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EP News: Allied Professionals
EP News: Allied Professionals Erica S. Zado, PA-C, FHRS From the Section of Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
Implantable cardioverter-defibrillator use in older patients Using a large database (National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines [ACTION registry-GWTG]) of patients who had an ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation MI (NSTEMI), Pokorney et al (JAMA 2015;313:2433-2440, PMID 26103027) sought to assess the utilization of implantable cardioverter-defibrillators (ICD) following MI in a group of older patients (465 years). They also sought to determine factors associated with ICD utilization in the year following MI and whether there was a mortality benefit with ICD use in the 2 years after MI. The authors were able to gather a group of 10,318 Medicare beneficiaries with left ventricular ejection fraction (EF) r35% from the ACTION registry (MI hospitalization between 2007 and 2010 from 441 hospitals in the United States) who also had information from 1 year prior to the index MI, in order to exclude those who already had an ICD. By linking the data from the ACTION registry with Medicare claims data, they were able to determine who subsequently received an ICD within the next year, as well as mortality over a median 718 days of follow-up. The authors found that only 8.1% of patients had an ICD implant in the first year. The rate was higher in those with r25% (11.5%) and in those with the highest troponins (10.4%). Some of the factors associated with ICD implantation include younger age (median age was 78), male sex, STEMI, higher troponin, shock during the index hospitalization, and prior coronary artery bypass surgery. Also associated with ICD implantation were readmission for heart failure or MI and appointment with a cardiologist within 2 weeks of discharge. There was lower mortality in those with ICD implantation (15.3 per 100 patient-years) than in those with no ICD (26.4 events per 100 patient-years). The authors conclude that in a large group of Medicare patients who had MI with EF r35% and were eligible for ICD, (1) o10% received an ICD in the year
following the MI and (2) ICD implantation is associated with significantly lower mortality at 2 years.
Utilization of ICDs Under current guidelines, ICDs are recommended for patients with EF r35% following an MI if New York Heart Association (NYHA) class 2 or 3 or r30% if NYHA class 1. However, there is a 40-day waiting period post MI or revascularization because no benefit has been shown for ICD implantation early post MI. Pokorney et al and Dr Hauser in the accompanying editorial (JAMA 2015;313:2429-2430, PMID 26103025) offered up various hypotheses for the very low (8.1%) implant rate in the study. These include fragmented health care. Those patients that had follow-up appointments with cardiologists within 2 weeks of discharge or had repeated exposures to cardiologists via repeated admissions for heart failure or recurrent MI were more likely to have an ICD implanted. The others may have “slipped through the cracks” because of the 40-day wait. Additionally, the study group was composed of older individuals. This group has not been included in large numbers in prior studies and there may be reluctance among health care providers to provide ICD therapy to the elderly because of lack of extensive evidence that it provides benefit. Dr Hauser also pointed out that it is possible that a significant number of patients may have had improved EF in follow-up and therefore ICD was no longer indicated, but this certainly does not account for the entirety of those that did not have ICD implantation. He also mentioned possible patient bias against ICD implant owing to prior recalls and other negative publicity. All that being said, it is incumbent upon us as health care providers to at least consider ICD implantation in patients post MI with EF r35%, regardless of age. Offering ICD therapy to any patient involves a discussion regarding real and perceived benefits, risks of the procedure and long-term risks of the device (including infection, lead/component problems, and inappropriate shocks), patient’s quality of life, and life expectancy related to comorbidities. If we work together with the patient, the appropriate decision can be made.
Address reprint requests and correspondence: Ms Erica S. Zado, Section of Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, Founders 9, 3400 Spruce St, Philadelphia, PA 19104. E-mail address: [email protected].
1547-5271/$-see front matter
http://dx.doi.org/10.1016/j.hrthm.2015.07.014
Implantable cardioverter-defibrillator use in older patients Using a large database (National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines [ACTION registry-GWTG]) of patients who had an ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation MI (NSTEMI), Pokorney et al (JAMA 2015;313:2433-2440, PMID 26103027) sought to assess the utilization of implantable cardioverter-defibrillators (ICD) following MI in a group of older patients (465 years). They also sought to determine factors associated with ICD utilization in the year following MI and whether there was a mortality benefit with ICD use in the 2 years after MI. The authors were able to gather a group of 10,318 Medicare beneficiaries with left ventricular ejection fraction (EF) r35% from the ACTION registry (MI hospitalization between 2007 and 2010 from 441 hospitals in the United States) who also had information from 1 year prior to the index MI, in order to exclude those who already had an ICD. By linking the data from the ACTION registry with Medicare claims data, they were able to determine who subsequently received an ICD within the next year, as well as mortality over a median 718 days of follow-up. The authors found that only 8.1% of patients had an ICD implant in the first year. The rate was higher in those with r25% (11.5%) and in those with the highest troponins (10.4%). Some of the factors associated with ICD implantation include younger age (median age was 78), male sex, STEMI, higher troponin, shock during the index hospitalization, and prior coronary artery bypass surgery. Also associated with ICD implantation were readmission for heart failure or MI and appointment with a cardiologist within 2 weeks of discharge. There was lower mortality in those with ICD implantation (15.3 per 100 patient-years) than in those with no ICD (26.4 events per 100 patient-years). The authors conclude that in a large group of Medicare patients who had MI with EF r35% and were eligible for ICD, (1) o10% received an ICD in the year
following the MI and (2) ICD implantation is associated with significantly lower mortality at 2 years.
Utilization of ICDs Under current guidelines, ICDs are recommended for patients with EF r35% following an MI if New York Heart Association (NYHA) class 2 or 3 or r30% if NYHA class 1. However, there is a 40-day waiting period post MI or revascularization because no benefit has been shown for ICD implantation early post MI. Pokorney et al and Dr Hauser in the accompanying editorial (JAMA 2015;313:2429-2430, PMID 26103025) offered up various hypotheses for the very low (8.1%) implant rate in the study. These include fragmented health care. Those patients that had follow-up appointments with cardiologists within 2 weeks of discharge or had repeated exposures to cardiologists via repeated admissions for heart failure or recurrent MI were more likely to have an ICD implanted. The others may have “slipped through the cracks” because of the 40-day wait. Additionally, the study group was composed of older individuals. This group has not been included in large numbers in prior studies and there may be reluctance among health care providers to provide ICD therapy to the elderly because of lack of extensive evidence that it provides benefit. Dr Hauser also pointed out that it is possible that a significant number of patients may have had improved EF in follow-up and therefore ICD was no longer indicated, but this certainly does not account for the entirety of those that did not have ICD implantation. He also mentioned possible patient bias against ICD implant owing to prior recalls and other negative publicity. All that being said, it is incumbent upon us as health care providers to at least consider ICD implantation in patients post MI with EF r35%, regardless of age. Offering ICD therapy to any patient involves a discussion regarding real and perceived benefits, risks of the procedure and long-term risks of the device (including infection, lead/component problems, and inappropriate shocks), patient’s quality of life, and life expectancy related to comorbidities. If we work together with the patient, the appropriate decision can be made.
Address reprint requests and correspondence: Ms Erica S. Zado, Section of Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, Founders 9, 3400 Spruce St, Philadelphia, PA 19104. E-mail address: [email protected].
1547-5271/$-see front matter
http://dx.doi.org/10.1016/j.hrthm.2015.07.014