Key result
Higher comorbidity burden is linked to a ~191% increase in inappropriate ICD therapy.
Why the study?
The influence of multiple chronic conditions on the risk of inappropriate versus appropriate ICD therapies in primary prevention patients was unclear.
Does higher comorbidity burden increase the risk of inappropriate ICD therapies in adults with left ventricular systolic dysfunction receiving a primary prevention ICD?
Cohort (n=2,235)
Yes
Does higher comorbidity burden increase the risk of inappropriate ICD therapies in adults with left ventricular systolic dysfunction receiving a primary prevention ICD?
In primary prevention ICD recipients, a higher burden of multiple chronic conditions is independently associated with an increased risk of inappropriate device therapies, highlighting the need to consider comorbidity burden in shared decision-making.
Supports incorporating comorbidity into ICD shared decision-making; leaves open whether targeted interventions reduce inappropriate therapies.
OBJECTIVE: To determine whether burden of multiple chronic conditions (MCCs) influences the risk of receiving inappropriate vs appropriate device therapies. DESIGN: Retrospective cohort study. SETTING: Seven US healthcare delivery systems. PARTICIPANTS: Adults with left ventricular systolic dysfunction receiving an implantable cardioverter-defibrillator (ICD) for primary prevention. MEASUREMENTS: Data on 24 comorbid conditions were captured from electronic health records and categorized into quartiles of comorbidity burden (0-3, 4-5, 6-7 and 8-16). Incidence of ICD therapies (shock and antitachycardia pacing [ATP] therapies), including appropriateness, was collected for 3 years after implantation. Outcomes included time to first ICD therapy, total ICD therapy burden, and risk of inappropriate vs appropriate ICD therapy. RESULTS: Among 2235 patients (mean age = 69 ± 11 years, 75% men), the median number of comorbidities was 6 (interquartile range = 4-8), with 98% having at least two comorbidities. During a mean 2.2 years of follow-up, 18.3% of patients experienced at least one appropriate therapy and 9.9% experienced at least one inappropriate therapy. Higher comorbidity burden was associated with an increased risk of first inappropriate therapy (adjusted hazard ratio [HR] = 1.94 [95% confidence interval {CI} = 1.14-3.31] for 4-5 comorbidities; HR = 2.25 [95% CI = 1.25-4.05] for 6-7 comorbidities; and HR = 2.91 [95% CI = 1.54-5.50] for 8-16 comorbidities). Participants with 8-16 comorbidities had a higher total burden of ICD therapy (adjusted relative risk [RR] = 2.12 [95% CI = 1.43-3.16]), a higher burden of inappropriate therapy (RR = 3.39 [95% CI = 1.67-6.86]), and a higher risk of receiving inappropriate vs appropriate therapy (RR = 1.74 [95% CI = 1.07-2.82]). Comorbidity burden was not significantly associated with receipt of appropriate ICD therapies. Patterns were similar when separately examining shock or ATP therapies. CONCLUSIONS: In primary prevention ICD recipients, MCC burden was independently associated with an increased risk of inappropriate but not appropriate device therapies. Comorbidity burden should be considered when engaging patients in shared decision making about ICD implantation.
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Hajduk et al. (2019) conducted a cohort in Left ventricular systolic dysfunction with primary prevention ICD (n=2,235). Higher comorbidity burden (8-16 comorbidities) vs. Lower comorbidity burden (0-3 comorbidities) was evaluated on first inappropriate ICD therapy (HR 2.91, 95% CI 1.54-5.50). Higher comorbidity burden (8-16 vs 0-3 conditions) was associated with an increased risk of first inappropriate ICD therapy (HR 2.91; 95% CI 1.54-5.50).
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