Arrhythmia Management in the Elderly—Implanted Cardioverter Defibrillators and Prevention of Sudden Death

doi:10.1016/j.cjca.2016.03.009

Canadian Journal of Cardiology

Volume 32, Issue 9, September 2016, Pages 1117-1123

https://doi.org/10.1016/j.cjca.2016.03.009 Get rights and content

Abstract

We present an overview of arrhythmia management in elderly patients as it pertains to implantable cardioverter defibrillator (ICD) therapy and prevention of sudden death. Treatment of arrhythmia in elderly patients is fraught with challenges pertaining to goals of care and patient frailty. With an ever increasing amount of technology available, realistic expectations of therapy need to balance quality and quantity of life. The ICD is an important treatment option for selected patients at risk of ventricular arrhythmia and sudden cardiac death. However, the incidence of sudden death as a percentage of all-cause mortality decreases with age. Studies have reported that 20% of elderly patients might die within 1 year of an episode of life-threatening ventricular arrhythmia, but most because of nonarrhythmic causes. This illustrates the ‘sudden cardiac death paradox,’ with a great proportion of death in elderly patients, even those at risk for ventricular arrhythmias, attributable to medical conditions that cannot be addressed by an ICD. We discuss current practices in ICD therapy in elderly patients, existing evidence from registries and clinical trials, approaches to risk stratification, and important ethical considerations. Although the decision on whether ICD insertion is appropriate in the elderly population remains an area of uncertainty from an evidence-based and ethical perspective, we offer insight on potential clinical and research strategies for this growing population.

Résumé

Nous présentons un aperçu de la prise en charge de l’arythmie chez les patients âgés concernant le traitement par défibrillateur cardioverteur implantable (DCI) et la prévention de la mort subite. Le traitement de l’arythmie chez les patients âgés comporte des défis liés aux objectifs de soins et à la fragilité des patients. Avec l’augmentation constante du nombre de technologies disponibles, des attentes réalistes de traitement doivent équilibrer la qualité et l’espérance de vie. Le DCI est une option importante de traitement pour certains patients exposés au risque d’arythmie ventriculaire et de mort subite d’origine cardiaque. Cependant, la fréquence de mort subite en pourcentage de la mortalité toutes causes confondues diminue avec l’âge. Les études ont signalé que 20 % des patients âgés mourraient d’un épisode d’arythmie ventriculaire mettant en danger la vie au cours de la 1^re année, mais surtout en raison de causes non liées à l’arythmie. Cela illustre le « paradoxe de la mort subite d’origine cardiaque », soit une grande proportion de décès chez les patients âgés, même chez ceux exposés au risque d’arythmies ventriculaires attribuables à des états de santé qui ne peuvent pas être traités par DCI. Nous discutons des pratiques actuelles en matière de traitement par DCI chez les patients âgés, des données probantes existantes issues des registres et des essais cliniques, des approches de stratification du risque et des considérations éthiques importantes. Bien que la décision sur la question de savoir si l’implantation du DCI est appropriée chez la population âgée conserve une zone d’incertitude d’un point de vue éthique et factuel, nous donnons un aperçu sur les stratégies cliniques et de recherche potentielles pour cette population grandissante.

Section snippets

Current Practices in ICD Therapy

The indication for insertion of an ICD is classified as either primary prevention of SCD, largely in the chronic heart failure population with reduced ejection fraction (EF), or as secondary prevention of SCD in patients who have survived a shockable cardiac arrest or sustained ventricular tachycardia in the context of structural heart disease. Insertion of an ICD can entail significant risks including periprocedural and late complications such as infection and pocket erosion, inappropriate

Generator Change

The 2010-2011 National Registry data¹³ showed that generator changes constituted 40% of all ICD procedures. Patients who underwent generator replacement had a mean age of 69.5 ± 12.5 years, older than patients with new ICDs, and mean EF was higher in patients with new ICDs at 32.7% ± 13.4% compared with 28.9% ± 11.7%. Accordingly, the discussion of ICD appropriateness in the elderly and frail patient has recently progressed to include the issue of generator replacement. ICD generator

Existing Evidence Regarding Device Therapy in the Elderly Population

The 2 major randomized control trials of primary prevention ICD therapy are the Multicenter Automatic Defibrillator Implantation Trial (MADIT II)¹⁹ and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) trial.² These 2 trials showed that a selected population with few comorbidities and mild to moderate heart failure symptoms have a mortality reduction with ICD therapy. Mortality was reduced by 23% over 45.5 months in the ischemic cardiomyopathy population with EF < 30%¹⁹ and by 21% over

Risk Stratification in ICD Decisions

Since the first ICD implant in 1980, numerous technologic advances have been made in device size and weight, arrhythmia detection, battery technologies, monitoring capabilities, and lead design, which have allowed wider use and greater patient acceptance.²⁴ However, appropriate patient selection for ICD therapy continues to be sought, from a safety and efficacy viewpoint. Availability and ease of access to ICD therapy should not be a driving factor in complicated ICD decisions. This is

Frailty and ICD Implantation

Frailty is associated with age and represents a state of vulnerability. It is a reflection of biologic rather than chronologic age. Although there is an increased incidence of frailty among the elderly population, the 2 terms are not equivalent. Rockwood et al.³¹ have developed the Clinical Frailty Scale, a 7-point scale ranging from robust health (1) to complete functional dependence on others (7). This has been validated against the Frailty Index, an assessment of 70 clinical deficits,

Cardiac Resynchronization Therapy

CRT is an important consideration for improving quality of life in heart failure patients. Pacing the left ventricle through the coronary sinus coordinates ventricular contraction, increases cardiac output, improves symptoms of heart failure, and reduces hospitalization in many patients. Recent evidence has also shown a survival benefit in patients with mild to moderate heart failure and EF < 30%.³⁴ Studies have documented safety and efficacy of CRT in elderly patients.35, 36 Those older than

Ethical Considerations of Device Therapy in the Elderly Patient

There are multiple ethical considerations that have a role in ICD decisions for the elderly and frail patient. These include balancing survival with quality of life, an advance discussion regarding the nonmandatory nature of generator replacements according to changes in health, and the possibility of deactivating therapies in end of life circumstances. These discussions are particularly important in the elderly population because mortality from nonarrhythmic causes is prevalent.

Patients must

Future Clinical Directions

As the number of elderly patients being considered for ICD implantation rises, physicians need to be vigilant in advocating for their patients and for the health care system and resources. Existing guidelines provide minimal guidance on how best to care for elderly patients apparently eligible for ICD therapy. The age of a patient should probably not be a major factor alone, but assessment of frailty and overall prognosis are important. The following system approaches might be helpful to

Conclusions

Elderly and frail patients referred for ICD therapy to reduce the risk of SCD pose several challenges. Prospective evidence from the literature on ICD benefit in the elderly and frail patient is lacking and would be a welcome addition to the literature. In the meantime, decisions must be individualized among patients according to their unique health states and risks. Numerous ethical issues can arise and are best addressed with an organized system of frank discussions between the patient, their

Funding Sources

Supported by Western University Program of Experimental Medicine.

Disclosures

The authors have no conflicts of interest to disclose.

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ReviewArrhythmia Management in the Elderly—Implanted Cardioverter Defibrillators and Prevention of Sudden Death

Abstract

Résumé

Section snippets

Current Practices in ICD Therapy

Generator Change

Existing Evidence Regarding Device Therapy in the Elderly Population

Risk Stratification in ICD Decisions

Frailty and ICD Implantation

Cardiac Resynchronization Therapy

Ethical Considerations of Device Therapy in the Elderly Patient

Future Clinical Directions

Conclusions

Funding Sources

Disclosures

Am Heart J

Indian Pacing Electrophysiol J

Heart Rhythm

J Am Coll Cardiol

J Am Coll Cardiol

Heart Rhythm

Am Heart J

J Am Coll Cardiol

Heart Rhythm

Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators

N Engl J Med

Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure

N Engl J Med

Role of the implantable defibrillator among elderly patients with a history of life-threatening ventricular arrhythmias

Eur Heart J

Implantable cardiac device procedures in older patients: use and in-hospital outcomes

Arch Intern Med

2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society

J Am Coll Cardiol

Canadian Cardiovascular Society/Canadian Heart Rhythm Society position paper on implantable cardioverter defibrillator use in Canada

Can J Cardiol

Improved survival associated with prophylactic implantable defibrillators in elderly patients with prior myocardial infarction and depressed ventricular function: a MADIT-II substudy

J Cardiovasc Electrophysiol

Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Antiarrhythmics vs Implantable Defibrillator study. Cardiac Arrest Study Hamburg. Canadian Implantable Defibrillator Study

Eur Heart J

Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy

N Engl J Med

Sex differences in implantable cardioverter-defibrillator outcomes: findings from a prospective defibrillator database

Ann Intern Med

Survival after implantable cardioverter-defibrillator implantation in the elderly

Circulation

Real world effectiveness of primary implantable cardioverter defibrillators implanted during hospital admissions for exacerbation of heart failure or other acute co-morbidities: cohort study of older patients with heart failure

BMJ

Predictors of short-term complications after implantable cardioverter-defibrillator replacement: results from the Ontario ICD Database

Circ Arrhythm Electrophysiol

Complication rates associated with pacemaker or implantable cardioverter-defibrillator generator replacements and upgrade procedures: results from the REPLACE registry

Circulation

Outcomes of elderly recipients of implantable cardioverter defibrillators

Pacing Clin Electrophysiol

Review
Arrhythmia Management in the Elderly—Implanted Cardioverter Defibrillators and Prevention of Sudden Death