Is it time to consider a “time-out” before primary prevention implantable cardioverter-defibrillator placement in currently or recently hospitalized older patients with heart failure?

Abstract

BackgroundTrajectories of mortality after primary prevention implantable cardioverter-defibrillator (ICD) placement for older patients with heart failure during or soon after acute hospitalization have not been assessed. ObjectiveThe purpose of this study was to compare trajectories of mortality after primary prevention ICD placement during or soon after acute cardiac or non-cardiac hospitalization. MethodsWe identified older patients with heart failure undergoing primary prevention ICD placement using 20% Medicare data (2008–2018). Placement settings were as follows: (1) Current-H—during current hospitalization, (2) Recent-H—within 90 days of hospitalization, or (3) Chronic stable. Hospitalization was categorized as cardiac vs non-cardiac. Interval mortality rates and hazard ratios (HRs) using Cox regression were estimated at 0–30, 31–90, and 91–365 days after ICD placement. ResultsOf the 61,710 patients (mean age 76 years; 35% female; 85% white), 19% (11,947), 25% (15,147), and 56% (34,616) had ICDs in Current-H, Recent-H, and Chronic stable settings. Mortality rates (per 100 person-years) were highest during 0–30 days, with 38 (34–42) and 22 (19–24) for Current-H and Recent-H, which declined to 21 (20–22) and 16 (15–17) during 91–365 days, respectively. Compared to Chronic stable, HRs were highest during 0–30 days post–ICD placement (5.5 [4.5–6.8] for Current-H and 3.4 [2.8–4.2] for Recent-H) and decreased during 91–365 days (2.0 [1.8–2.1] for Current-H and 1.6 [1.5–1.7] for Recent-H). HR pattens were similar for cardiac and non-cardiac hospitalizations. ConclusionPrimary prevention ICD placement during or soon after hospitalization for any reason was associated with worse mortality with diminishing risks after 90 days. Hospitalization likely identifies a sicker population in whom early mortality with or without ICD may be higher. Our results support careful consideration regarding ICD placement during the 90 days after hospitalization.