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Frailty, dementia may predict increased mortality risk in older patients receiving ICDs
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Researchers for a new study published in Circulation: Cardiovascular Quality and Outcomes suggest that screening older adults for frailty and dementia before they receive an implantable cardioverter defibrillator could reduce 1-year mortality risk after implantation.
Ariel R. Green, MD, MPH , assistant professor of medicine at the Johns Hopkins University School of Medicine, and colleagues assessed the prevalence of frailty and dementia in Medicare beneficiaries receiving ICDs for primary prevention, and the impact these and other geriatric conditions have on 1-year mortality rates.
Using the National Cardiovascular Data Registry ICD Registry, 83,792 patients at 1,314 hospitals who received their first ICD between 2006 and 2009 were enrolled in the cohort study. The mean age of the cohort was 75.42 6.08 years. Most patients were white men and one-third had left ventricular ejection fraction < 20%. Ninety-two patients had NYHA class II or II HF.
Prevalence of geriatric conditions
Ten percent of patients with ICDs were frail and 1% had dementia. Nineteen percent of patients had HF in the absence of all other comorbidities. The prevalence of diabetes was 47%; chronic obstructive pulmonary disease, 35%; cerebrovascular accident, 27%; chronic kidney disease, 26%; and hyponatremia, 19%.
One-year mortality rates
The primary endpoint was death within 1 year of ICD implantation. Green and colleagues observed that, compared with a rate of 12% in the total cohort, 1-year mortality was 22% for patients with frailty and 27% for patients with dementia.
In a multimorbidity patterns analysis, the rate of 1-year mortality after ICD implantation was 29% in patients with dementia and frailty, 25% in patients with frailty and chronic obstructive pulmonary disease and 23% in patients with frailty and diabetes. Only CKD was associated with a higher 1-year mortality rate than frailty. Four percent of patients who had no conditions other than HF died within the first year. Patients with both frailty and dementia had the greatest risk for death within the first year after implantation compared with those with no comorbidities (OR = 8.68; 95% CI, 7.33-10.27). Patients with both frailty and diabetes were six times more likely to die within the first year after implantation than those with HF alone (OR = 6.49; 95% CI, 5.81-7.24).
“Shared decision-making on the use of complex medical technologies such as ICDs should go beyond individual diseases and consider geriatric conditions, as well as the overall context of the patient,” Green told Cardiology Today. “The NCDR ICD Registry could include additional measures, such as a physical performance test, measurement of walking speed or a frailty scale. These data are already being collected from patients undergoing aortic valve replacement and cardiac surgery. Future studies could then determine how these prospective, clinical assessments of frailty impact outcomes among older adults receiving primary prevention ICDs.”
Green also suggested that future studies compare quality of life and functional outcomes for ICD-eligible patients with dementia and frailty who do or do not receive an ICD. “Mortality isn’t the only important outcome for many older adults. They want to know what life will be like after they undergo a medical intervention like an ICD. Will they feel better? Will they be able to do more?” she said. – by Tracey Romero
Disclosure: Green reports receiving research funding from the National Institute on Aging, the Health Resources and Services Administration and the Johns Hopkins Clinical Research Scholars Program. Please see the full study for a list of the other authors’ relevant financial disclosures.
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