Evaluation of primary prevention ICD efficacy in late elderly heart failure patients: a multicenter study
A Brin, O Koren, A Demitriev, M Abo-Alasal, M Glikson, A Katz, A Shauer, M Rav-AchaAbstract
Introduction
The benefit of primary prevention implantable cardioverter defibrillator (ICD) in heart failure (HF) patients aged ≥75 years, particularly those with significant non-cardiac comorbidities, is questionable. We aimed to evaluate the clinical yield of primary prevention ICD in late-elderly HF patients.
Method
A multicenter, retrospective cohort study of all HF patients aged ≥75 years who underwent prophylactic ICD or cardiac resynchronization therapy defibrillator implantation for primary prevention at three medical centers between 2000-2020. Study endpoints included: a) First appropriate therapy event (anti-tachycardia pacing or shock) for ventricular arrhythmia; b) Mortality without prior appropriate device therapies, a surrogate for ICD non-benefit; c) Comparing Madit Risk Stratification Score (MRSS) and Charlson Comorbidity Index (CCI) with mortality endpoint.
Results and discussion
A total of 140 HF patients were included, mean age at implant was 79.1±3.1 years and 69.2% had ischemic HF etiology. 116 (82.8%) patients had no appropriate therapy during 60 (IQR 31-81) months follow-up, of which 99/116 (86.1%) died without any prior appropriate therapy. Twenty-four (17%) patients received appropriate device therapy during follow-up; time to first therapy was 19.5 (IQR 11.2-55.2) months. Importantly, Kaplan–Meier survival curves did not differ between the subgroup with appropriate device therapy and the subgroup without any appropriate therapy (log-rank p=0.351). Evaluation of the 81 cases with sufficient data for score calculation showed that all patients who died without appropriate therapy were classified as intermediate or high risk by the MRSS, and all were high-risk for early mortality by the CCI.
Conclusion
In late-elderly HF patients, the efficacy of prophylactic ICD appears limited, as only 17% experienced an appropriate device therapy, while the majority had no appropriate therapy during ~4.8 years follow-up, and the survival of those who apparently benefited from appropriate device therapy was not improved. The CCI and MRSS mortality indexes predicted most of these deaths. Thus, primary prevention ICD in late-elderly HF patients should be individualized based on patient comorbidities, considering the CCI and MRSS scores for death despite ICD.