Abstract
PurposePatients at high non-sudden cardiac death risk may gain no significant benefit from implantable cardioverter-defibrillator (ICD) therapy. A number of approaches have been proposed to identify these patients, including single clinical markers and more complex scoring systems. The aims of this study were to use the proposed scoring systems to (1) establish how many current ICD recipients may be too high risk to derive significant benefit from ICD therapy and (2) evaluate how well the scoring systems predict short-term mortality in an unselected ICD cohort.MethodsWe performed a single-centre retrospective observational study of all new ICD implants over 5 years (2009–2013). We used four published scoring systems (Bilchick, Goldenberg, Kramer and Parkash) and serum urea to identify new ICD recipients whose short-term predicted mortality risk was high. We evaluated how well the scoring systems predicted death.ResultsOver 5 years, there were 406 new implants (79% male, mean age 70 (60–76), 58% primary prevention). During a follow-up of 936 ± 560 days, 96 patients died. Using the scoring systems, the proportion of ICD recipients predicted to be at high short-term mortality risk were 5.9% (Bilchick), 34.7% (Goldenberg), 7.4% (Kramer), 21.4% (Parkash) and 25% (urea, cut-off of >9.28 mM). All four risk scores predicted mortality (P < 0.0001); however, none outperformed urea for the prediction of 1- or 3-year mortality.ConclusionsUsing published scoring systems, a significant proportion of current ICD recipients are at high short-term mortality risk. Although all four scoring systems predicted mortality during follow-up, none significantly outperformed serum urea.
Highlights
The implantable cardioverter-defibrillator (ICD) is a highly effective therapy for the prevention of sudden cardiac death (SCD) in high-risk patients [1]
Using published scoring systems, a significant proportion of current ICD recipients are at high short-term mortality risk
The presence or absence of specific clinical variables such as atrial fibrillation (AF), diabetes, peripheral arterial disease (PAD) and chronic obstructive pulmonary disease at the time of ICD implant were determined by review of the clinical records
Summary
The implantable cardioverter-defibrillator (ICD) is a highly effective therapy for the prevention of sudden cardiac death (SCD) in high-risk patients [1]. Many patients whose risk of short-term mortality following device implantation is high may gain no significant benefit from an ICD, irrespective of their SCD risk Such patients, who have significant non-cardiac comorbidity or advanced heart failure, typically die of a non-cardiac cause or pump failure [2, 3]. These patients are important as they are exposed to all of the risks of ICD therapy, without the opportunity to gain significant mortality benefit. A number of complex scoring systems have been proposed to identify these high-risk patients [4,5,6,7] (Table 1). It is unclear which scoring system is most useful and whether any add incremental value compared to a single risk marker alone (serum urea)
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