Use Of Primary Prevention Implantable Cardioverter-defibrillators Research Articles

Association Between Use of Primary-Prevention Implantable Cardioverter-Defibrillators and Mortality in Patients With Heart Failure: A Prospective Propensity Score-Matched Analysis From the Swedish Heart Failure Registry.

Most randomized trials on implantable cardioverter-defibrillator (ICD) use for primary prevention of sudden cardiac death in heart failure with reduced ejection fraction enrolled patients >20 years ago. We investigated the association between ICD use and all-cause mortality in a contemporary heart failure with reduced ejection fraction cohort and examined relevant subgroups. Patients from the Swedish Heart Failure Registry fulfilling the European Society of Cardiology criteria for primary-prevention ICD were included. The association between ICD use and 1-year and 5-year all-cause and cardiovascular (CV) mortality was assessed by Cox regression models in a 1:1 propensity score-matched cohort and in prespecified subgroups. Of 16 702 eligible patients, only 1599 (10%) had an ICD. After matching, 1305 ICD recipients were compared with 1305 nonrecipients. ICD use was associated with a reduction in all-cause mortality risk within 1 year (hazard ratio, 0.73 [95% CI, 0.60-0.90]) and 5 years (hazard ratio, 0.88 [95% CI, 0.78-0.99]). Results were consistent in all subgroups including patients with versus without ischemic heart disease, men versus women, those aged <75 versus ≥75 years, those with earlier versus later enrollment in the Swedish heart failure registry, and patients with versus without cardiac resynchronization therapy. In a contemporary heart failure with reduced ejection fraction population, ICD for primary prevention was underused, although it was associated with reduced short- and long-term all-cause mortality. This association was consistent across all the investigated subgroups. These results call for better implementation of ICD therapy.

Gender differences in the use of primary prevention ICDs in New Zealand patients with heart failure

ObjectiveWomen have been under-represented in randomised clinical trials for primary prevention implantable cardioverter defibrillators (ICDs), and there are concerns about the efficacy of devices between genders. Our study aimed to...

Long-term follow-up of implantable cardioverter-defibrillators in adult congenital heart disease patients: indications and outcomes.

Ventricular arrhythmias are a major cause of mortality in adult congenital heart disease (ACHD) patients. The European Society of Cardiology guidelines state that implantable cardioverter-defibrillators (ICD) should be considered in patients with congenital heart disease following spontaneous sustained ventricular tachycardia (VT) or cardiac arrest and in patients at presumed high risk. This study sought to analyse the circumstances in which ACHD patients received ICD and to assess outcomes of ICD implantation, including therapies delivered and the rate of complications. A retrospective review was performed of all adult patients with congenital heart disease undergoing ICD implant between 2000 and 2014, in a large quaternary referral centre with over 4000 adults with congenital heart disease under active follow-up. Demographics: 42 patients with congenital heart disease had ICD implants: 55% male; age range 21-71 years and mean age 45 years. Mean age at implantation of ICD was 41 years. Mean follow-up was 5 years. Diagnosis: 50% of patients had repaired tetralogy of Fallot (TOF). Twelve per cent of patients had repaired transposition of the great arteries. Reason for ICD: 15 patients (35.7%) received ICD after sustained VT. Eleven patients (26.2%) received ICD after cardiac arrest. Sixteen (38%) had ICD implanted as primary prophylaxis. Outcome: Since implantation, six patients received an appropriate full-output shock for VT from ICD. Nineteen (45%) patients suffered significant complications (inappropriate shocks 11, inappropriate anti-tachycardia pacing resulting in VF 1, infection requiring extraction 3, lead abnormalities 3, and pneumothorax 1). Equal proportions of primary and secondary prevention patients received appropriate shocks. Most patients had ICD for secondary prevention (62%), and the majority had repaired TOF. There was a 2.9% annual appropriate shock rate. However, there was a high incidence of complications with more than a third suffering a major complication (9% per annum). The risks and benefits of ICD implantation are patient and disease specific, and must be clearly discussed prior to implantation. Further research is warranted into the use of primary prevention ICD in ACHD and in alternatives to ICD such as ablation in specific patient groups.

Primary Prevention Implantable Cardioverter-Defibrillators and Survival in Older Women

ObjectivesThe purpose of this study was to assess the benefit of primary prevention implantable cardioverter defibrillators (ICDs) in women. BackgroundClinical trials of primary prevention ICDs enrolled a limited number of women. MethodsUsing a propensity score method, we matched 490 women ≥65 years of age who received an ICD during a hospitalization for heart failure in the National Cardiovascular Data Registry ICD Registry from January 1, 2006, through December 31, 2007, to 490 ICD-eligible women without an ICD hospitalized for heart failure in the Get With The Guidelines for Heart Failure database from January 1, 2006, through December 31, 2009. The primary endpoint was all-cause mortality obtained from the Medicare Claims Database. An identical analysis was conducted in men. ResultsMedian follow-up for patients with an ICD was 4.6 years versus 3.2 years for patients with no ICD. Compared with women with no ICD, those with an ICD were younger and less frequently white. In the matched cohorts, the survival of women with an ICD was significantly longer than that of women without an ICD (adjusted hazard ratio: 0.79, 95% confidence interval: 0.66 to 0.95; p = 0.013). Similarly, men with an ICD had longer survival than men without an ICD (adjusted hazard ratio: 0.73, 95% confidence interval: 0.65 to 0.83; p < 0.0001). There was no interaction between sex and the presence of an ICD with respect to survival (p = 0.44). ConclusionsAmong older women with left ventricular dysfunction, a primary prevention ICD was associated with a significant survival benefit that was nearly identical to that seen in men. These findings support the use of primary prevention ICDs in eligible patients regardless of sex.

7 Long-Term Follow-Up of ICD in Adult Congenital Heart Disease Patients: A Large Single Centre Experience

Background Sustained ventricular tachycardia (VT) and cardiac arrest are a major cause of mortality in adult congenital heart disease patients. Implantable cardioverter defibrillators (ICD) can protect against this. ESC guidelines state that ICDs should be considered following spontaneous sustained VT and in all survivors of cardiac arrest; and in patients at high risk of this. Methods All ICD recipients in the GUCH database were included (n = 40). Medical records were retrospectively analysed. Data were collected on initial diagnosis, reason for ICD implantation, date of implantation, complications, and ICD discharges between the time of implant and data collection. Results Demographics: 55% of patients were male; age range 20–71 years, mean age 45 years, median age 43 years. Mean age at implantation of ICD was 41 years. Mean follow up was 4.2 years (median 2.5 years). Diagnosis: 47.5% of patients had repaired Tetralogy of Fallot (TOF). 15% of patients had transposition of the great arteries. Reason for ICD: Fifteen patients (37.5%) received ICD after symptomatic sustained VT. One patient underwent catheter ablation of VT before ICD was implanted. Eleven patients (27.5%) received ICD after cardiac arrest. Fourteen (35%) had an ICD implanted as primary prophylaxis. Outcome: Since implantation, five patients received an appropriate full-output shock for VT from ICD. 11 (27.5%) patients suffered significant complications (inappropriate shocks secondary to atrial arrhythmias 7, infection requiring extraction 3 and lead fracture 1). Of inappropriate shocks, 6 were due to atrial flutter or fibrillation and 1 due to oversensing. Tetralogy of Fallot patients had comparatively much higher complication rate than patients of other diagnoses (42% vs 14%). Similar proportions of primary and secondary prevention patients received appropriate shocks from the device (14% vs 11.5%). Conclusions Most patients had ICD for secondary prevention (a total of 65%) due to sustained VT or cardiac arrest, the majority being in patients with repaired Fallot’s tetralogy. There was a 3.0% annual appropriate shock rate. However, there was a high incidence of complications with nearly a third suffering a major complication (6.5% per annum); a risk that was increased for Tetralogy of Fallot patients. The rate of adverse effects from ICD identified here is similar to that previously reported for hypertrophic cardiomyopathy patients. The risks and benefits of ICD implantation must be clearly discussed with patients prior to implantation. There was a near-equal incidence of appropriate therapy in both primary and secondary prevention groups. Further research is warranted into the use of primary prevention ICDs in adult congenital heart disease.

Regional Variation in the Use of Implantable Cardioverter-Defibrillators for Primary Prevention

Although the use of implantable cardioverter-defibrillators (ICDs) for the primary prevention of sudden cardiac death varies by sex, race, and hospital, geographic variation in ICD use remains unexplored. Our objective was to quantify regional variations in the utilization of primary prevention ICDs in the United States, and to evaluate if an association exists between utilization and physician supply or the proportion of patients meeting the trial inclusion criteria. This is a cross-sectional analysis among the Medicare, fee-for-service population from the National Cardiovascular Data Registry. Using hospital referral regions, we calculated the age-, sex-, and race-adjusted rates of ICD placement for each region and assessed the correlation between these rates and (1) physician supply and (2) the proportion of patients meeting trial inclusion criteria. Substantial variation was found across quintiles of rate ratios of ICD implantation, ranging from 0.39 to 1.77 (compared with a national mean rate of 1.0). This ratio was not correlated with the supply of cardiologists (R(2)=0.01), electrophysiologists (R(2)=0.01), or with the proportion of patients meeting trial inclusion criteria (R(2)<0.01). Over all, 13% of all patients receiving ICDs did not meet trial criteria. Marked geographic variation in the use of primary prevention ICDs exists across the United States that is not correlated with physician supply. Although >1 in 10 patients received ICDs outside of trial criteria, this potential overuse did not explain the variation. Future studies should consider underuse or misuse of primary prevention ICDs as causes of geographic variation.