heart Assoc 2017; 6:JAHA.117.006937. [PMID: 29122811 PMCID: PMC5721776 DOI: 10.1161/jaha.117.006937] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In US clinical practice, many patients who undergo placement of an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death receive dual-chamber devices. The superiority of dual-chamber over single-chamber devices in reducing the risk of inappropriate ICD shocks in clinical practice has not been established. The objective of this study was to compare risk of adverse outcomes, including inappropriate shocks, between single- and dual-chamber ICDs for primary prevention. METHODS AND RESULTS We identified patients receiving a single- or dual-chamber ICD for primary prevention who did not have an indication for pacing from 15 hospitals within 7 integrated health delivery systems in the Longitudinal Study of Implantable Cardioverter-Defibrillators from 2006 to 2009. The primary outcome was time to first inappropriate shock. ICD shocks were adjudicated for appropriateness. Other outcomes included all-cause hospitalization, heart failure hospitalization, and death. Patient, clinician, and hospital-level factors were accounted for using propensity score weighting methods. Among 1042 patients without pacing indications, 54.0% (n=563) received a single-chamber device and 46.0% (n=479) received a dual-chamber device. In a propensity-weighted analysis, device type was not significantly associated with inappropriate shock (hazard ratio, 0.91; 95% confidence interval, 0.59-1.38 [P=0.65]), all-cause hospitalization (hazard ratio, 1.03; 95% confidence interval, 0.87-1.21 [P=0.76]), heart failure hospitalization (hazard ratio, 0.93; 95% confidence interval, 0.72-1.21 [P=0.59]), or death (hazard ratio, 1.19; 95% confidence interval, 0.93-1.53 [P=0.17]). CONCLUSIONS Among patients who received an ICD for primary prevention without indications for pacing, dual-chamber devices were not associated with lower risk of inappropriate shock or differences in hospitalization or death compared with single-chamber devices. This study does not justify the use of dual-chamber devices to minimize inappropriate shocks.
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Affiliation(s)
- Pamela N Peterson
- Denver Health Medical Center, Denver, CO .,University of Colorado Denver Anschutz Medical Campus, Aurora, CO.,Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Robert T Greenlee
- Marshfield Clinic Research Foundation, Marshfield, WI.,Marshfield Clinic, Marshfield, WI
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,University of California San Francisco, San Francisco, CA.,Stanford University School of Medicine, Palo Alto, CA
| | - David J Magid
- University of Colorado Denver Anschutz Medical Campus, Aurora, CO.,Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | | | | | - Karen A Glenn
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | | | | | - John Hayes
- Marshfield Clinic Research Foundation, Marshfield, WI
| | | | - Kristi Reynolds
- Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena, CA
| | - Param Sharma
- Marshfield Clinic Research Foundation, Marshfield, WI
| | - David H Smith
- Kaiser Permanente Northwest Center for Health Research, Portland, OR
| | - Paul D Varosy
- University of Colorado Denver Anschutz Medical Campus, Aurora, CO.,Institute for Health Research, Kaiser Permanente Colorado, Denver, CO.,Eastern Colorado VA Health Care System, Denver, CO
| | | | - Chan X Zeng
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | | | - Frederick A Masoudi
- University of Colorado Denver Anschutz Medical Campus, Aurora, CO.,Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
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Kramer DB, Hatfield LA, McGriff D, Ellis CR, Gura MT, Samuel M, Retel LK, Hauser RG. Transvenous implantable cardioverter-defibrillator lead reliability: implications for postmarket surveillance. J Am Heart Assoc 2015; 4:e001672. [PMID: 26025935 PMCID: PMC4599526 DOI: 10.1161/jaha.114.001672] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background As implantable cardioverter-defibrillator technology evolves, clinicians and patients need reliable performance data on current transvenous implantable cardioverter-defibrillator systems. In addition, real-world reliability data could inform postmarket surveillance strategies directed by regulators and manufacturers. Methods and Results We evaluated Medtronic Sprint Quattro, Boston Scientific Endotak, and St Jude Medical Durata and Riata ST Optim leads implanted by participating center physicians between January 1, 2006 and September 1, 2012. Our analytic sample of 2653 patients (median age 65, male 73%) included 445 St Jude, 1819 Medtronic, and 389 Boston Scientific leads. After a median of 3.2 years, lead failure was 0.28% per year (95% CI, 0.19 to 0.43), with no statistically significant difference among manufacturers. Simulations based on these results suggest that detecting performance differences among generally safe leads would require nearly 10 000 patients or very long follow-up. Conclusions Currently marketed implantable cardioverter-defibrillator leads rarely fail, which may be reassuring to clinicians advising patients about risks and benefits of transvenous implantable cardioverter-defibrillator systems. Regulators should consider the sample size implications when designing comparative effectiveness studies and evaluating new technology for preventing sudden cardiac death.
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Affiliation(s)
- Daniel B Kramer
- Beth Israel Deaconess Medical Center, Boston, MA (D.B.K., M.S.) Hebrew SeniorLife Institute for Aging Research, Boston, MA (D.B.K.) Harvard Medical School, Boston, MA (D.B.K., L.A.H.)
| | | | - Deepa McGriff
- Minneapolis Heart Institute Foundation, Minneapolis, MN (D.M.G., L.K.R., R.G.H.)
| | | | - Melanie T Gura
- Northeast Ohio Cardiovascular Specialists, Akron, OH (M.T.G.)
| | - Michelle Samuel
- Beth Israel Deaconess Medical Center, Boston, MA (D.B.K., M.S.)
| | - Linda Kallinen Retel
- Minneapolis Heart Institute Foundation, Minneapolis, MN (D.M.G., L.K.R., R.G.H.)
| | - Robert G Hauser
- Minneapolis Heart Institute Foundation, Minneapolis, MN (D.M.G., L.K.R., R.G.H.)
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Kramer DB, Mitchell SL, Monteiro J, Jones PW, Normand SL, Hayes DL, Reynolds MR. Patient Activity and Survival Following Implantable Cardioverter-Defibrillator Implantation: The ALTITUDE Activity Study. J Am Heart Assoc 2015; 4:JAHA.115.001775. [PMID: 25979902 PMCID: PMC4599410 DOI: 10.1161/jaha.115.001775] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Physical activity data are collected automatically by implantable cardioverter-defibrillators (ICDs). Though these data potentially provide a quantifiable and easily accessible measure of functional status, its relationship with survival has not been well studied. Methods and Results Patients enrolled in the Boston Scientific LATITUDE remote monitoring system from 2008 to 2012 with ICDs were eligible. Remote monitoring data were used to calculate mean daily activity at baseline (30 to 60 days after implantation), and longitudinally. Cox regression was used to examine the association between survival and increments of 30 minutes/day in both (1) mean baseline activity and (2) time-varying activity, with both adjusted for demographic and device characteristics. A total of 98 437 patients were followed for a median of 2.2 years (mean age of 67.7±13.1 years; 71.7% male). Mean baseline daily activity was 107.5±66.2 minutes/day. The proportion of patients surviving after 4 years was significantly higher among those in the most versus least active quintile of mean baseline activity (90.5% vs. 50.0%; log-rank P value, <0.001). Lower mean baseline activity (i.e., incremental difference of 30-minutes/day) was independently associated with a higher risk of death (adjusted hazard ratio [AHR], 1.44; 95% confidence interval [CI], 1.427 to 1.462). Time-varying activity was similarly associated with a higher risk of death (AHR, 1.48; 95% CI, 1.451 to 1.508), indicating that a patient having 30 minutes per day less activity in a given month has a 48% increased hazard for death when compared to a similar patient in the same month. Conclusions Patient activity measured by ICDs strongly correlates with survival following ICD implantation.
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Affiliation(s)
- Daniel B Kramer
- Beth Israel Deaconess Medical Center, Boston, MA (D.B.K., S.L.M.) Harvard Medical School, Boston, MA (D.B.K., S.L.M., S.L.N.) Hebrew SeniorLife Institute for Aging Research, Boston, MA (D.B.K., S.L.M.)
| | - Susan L Mitchell
- Beth Israel Deaconess Medical Center, Boston, MA (D.B.K., S.L.M.) Harvard Medical School, Boston, MA (D.B.K., S.L.M., S.L.N.) Hebrew SeniorLife Institute for Aging Research, Boston, MA (D.B.K., S.L.M.)
| | - Joao Monteiro
- North American Science Associates, Inc, Minneapolis, MN (J.M.)
| | | | - Sharon-Lise Normand
- Harvard Medical School, Boston, MA (D.B.K., S.L.M., S.L.N.) Harvard School of Public Health, Boston, MA (S.L.N.)
| | | | - Matthew R Reynolds
- Lahey Clinic, Burlington, MA (M.R.R.) Harvard Clinical Research Institute, Boston, MA (M.R.R.)
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