Survival after implantable cardioverter-defibrillator implantation in the elderly
Yung D, Birnie D, Dorian P, Healey JS, Simpson CS, Crystal E, Krahn AD, Khaykin Y, Cameron D, Chen Z, Lee DS. Circulation. 2013; 127(24):2383-92.
Background — The benefit of implantable cardioverter-defibrillators (ICDs) among elderly patients is controversial and may be attenuated by non-arrhythmic death. The authors examined the impact of age on device-delivered therapies and outcomes after primary or secondary prevention ICD.
Methods and Results — In a prospective, inclusive registry of 5399 ICD recipients in Ontario, Canada (February 2007-September 2010), device-delivered therapies and complications were determined at routine clinic visits. Among primary prevention ICD recipients aged 18-49 (n=317), 50-59 (n=769), 60-69 (n=1336), 70-79 (n=1242), and ≥80 (n=275) years, respectively, mortality increased with age: 2.1, 3.0, 5.4, 6.9, and 10.2 deaths per 100 person-years, respectively (p<0.001). Secondary prevention ICD recipients aged 18-49 (n=114), 50-59 (n=244), 60-69 (n=481), 70-79 (n=462), and ≥80 (n=159) years also exhibited increasing mortality: 2.2, 3.8, 6.1, 8.7, and 15.5 deaths per 100 person-years (p<0.001). However, rates of appropriate shock were similar across age groups: from 6.7 (18-49 years) to 4.2 (≥80 years) per 100 person-years after primary (p=0.139) and from 11.4 (18-49 years) to 11.9 (≥80 years) per 100 person-years after secondary prevention ICDs (p=0.993). Covariate-adjusted competing risk analysis demonstrated higher risk of death (p-trend <0.001 for both primary and secondary prevention), but no significant decline in appropriate shocks with older age after primary (p=0.130) or secondary (p=0.810) prevention defibrillators.
Conclusions — While elderly patients exhibited increased mortality after ICD implantation, rates of appropriate device shocks were similar across age groups. Decisions regarding ICD candidacy should not be based on age alone, but should consider factors that predispose to mortality despite defibrillator implantation.
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