Implantable cardioverter defibrillators among elderly survivors of out-of-hospital cardiac arrest

Abstract

Abstract Background Survivors of out-of-hospital cardiac arrest (OHCA) with a shockable rhythm are at increased risk of cardiac arrest, and clinical practice guidelines recommend placement of an implantable cardioverter defibrillator (ICD) in the absence of a reversible cause and an expected meaningful survival of at least one year. Contemporary data on the prevalence of secondary prevention ICD placement among OHCA survivors remain limited. Purpose Examine patterns of secondary prevention ICD implantation in survivors of OHCA due to a shockable rhythm in a large national registry. Methods Using 2013-2019 data from the Cardiac Arrest Registry to Enhance Survival (CARES) linked to Medicare files, we identified 3,226 patients aged >65 years who survived to discharge following OHCA due to an initial shockable rhythm from January 1, 2013 to December 31, 2019. Patients with severe neurological disability, prior history of cancer, and those discharged to hospice were excluded. We calculated cumulative prevalence of ICD implantation at discharge, 90 days, and 6 months post cardiac arrest. Multivariable hierarchical regression models with random hospital effects were used to determine the adjusted association of patient characteristics with ICD implantation and quantify the extent of variation in ICD implantation across sites, using a median odds ratio (OR) and 95% confidence interval (CI). Results Patients’ mean age was 72.2 years; 23.5% were women, 10% were Black and 4% Hispanic. Among 3,226 OHCA patients, 997 (30.9%) received an ICD before discharge; 1,266 (39.2%) received an ICD within 90 days of cardiac arrest, and 1,287 (39.9%) received an ICD by 6 months. After adjusting for differences in demographics and co-morbidities, the odds of receiving an ICD at discharge were significantly lower in patients aged 85 years and older, women, patients with prior history of stroke or diabetes, patients who presented with acute myocardial infarction (P<0.05 for all). There was no significant difference in ICD implantation by race and ethnicity (P=0.94) (Table 1). Even after adjusting for patient demographics, co-morbidities, and presentation with acute myocardial infarction, there was large variation in hospital rate of ICD implantation at discharge, with a median odds ratio of 1.65 (95% CI 1.41-1.86). Conclusion Fewer than 1 in 3 patients with OHCA due to a shockable rhythm are discharged with a secondary prevention ICD. Although implantation of ICD was associated with patient variables, there was no difference in ICD implantation by race and ethnicity. There was large variation across hospitals in ICD implantation even after adjusting for patient variables highlighting an opportunity for improving post-arrest management of cardiac arrest survivors.