AIM: Are hospitals risking death for elderly by implanting ICDs?

Older patients may be more likely to die in the hospital following the implantation of implantable cardioverter-defibrillators (ICDs) or pacemakers, according to a study in the April 12 issue of Archives of Internal Medicine. More than one-fifth of cardiac devices appear to be implanted in individuals aged 80 and older, despite the fact that most clinical trials have not included adults in this age group.

Although the effectiveness of ICDs and cardiac resynchronization therapy (CRT) alone or in combination is well established, limited data are available on device use and short-term outcomes in older patients because the average age in major clinical trials has ranged from 58 to 67 years and some have specified an upper age limit of 80 years, according to Jason P. Swindle, PhD, and colleagues from the Saint Louis University School of Medicine in Mo.

“[I]t has become increasingly apparent that certain patient subgroups may not benefit from device implantation; for example, use of ICDs in patients with renal failure and in those with advanced heart failure symptoms has not been associated with a survival benefit," they wrote.

The researchers sought to characterize age-specific practices and outcomes among patients with heart failure undergoing device implantation using a large nationally representative administrative database. They analyzed data from 26,887 adults who were hospitalized with a diagnosis of heart failure and underwent implantation of an ICD or CRT in 2004 or 2005.

The median age of all patients was 70 years. Patients aged 80 and older accounted for 17.5 percent of the procedures (4,694 patients), including 21.1 percent who were older than 85 years and 6.6 percent who were 89 years or older.

Swindle and colleagues reported that in-hospital death rates increased from 0.7 percent among patients younger than 80 years to 1.2 percent among those age 80 to 85 and 2.2 percent among those older than 85 years.

They found that independent predictors of in-hospital mortality included age 80 years or older, elevated comorbidity score, inotrope use and procedure-related complications.

"We found that older patients were less likely to have a concomitant cardiac procedure or a high comorbidity score, suggesting that these patients may be, in fact, somewhat more carefully selected than the younger cohort," the authors wrote. "However, older patients had slightly more complications related to the device procedure.

"Given trends in the demographics of heart failure and the costs of device therapy, additional studies are required to clarify the appropriateness of device implantation in older patients with heart failure, as well as the merits of less invasive options," Swindle and colleagues concluded.