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Published on: February 28, 2012
Age differences in primary prevention implantable cardioverter-defibrillator use in U.S. individuals
Vivian Tsai1, Mary K Goldstein, Henry H Hsia
1School of Medicine, Stanford University Stanford, California 94305, USA. vtsai@stanford.edu
Insights
Potentially inappropriate use of implantable cardioverter-defibrillators (ICDs) was less common in older adults. Physicians appropriately deferred ICD implantation in many older patients with high comorbid burden.
Area of Science:
- Cardiology
- Medical Device Research
- Geriatric Medicine
Background:
- Implantable cardioverter-defibrillators (ICDs) are crucial for preventing sudden cardiac death.
- Assessing appropriate ICD use in older populations is essential due to age-related changes and comorbidities.
Purpose of the Study:
- To estimate the potentially inappropriate use of ICDs in older U.S. adults.
- To analyze the relationship between age, risk stratification, and ICD implantation.
Main Methods:
- Retrospective study utilizing the National Cardiovascular Data ICD Registry.
- Included 44,805 individuals receiving ICDs for primary prevention (2006-2008).
- Risk stratification used the Multicenter Automatic Defibrillator Implantation (MADIT) II system.
Main Results:
- 67% of ICD recipients were aged 65+, with 51% aged 75+.
- Potentially inappropriate ICD use was 10% in those aged 75+, compared to 40% in those <65.
- Age's association with nonarrhythmic death risk attenuated after adjusting for comorbidities.
Conclusions:
- Potentially inappropriate ICD use is less prevalent in older Americans compared to younger groups.
- Physicians appear to conservatively select older adults for ICDs, deferring those with high comorbidity.
- Nearly a quarter of all individuals may have received ICDs inappropriately based on mortality risk.
Objectives:
To estimate the potentially inappropriate use of implantable cardioverter-defibrillator ICDs in older U.S. adults.
Design:
Retrospective study.
Setting:
The National Cardiovascular Data ICD Registry.
Participants:
Forty-four thousand eight hundred five individuals in the National Cardiovascular Data's ICD Registry(™) who had received ICDs for primary prevention from January 2006 to December 2008. Individuals with a prior myocardial infarction and ejection fraction less than 30% were included.
Measurements:
Mortality risk was categorized using the Multicenter Automatic Defibrillator Implantation (MADIT) II risk-stratification system. Low-risk and very-high-risk individuals were considered potentially inappropriate recipients.
Results:
Of 44,805 individuals, 67% (n = 29,893) were aged 65 and older, of whom 51% were aged 75 and older. A significant proportion of ICD recipients had a low risk of death (16%, n = 6,969) or very high risk of nonarrhythmic death (8%, n = 3,693). Potentially inappropriate ICD use was 10% in those aged 75 and older, much less than in younger groups (40%, <65; 21%, 65-74, P < .001). Although age was associated with a high risk of nonarrhythmic death, its influence was markedly attenuated after adjusting for comorbidities and timing of ICD implantation (odds ratio = 1.02, 95% confidence interval = 1.02-1.03, P < .001).
Conclusion:
Potentially inappropriate ICD use appears significantly less--and at modest rates--in older Americans than in younger age groups. Overall, almost one-quarter of individuals may have received ICDs inappropriately based on their risk of death. Physicians appear to be conservatively referring older adults and wisely deferring those with high comorbid burden.
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