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Editorials

Is Anyone Too Old for an Implantable Cardioverter-Defibrillator?

Paul A. Heidenreich, MD, MS and Vivian Tsai, MD

From the Veterans Affairs Palo Alto Health Care System (P.H.), Palo Alto, Calif; and the Stanford University School of Medicine (P.H., V.T.), Stanford, Calif.

Correspondence to Paul Heidenreich, MD, MS, 111C Cardiology, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304. E-mail heiden@stanford.edu

Key Words: editorials • cost-benefit analysis • defibrillation • heart failure • aged • defibrillators • implantable • heart failure

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Implantable cardioverter-defibrillators (ICDs) are one of the few interventions where we can be reasonably confident that a patient did or did not benefit from the treatment. If one is to benefit from an ICD, then the person must survive long enough to have an arrhythmic event and receive therapy from the device. Thus, the patients who benefit the most are those with a high rate of arrhythmic death and a low rate of nonarrhythmic death. Indeed the enrollment criteria for clinical trials of ICDs were designed to optimize these 2 rates. Accordingly, the patients enrolled in the primary prevention ICD trials were much younger and had less comorbidity than the community heart failure population.¹

Article see p 16

On the basis of trial results, we now have guidelines for ICDs that limit them to patients with an ejection fraction below 35% if symptomatic (New York Heart Association Class II or III) or <30% if asymptomatic (New York Heart Association Class I) and expected survival of at least one year.² However, the clinician is frequently confronted with a patient who meets the primary prevention ICD criteria yet has other characteristics (advanced age or multiple comorbidities) that create legitimate concern that the patient will not benefit from the device. Payers, policy makers, and society warn that even if there is a benefit in these patients, it may be too small to justify the cost. In other words, they question whether an ICD has value in the elderly and those with multiple comorbidities. . . . [Full Text of this Article]

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

Paul S. Chan, Brahmajee K. Nallamothu, John A. Spertus, Frederick A. Masoudi, Cheryl Bartone, Dean J. Kereiakes, and Theodore Chow
Circ Cardiovasc Qual Outcomes 2009 2: 16-24. [Abstract] [Full Text] [PDF]