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Meta-analysis: age and effectiveness of prophylactic implantable cardioverter-defibrillators
Pasquale Santangeli1, Luigi Di Biase, Antonio Dello Russo
1Catholic University of the Sacred Heart, Rome, Italy. pasquale.santangeli@libero.it
Insights
Implantable cardioverter-defibrillators (ICDs) reduce mortality in younger patients with severe left ventricular dysfunction. However, the survival benefit for elderly patients is less clear and may be smaller.
Area of Science:
- Cardiology
- Medical Devices
- Public Health
Background:
- Implantable cardioverter-defibrillators (ICDs) are established for primary prevention of sudden cardiac death.
- Severe left ventricular dysfunction is a key indication for ICDs.
Purpose of the Study:
- To evaluate the effectiveness of ICDs versus standard medical therapy.
- To compare ICD efficacy in different age groups for primary prevention of sudden cardiac death.
Main Methods:
- Systematic review and meta-analysis of randomized controlled trials.
- Searched multiple databases (MEDLINE, Embase, etc.) from January 1970 to April 2010.
- Extracted mortality data and hazard ratios for all-cause mortality by age group.
Main Results:
- Five trials with 5783 patients were included; 44% were elderly.
- Prophylactic ICD therapy significantly reduced mortality in younger patients.
- A smaller, less consistent survival benefit was observed in elderly patients.
Conclusions:
- Prophylactic ICD therapy may offer less benefit to elderly patients with severe left ventricular dysfunction compared to younger patients.
- Limitations include unavailable age-specific mortality data in some trials and inability to adjust for comorbidities.
Background:
Implantable cardioverter-defibrillators (ICDs) for the primary prevention of sudden cardiac death have been proven effective in several clinical trials.
Purpose:
To summarize evidence about the effectiveness of ICDs versus standard medical therapy for the primary prevention of sudden cardiac death in different age groups of patients with severe left ventricular dysfunction.
Data Sources:
MEDLINE, Embase, CENTRAL, BioMed Central, Cardiosource, ClinicalTrials.gov, and ISI Web of Science (January 1970 to April 2010) were searched with no language restrictions.
Study Selection:
Two independent reviewers screened titles and abstracts to identify randomized, controlled trials of prophylactic ICD versus medical therapy in patients with severe left ventricular dysfunction that provided data about mortality outcomes for different age groups.
Data Extraction:
Two independent reviewers assessed risk for bias of trials and extracted patient and study characteristics and hazard ratios (HRs) relevant to all-cause mortality.
Data Synthesis:
Five trials (MADIT-II, DEFINITE, DINAMIT, SCD-HeFT, and IRIS) that enrolled 5783 patients (44% were elderly) were included. The primary analysis, which excluded the 2 trials enrolling patients early after acute myocardial infarction (DINAMIT and IRIS), found that prophylactic ICD therapy reduced mortality in younger patients (HR, 0.65 [95% CI, 0.50 to 0.83]; P < 0.001). A smaller survival benefit was found in elderly patients (HR, 0.75 [95% CI, 0.61 to 0.91]) that was not confirmed when MADIT-II patients older than 70 years were excluded or when data from DINAMIT and IRIS were included [corrected].
Limitations:
Four potentially eligible trials were not included in the meta-analysis because mortality data by age group were not available. Adjustment for differences in comorbid conditions and medical therapies among patients enrolled in the trials was not possible.
Conclusion:
Available data suggest that prophylactic ICD therapy may be less beneficial for elderly patients with severe left ventricular dysfunction than for younger patients [corrected].
Primary Funding Source:
None.
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