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Elderly patients can benefit from ICDs
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Elderly and younger patients may derive similar benefits from implantable cardioverter defibrillators, according to new research in Circulation.
The data suggest that elderly patients experienced increased mortality after ICD implantation, but rates of appropriate device shocks were similar across age groups. The Canadian research team suggested that overall health, not age alone, should determine patient outcomes after ICD implantation.
“Older patients were just as likely to experience an appropriate electrical shock from the device to treat a life-threatening heart rhythm,” Douglas S. Lee, MD, scientist at the Institute for Clinical Evaluative Sciences, cardiologist at Peter Munk Cardiac Center and associate professor of medicine at University of Toronto, said in a press release. “However, older patients experienced more non-cardiac and cardiovascular hospitalizations and higher associated rates of death overall.”
The researchers studied a prospective, inclusive registry of ICD recipients (n=5,399, 19.1% women) in Ontario from February 2007 to September 2010.
Mortality increased with age among primary prevention ICD recipients aged 18 to 49 (n=317; 2.1 deaths per 100 person-years), 50 to 59 (n=769; 3 deaths per 100 person-years), 60 to 69 (n=1,336; 5.4 deaths per 100 person-years), 70 to 79 (n=1,242; 6.9 deaths per 100 person-years) and older than 80 (n=275; 10.2 deaths per 100 patient-years; P<.001). A similar mortality trend emerged for secondary prevention ICD recipients: 18 to 49 (n=114; 2.2 deaths per 100 patient-years), 50 to 59 (n=244; 3.8 deaths per 100 patient-years), 60 to 69 (n=481; 6.1 deaths per 100 patient-years), 70 to 79 (n=462; 8.7 deaths per 100 patient-years) and older than 80 (n=159; 15.5 deaths per 100 patient-years; P<.001).
However, rates of appropriate shock were similar across age groups, from 6.7 per 100 patient-years in the 18 to 49 age group to 4.2 per 100 patient-years in the older than 80 age group who received primary prevention ICDs (P=.139) and from 11.4 per 100 patient-years in the 18 to 49 age group to 11.9 per 100 patient-years in the older than 80 age group who received secondary prevention ICDs (P=.993). Covariate-adjusted competing risk analysis demonstrated increased risk for death (P<.001 for both primary and secondary prevention), but no significant decline in appropriate shocks with older age after primary (P=.13) or secondary (P=.81) prevention ICD implantation.
The researchers also found that rates of inappropriate therapy and complications were similar regardless of age. The team concluded that “consideration of prognostic factors that predict mortality in conjunction with individualized clinical judgment will help to identify older patients who are more likely to benefit from ICD implantation.”
For more information:
Yung D. Circulation.2013;127:2383-2392.
Disclosure: The study was funded by the Canadian Institutes of Health Research and the Ontario Ministry of Health and Long-Term Care. Lee reports no relevant financial disclosures. See the full study for the other researchers’ relevant financial disclosures.
Perspective
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Gordon F. Tomaselli, MD
It is not surprising that selected elderly patients did benefit from ICD implantation and that the conclusion was that age alone should not be used as criteria for implantation of ICD. There are several things to note: Mortality was still highest in the ≥80 and 70 to 79 age groups; the average age of the ≥80 group was 82 years, so most were in their early 80s; and this was a Canadian registry study. In selecting patients for ICD implant, it was likely the competing mortality risk was considered in all age cohorts, and I suspect that eliminated many older patients who might otherwise have been candidates. It is important to remember that this was a registry study, and ideally these findings need to be validated in a prospective, randomized cohort.
It is important to recognize that age is only one factor that will impact outcome; however, in the elderly there is likely to be greater life-limiting morbidity that will factor into the decision regarding invasive therapies like ICDs. Ensuring that one considers significant comorbidities in all age groups will improve patient outcomes and lead to more efficient use of resources.
These findings will not change anything in my practice, since we do consider both comorbidity and age, particularly when it comes to primary prevention ICD implantation. This puts our practice on firmer ground, even if a randomized trial is never performed. In general, the findings are consistent with my experience. Age is the main determinant of mortality in all patient cohorts, and a patient who is in generally good condition even at an advanced age can tolerate many types of invasive treatments with benefit.
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