Should ICD Replacement Be Performed in Octogenarians and/or Severe Comorbidities?
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1 Should ICD Replacement Be Performed in Octogenarians and/or Severe Comorbidities? JC Daubert Rennes, France Disclosure Medical devices Speaker Consultant Trial committees EBR + + Impulse Dynamics + Medtronic St Jude Medical Sorin group + + Drug companies Boehringer-Ingelheim + Novartis + Pierre Fabre + + Pfizer + Sanofi-aventis + +
2 ICD in Octogenarians Age, Comorbidity, Life-expectancy and Quality of life are important parameters to consider when discussing indication for implantation or replacement of an ICD ICD indications in octogenarians: Role of comorbidities Device replacement in octogenarians with previously implanted ICD
3 Age-dependency of the Clinical Benefit of ICD The only clinical benefit conferred by the ICD is increased survival by reducing the risk of arrhythmic death in high-risk patients International guidelines from 2006: reasonable expectation of survival with a good functional status for more than 1 year Survival benefit depends on: Age,comorbidities, clinical indication
4 Age-dependency of the Survival Benefit from ICD in Secondary Prevention Indications Pooled data from AVID, CASH and CIDS N=1614 N=252 JS Healey et Al. Eur Heart J 2007; 28:
5 Age-dependency of the Survival Benefit by the ICD Primary prevention In trials, the relative survival benefit conferred by the ICD seems to be independent upon age at implant But, small proportion of elderly patients in trials MADIT II: No interaction of age in the main study AJ Moss et Al. N Eng J Med 2002; 346: Post-hoc comparison of 204 pts>75 yrs and 1024 pts<75 yrs All-cause death: HR at 20.8 months <75yrs: 0.63 ( ; P=0.01) >75yrs: 0.56 ( ; P=0.08) DT Huang et Al J Cardiovasc Electrophysiol 2007
6 MADIT II: No interaction of Age AJ Moss et Al. N Eng J Med 2002; 346:
7 Survival Benefit of ICD The absolute survival benefit conferred by the ICD decreases with increasing age at implant in relation to reduced longevity
8 Survival after ICD Implantation by Age Categories N=502 pts CN Pellegrini et Al. Europace 2008; 10:
9 Survival in ICD recipients stratified by age at implant Age 60-70; N=241 Median S=7 yrs Age>80 yrs ; N=107 Median S: 4.2 yrs BA Koplan et Al. Am Heart J 2006; 152:
10 Defibrillator Implantation in the Elderly Advanced age alone should not be considered a contraindication to ICD implantation or device replacement A cautious and considered approach to ICD implantation in the elderly appears warranted, SM Markowitz J Cardiovasc Electrophy 2010, 21: Based upon Estimates of life expectancy Consideration of comorbidities Procedural risk Patient preferences AE Epstein et Al. ACC/AHA/HRS Guidelines Circulation 2008
11 Growing Prescription of the ICD in the Elderly US National Cardiovascular Data Registry (N=74476 pts) Age (yr) >80 % Indication Primary Secondary 77.5% 22.5% 79.5% 20.5% 80.6% 19.4% 81.3% 18.7% 82.1% 17.9% 79.3% 20.7% AS Epstein et Al. Heart Rhythm 2009; 6:
12 Patient Selection in Very Elderly Impact of Comorbidities Comorbidity has a major impact on survival Prevalence and severity of comorbidities increase with age Approaches to comorbidity? Predictors of risk/combination in randomised trials: ex: MADIT II (Goldenberg et al. JACC 2008; 51: ) The real life: multiparametric approach and Comorbidity scores ex: Charlson index (J Clin Epidemiol 1995; 47: )
13 Impact of Age and Comorbidity on the Survival Benefit from ICD in Primary Prevention 965 pts (51% implanted, 49% non-implanted) F/u= months PS Chan et Al. Circ Cardiovasc Qual Outcomes 2009; 2:16-24
14 Risk stratification for primary prevention Goldenberg et al. JACC 2008; 51:
15 Real Life: Use of Comorbidity Score Charson Comorbidity Score Index Calculator Charlson Comorbidity Index 3 2 1
16 Assessment of the Charlson Comorbidity Score in a CRT-D Population
17 ICD Replacement in Octogenarians Appropriate therapies delivered: Yes/No Reconsider comorbidities Re-estimate life expectancy CRT-D patients: discuss downgrading to CRT-P Patient preferences If replacement decided: «ICD deactivation is ethical and legal» EHRA Expert Consensus Statement on the management of CIED s in patients nearing end of life or requesting withdrawal of therapy L Padeletti et Al. Europace (2010) 12,
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