ReviewImplantable Cardioverter Defibrillators (ICDs) in Octogenarians
Introduction
There are only limited options in treatment of life threatening ventricular arrhythmias.
- 1.
Antiarrhythmic drugs: which do not prolong life and have significant side effects.
- 2.
Radiofrequency ablation: which has a limited role in patients who already have an ICD.
- 3.
Implantable Cardioverter Defibrillators (ICDs): provide complete treatment for ventricular tachycardia/fibrillation and bradyarrhythmia including, where indicated, biventricular pacing. ICDs have also been shown to improve survival in many primary and secondary prevention trials; however, ICDs have their own limitations.
With increasing life expectancy, octogenarians are a growing sector of the population.
One in eight ICD implants in the USA are in patients aged 80 years or more, according to a paper published in 2009, and is currently estimated to be one in five [1], [2]. While Australian figures of ICD implants in octogenarians are not available, the number of ICD implants is certainly increasing. This article is an attempt to analyse the available data and attempt to rationalise the use of ICD in octogenarians.
ICDs are implanted for primary and secondary prophylaxis against sudden cardiac deaths. At present, a greater number of ICDs are implanted for primary rather than secondary prophylaxis. In the ACT (Advancement in ICD) trial, 75% of implants were for primary prophylaxis [1].
Currently, the only criterion for ICD implantation for primary prevention is a low ejection fraction. In an editorial on ICDs for primary prevention of sudden death, Dr. Alfred Buxton [3] cites a case of an 83 year-old with EF of 20%, functional class 3 with co-morbidities, referred for primary prevention ICD. There are many such examples in the literature of octogenarians receiving ICDs just because of an EF ≤ 35%. In addition to new implants, another important consideration is ICD replacements in this age group. ICD replacements receive less stringent scrutiny than new implants because of the perception that ICDs are for life.
ACC, AHA and HRS 2008 guidelines for ICD implantation [4] do not specify an age criterion for ICD implantation. These guidelines state that ‘ICD therapy is not indicated for patients who do not have a reasonable expectation of survival with an acceptable functional status for at least one year, even if they meet ICD implantation criteria specified in the Class I, IIa and IIb recommendations’. This statement is frequently used as an endorsement for ICD implantation in octogenarians.
Section snippets
Age Limit in Published Primary and Secondary ICD Trials
Table 1 lists secondary and primary prevention ICD trials. In all these trials the age range of patients was much lower than 80 years. Only a small number of octogenarians are represented in these major trials and there is no randomised trial data of ICDs in this age group. Low number of elderly patients in these trials has led to the use of variable age cut off for subgroup analysis. Age limits of 65, 70 and 75 years have been used as ‘elderly’ for the purpose of subgroup analysis. This
Subgroup Analysis of the ICDs in the Elderly
- (1)
Healy et al. [5] reported on the role of secondary prevention in patients ≥75 years. This was a subgroup analysis of secondary prevention ICD trials, AVID, CASH and CIDS amongst elderly patients aged 75 years and over. They compared 1614 patients under the age of 75 and 252 patients 75 and over. In under the age of 75, survival for ICD patients was much better compared to medical therapy (<0.0001) while there was no statistical difference between the two arms in patients aged 75 and over (P =
Trials Supporting ICD Implantation in the Elderly
- (1)
Strimmel et al. [11] report on 84 patients with a mean age of 82.68 years who had primary and secondary prevention ICDs. They report ‘low complication’ rate of 9.4% with serious complications in 4.8% but no mortality. Half of the patients received CRT-D implants. Survival during the follow-up period was good, 60% at five years but the benefit was mainly in the CRT-D group.
- (2)
Ertel et al. [12] reported on 2967 patients with ICD of which 7.6% were above the age of 80 years. Their mean survival was
Influence of Co-morbidities on Survival in ICD Patients
Octogenarian patients have a higher incidence of co-morbidities. Both heart failure and renal impairment are important determinants of survival in this group. A combination of these and other co-morbidities incrementally increases mortality. Bilchick et al. [14] published a risk model based on more than 45,000 primary prevention ICD patients over the age of 75 years. Heart failure, atrial fibrillation, chronic obstructive pulmonary disease, kidney disease, EF ≤ 20% and diabetes mellitus were
What are the Real Benefits of ICD Implantation?
It is worth noting the real life benefits of ICD implants. In AVID, the largest secondary prevention trial, ICD was not of clinical benefit if the ejection fraction was >35% or <20% and 11 ICD implants resulted in one life saved. In SCD-HeFT the largest primary prevention trial, 15 ICD implants were required to save one life and there was actually no benefit in the non-ischaemic cardiomyopathy group. Tung et al. [15] have stated that not a single trial has demonstrated a statistically
Device Related Adverse Events
In any consideration of ICD implants, particularly in octogenarians, it is worth considering device related adverse events. van Rees et al. [16] performed a systematic review of randomised 11 ICD and seven CRT trials. Average in-hospital mortality was 0.2 for ICD and 0.3% for CRT-D; pneumothorax incidence was 0.9%. For CRT coronary sinus, complication was 2%. There was a significant incidence of lead dislodgement (ICD 1.8% and CRT 5.7%). Other complications included haematomas and bleeding.
Quality vs. Quantity
The impact of ICD shocks on physical and emotional well-being needs to be considered in this age group. There is a 15–20% incidence of inappropriate shocks in ICD patients and the commonest cause of inappropriate shocks is atrial fibrillation [17]. It is an accepted fact that the incidence of atrial fibrillation rises with increasing age. Shocks, particularly repeated shocks, lead to increased mortality, morbidity and hospital admissions. This aspect is seldom discussed with the patients prior
Economics of ICD Implantation
ICDs are expensive and it is necessary to consider economics of ICD implantation [18]. None of the trials have shown improved survival during the first year of ICD implantation. Cost effectiveness data ($35,000–131,000 per QALY) have shown that ICDs are cost effective if the patient survives at least three years after implant.
Ethical Dilemma of Therapy Termination
Both the Heart Rhythm Society and the European Society of Cardiology [19] recommend candid discussion with the patient about ICD deactivation in an appropriate clinical context. A retrospective study of discussion with the next of kin of 100 patients with ICD revealed that ICD deactivation was discussed in only 27% of cases and eight patients received a shock from ICD minutes before death [20], [21]. Modern generation ICDs are small and are frequently forgotten particularly when the patient is
ICD Replacement in Octogenarians
The question of ICD replacement in octogenarians arises quite frequently. In a recent editorial, Kramer et al. [23] recommend a new approach to ICD replacement or battery depletion, lead fractures or infections.
The authors argue that ICD therapy is not a lifelong treatment commitment and comprehensive medical evaluation should occur before ICD replacement. In octogenarians requiring ICD replacement the following need to be considered: whether appropriate ICD therapy has been delivered; what
Conclusion
Octogenarians are a growing section of the community. Initial implantations and replacements in this age group are becoming frequent. There are no randomised control trials or large observational studies and indications are extrapolated from primary and secondary prevention trials where the age group has been in its sixties.
This review is not an argument against ICD implantation in octogenarians but the use of ICDs in octogenarians should be individualised and carefully scrutinised. It should
References (23)
- et al.
Implantable cardioverter-defibrillator prescription in the elderly
Heart Rhythm
(2009) Implantable cardioverter-defibrillators for primary prevention of sudden death: the quest to identify patients most likely to benefit
J Am Coll Cardiol
(2012)- et al.
Effectiveness of implantable defibrillators in octogenarians and nonagenarians for primary prevention of sudden cardiac death
Am J Cardiol
(2011) - et al.
Diminishing proportional risk of sudden death with advancing age: implications for prevention of sudden death
Am Heart J
(2004) - et al.
Prediction of mortality in clinical practice for medicare patients undergoing defibrillator implantation for primary prevention of sudden cardiac death
J Am Coll Cardiol
(2012) - et al.
A critical appraisal of implantable cardioverter-defibrillator therapy for the prevention of sudden cardiac death
J Am Coll Cardiol
(2008) - et al.
Implantation related complications of implantable cardioverter defibrillators and cardiac resynchronization therapy devices
J Am Coll Cardiol
(2011) - et al.
Inappropriate implantable cardioverter-defibrillator shocks: incidence, predictors, and impact on mortality
J Am Coll Cardiol
(2011) - et al.
Implantable cardiac device procedures in older patients; use and in-hospital outcomes
Arch Intern Med
(2010) - et al.
ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines
Circulation
(2008)
Role of implantable defibrillator among elderly patients with a history of life threatening ventricular arrhythmias
Eur Heart J
Cited by (3)
Outcomes Following Implantable Cardioverter-Defibrillator Insertion in Patients 80 Years of Age or Older: A Statewide Population Cohort Study
2024, Canadian Journal of CardiologyImplantable cardioverter-defibrillators and the older patient: the Dutch clinical practice
2022, European Journal of Cardiovascular NursingLatest NICE guidelines on CRT and ICD devices in heart failure may significantly increase implant rates
2015, British Journal of Cardiology