Impact of clinical frailty on the outcome of pacing for bradyarrhythmias in a district general hospital population

Abstract

Abstract Background and Aims There is good evidence for mortality with increasing age, heart disease, peripheral vascular disease, pulmonary disease and renal disease in implantable cardiac defibrillators. And while multimorbid states and fragility are considered in decision to offer for more complex cardiac electronic device implants1,2 we aimed to characterise how much frailty and co-morbidities impact mortality in patients receiving simple bradyarrhythmia cardiac pacing device implants. Methods Retrospective examination of 700 consecutive novel standard bradyarrhythmia cardiac device implants (DDD, VVI, AAI) at Walsall Manor Hospital between 01/01/2016 to 28/02/2021 was undertaken through the electronic patient record. Patients’ frailty was calculated with Rockwood Frailty Score (RFS) and comorbidities at the time of implant recorded.3 Prospective follow up until 14/02/2023 was conducted, allowing at least a 2 year follow-up for all surviving patients. Results were analysed with Kaplan-Meier survival curves and Hazard Ratios (HR) and Risk Ratios (RR). Results Mean age of implant was 78.4±10.3 with mortality rate of 87/700 (12.4%) at one year and total 282/700 (40.3%). Overall, a RFS of 5 or more was associated with death overall HR 2.05 (95% CI 1.61-2.60) and 3.42 (95% CI 2.23-5.24) within 1 year (Fig. 1). Heart failure (OR 2.38, 95% CI 1.59-3.57), valvular heart disease (OR 3.19, 95% CI 2.08-4.89), atrial fibrillation/flutter (OR 1.44, 95% CI 1.09-1.91), chronic kidney disease (OR 1.89, 95% CI 1.296-1.72), malignancy (OR 1.91, 95% CI 1.08-3.36) were important co-morbidities of death within one year of implant. Ischemic heart disease and cognitive impairment including dementia demonstrated a trend towards worse mortality but did not reach significance (Fig. 2). Conclusion High frailty score as well as comorbidities including heart failure, valvular heart disease, atrial fibrillation, chronic kidney disease and malignancy indicate increased risk of early death after novel implant of bradycardia cardiac pacing device implants. Although advanced age alone is not a barrier to offer pacing, consideration should be given to advanced frailty and multimorbid states which may detract from any perceived benefit bradyarrhythmia correction may offer. These data have impacted our shared decision making during the consent process with our patients and in our multidisciplinary team discussions.Figure 1Figure 2