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Original Articles

Impact of Age and Medical Comorbidity on the Effectiveness of Implantable Cardioverter-Defibrillators for Primary Prevention

Paul S. Chan, MD, MSc; Brahmajee K. Nallamothu, MD, MPH; John A. Spertus, MD, MPH; Frederick A. Masoudi, MD, MSPH; Cheryl Bartone, BS, MPH; Dean J. Kereiakes, MD and Theodore Chow, MD

From the Mid-America Heart Institute and University of Missouri (P.S.C., J.A.S.), Kansas City, Mo; The VA Ann Arbor Health Services Research and Development Center of Excellence and the University of Michigan Division of Cardiovascular Medicine (B.K.N.), Ann Arbor, Mich; Division of Cardiology (F.A.M.), Denver Health Medical Center and the University of Colorado at Denver and Health Sciences Center, Denver, Colo; and The Lindner Clinical Trial Center at the Christ Hospital and the Ohio Heart and Vascular Center (C.B., D.J.K., T.C.), Cincinnati, Ohio.

Correspondence to Paul Chan, MD, MSc, Mid-America Heart Institute, 5th Floor, 4401 Wornall Road, Kansas City, MO 64111. E-mail paul1chan{at}yahoo.com

Received July 14, 2008; accepted October 28, 2008.

Background— Although implantable cardioverter-defibrillators (ICDs) reduce mortality in primary prevention patients with left ventricular systolic dysfunction, recent studies have questioned their overall role in clinical practice, especially in older patients and those with major comorbid conditions.

Methods and Results— In a prospective cohort of 965 patients with ischemic and nonischemic cardiomyopathies (ejection fraction 35%) and no prior ventricular arrhythmias, we compared long-term mortality in patients who did (n=494 [51%]) and did not receive ICDs over a mean follow-up period of 34±16 months. Using a landmark analysis, multivariable Cox proportional hazards models that included propensity scores for ICD implantation assessed the relationship between ICD therapy and mortality in the entire cohort and by age and the presence of major comorbid conditions. Data from these analyses were then used as inputs in a Markov model to generate incremental cost-effectiveness ratios for ICD therapy. Patients who received ICDs were similar in age and prevalence of most major comorbid conditions, including symptomatic heart failure. After multivariable adjustment, ICD therapy was associated with a 31% lower risk for all-cause mortality (adjusted hazard ratio, 0.69; 95% CI, 0.50 to 0.96; P=0.03). The relationship between ICD therapy and lower all-cause mortality was consistent after stratification by age (<65, 65 to 74, and 75), ischemic etiology, ejection fraction (>25% versus 25%), and the presence of major comorbid conditions (probability values for all interactions >0.05). Incremental cost-effectiveness ratios for ICD therapy were similar between patients aged 75 years and younger patients but rose slightly in those with multiple comorbid conditions.

Conclusions— Routine use of ICDs in primary prevention patients with left ventricular systolic dysfunction was associated with lower all-cause mortality, even among older patients and those with major comorbid conditions. Although their use needs to be individualized, our findings suggest that these groups should not be routinely excluded from ICD treatment.

Key Words: implantable cardioverter-defibrillator • primary prevention • health outcomes

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CLINICAL PERSPECTIVE

The online-only Data Supplement is available at http://circimaging.ahajournals.org/cgi/content/full/CIRCIMAGING.108.807123/DC1.

Guest editor for this article was William S. Weintraub, MD.

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Impact of Age and Medical Comorbidity on the Effectiveness of Implantable Cardioverter-Defibrillators for Primary Prevention

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