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Eligibility and utilization of implantable cardioverter-defibrillators in a regional STEMI system
Benjamin K Johnson1, Ross F Garberich2, Timothy D Henry3
1Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota; Hennepin County Medical Center, Minneapolis, Minnesota.
Insights
Implantable cardioverter-defibrillators (ICDs) offer a mortality benefit for ST-elevation myocardial infarction (STEMI) patients with reduced ejection fraction. However, appropriate ICD utilization remains low, with only 10-15% of eligible patients receiving them post-STEMI.
Area of Science:
- Cardiology
- Medical Devices
- Public Health
Background:
- Implantable cardioverter-defibrillators (ICDs) are proven to reduce mortality in ST-elevation myocardial infarction (STEMI) patients with decreased left ventricular ejection fraction (LVEF).
- Contemporary data on ICD eligibility and appropriate use in STEMI survivors is limited.
Purpose of the Study:
- To evaluate the current rates of eligibility and appropriate utilization of ICDs in patients following STEMI.
Main Methods:
- A prospective regional STEMI registry was used to analyze LVEF.
- Patients were categorized into normal (LVEF ≥50%), mildly reduced (35%-49%), and severely reduced (<35%) LVEF groups.
- Eligibility for ICDs was assessed based on LVEF and New York Heart Association class at follow-up (≥40 days post-STEMI).
Main Results:
- Out of 3072 analyzed STEMI patients, 7.1% met ICD criteria at follow-up (LVEF ≤35% and NYHA class II+).
- Only 35.6% of eligible patients received an ICD within one year.
- Overall ICD implantation rates among potentially eligible patients were between 10% and 15%.
Conclusions:
- The rate of appropriate ICD implantation in STEMI patients is low.
- There is a need for improved strategies to identify and increase access to ICDs for high-risk patients.
Background:
Studies have shown mortality benefit for implantable cardioverter-defibrillators (ICDs) in ST-elevation myocardial infarction (STEMI) patients with reduced left ventricular ejection fraction (LVEF), but contemporary eligibility and appropriate utilization of ICDs is unknown.
Objective:
The purpose of this study was to determine the contemporary eligibility and appropriate utilization of ICDs post-STEMI.
Methods:
Using the prospective Minneapolis Heart Institute regional STEMI registry, LVEF before discharge and at follow-up were stratified into 3 groups: normal (LVEF ≥50%), mildly reduced (LVEF 35%-49%), and severely reduced (LVEF <35%).
Results:
From March 2003 to June 2012, 3626 patients were treated. Patients with in-hospital death (n = 187), ICD in place (n = 21), negative cardiac biomarkers (n = 337), and undocumented in-hospital LVEF (n = 9) were excluded, leaving 3072 patients in the final analysis, including 1833 (59.7%) with LVEF ≥50%, 875 (28.5%) with LVEF between 35% and 49%, and 364 (11.8%) with LVEF <35% before hospital discharge. Overall, 1029 patients (33.5%) underwent follow-up echocardiography ≥40 days post-STEMI, including 140 of the 364 patients (38.5%) discharged with LVEF <35%. In total, 73 patients (7.1%) with follow-up echocardiography ≥40 days post-STEMI met criteria for an ICD (68 LVEF ≤30%, 5 LVEF 30%-35%, and New York Heart Association class II or greater). Only 26 of these patients (35.6%) underwent ICD placement within 1 year post-STEMI. Overall, only 10% to 15% of potentially eligible patients had an ICD implemented.
Conclusion:
Rates of ICD implantation in appropriate STEMI patients after 40 days are low. Strategies are needed to identify and expand access to these high-risk patients.
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