Abstract 14804: Complications and Mortality Following CRT-D versus ICD Implants in Older Medicare Beneficiaries

Abstract

Introduction: Despite growing numbers of older HF patients, clinical trials of implantable defibrillators (ICDs) and cardiac resynchronization therapy (CRT) rarely include older patients (≥75 yrs). Hypotheses: (1) Among Medicare beneficiaries, older CRT-D patients have a higher risk of procedure-related complications than older ICD patients. (2) Compared with older ICD patients, older CRT-D patients have lower risk of death. Methods: We identified Medicare beneficiaries with HF and reduced LVEF who underwent ICD or CRT-D implant based on CPT codes (1/2008-8/2015) by age group (65-74, 75-84, and 85+). After matching device groups with inverse probability weighting (IPW), we estimated the comparative hazard ratio (HR) of death by age group and device type using a Cox proportional hazards model. Results: Compared with the ICD group, the CRT-D group was older and more likely to be white and female and have atrial fibrillation; CRT-D patients were less likely to have ischemic heart disease. Use of guideline directed medical therapy was similar between groups. In all age groups, complications were more common in the CRT-D group. IPW was successful, and after matching, the HR for death was lower in the CRT-D versus the ICD group; this finding was most pronounced in the 85+ age group in which the HR for death in the CRT-D versus ICD group was 0.76 (95% CI 0.64-0.88). (Table) Conclusions: Procedure-related complications in older HF patients were higher in CRT-D versus ICD patients and generally increased with age. Overall high post-implant mortality in ICD patients (± CRT) highlights the difficulty in assessing competing mortality risk when considering patients for an ICD especially in the oldest patients in whom clinical trial data are absent. However, in matched Medicare beneficiaries, CRT-D was associated with a lower risk of mortality in all age groups compared with ICD alone. These findings support the use of CRT in eligible older patients undergoing ICD implantation.