Device therapy in the elderly heart failure patient: what is the evidence?

Abstract

As the population ages, an increasing number of cardiac devices are being implanted in older patients. In the USA, for example, over 50% of pacemaker recipients are 70 years of age or older [1], and more than 40% of implantable cardio verter–defibrillators (ICDs) and cardiac resynchronization therapy (CRT) devices are inserted in patients in this age group, while 15–20% of ICD and CRT recipients are 80 years of age or older [2]. However, despite the high utilization of these devices in elderly patients, data from randomized clinical trials (RCTs) to support their use in octogenarians are sparse (in the case of ICDs) to nonexistent (in the case of CRT). Moreover, it has recently been shown that, perhaps not surprisingly, morbidity and mortality related to device implantation are substantially higher in patients 80 years or older than in younger device recipients [3]. It is thus appropriate to take a step back and pose the question: what is the current evidence base regarding the benefits and risks of ICDs and CRT in octogenarians and beyond? Implantable cardioverter–defibrillators The efficacy of ICDs, in terms of the capacity of the devices to recognize and successfully terminate life-threatening ventricular tachyarrhythmias, is similar in older and younger patients. However, since the incidence and prevalence of supraventricular tachyarrhythmias, especially atrial fibrillation, increase strikingly with age, elderly patients are at increased risk for ‘inappropriate’ ICD shocks triggered by non-life-threatening arrhythmias [4]. This is clinically important, since patients who experience one or more ICD shocks, whether appropriate or inappropriate, report reduced quality of life [5]. Moreover, whereas younger patients may accept a modest reduction in quality of life in exchange for prolonged survival, older patients often (although not invariably) consider quality of life to be of equal or greater importance than length of life [6].