Key result
Older age is linked to a ~4-fold increase in 1-year mortality after ICD placement.
Why the study?
The value of implantable cardioverter-defibrillators (ICDs) in patients with heart failure and reduced ejection fraction, particularly with advancing age, remains uncertain.
Absolute Event Rate: 32% vs 7%
High one-year post-ICD mortality in older VA patients warrants selection caution; leaves open need for better mortality prediction models.
This article refers to 'One-year mortality after implantable cardioverter-defibrillator placement within the Veterans Affairs Health System' by M. Fudim et al., published in this issue on pages 859-867.In this issue of the Journal, Fudim et al. 1 examine all-cause mortality over a median follow-up of 2.1 years in 17 901 patients with heart failure and reduced ejection fraction receiving an implantable cardioverter-defibrillator (ICD) in the Veterans Affairs Health System.As expected in the Veterans Affairs Health System, the population was predominantly male (99%) with ischaemic cardiomyopathy (81% coronary artery disease), frequent cardiovascular risk factors, but only modest comorbidity burden [mean Charlson comorbidity index (CCI) 3.0].The analysis treads a familiar path of questioning the value of ICDs with advancing age, focusing on 1-year mortality which averaged 13% and was unchanged from 2007 to 2014.Independent predictors of death included age, coronary artery disease and risk factors, and non-cardiac conditions.The relationship between age and 1-year mortality was striking, rising from a few percentage age 40, to 30% in nonagenarians.Expressed by age quartile, 1-year mortality rose from 7% to 32% from the lowest to the highest quartile.Though tempting to largely attribute the relationship between age and survival to comorbidities, several observations temper this argument.First, only a minor increase in CCI occurred from youngest to oldest quartiles (2.75 to 3.07, respectively).Second, an extreme increase in CCI only correlated with a modest increase in 1-year mortality from around 10% to 20%.Third, comorbidities actually declined from 2007 to 2014 (CCI 3.1 to 2.8, P < 0.001), while overall mortality remained stable.Finally, age remained a powerful independent predictor of survival after adjustment for individual comorbidities.The opinions expressed in this article are not necessarily those of the Editors of the
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Hawkins et al. (2020) conducted an editorial in Heart failure and reduced ejection fraction (n=17,901). Advancing age vs. Younger age (lowest age quartile) was evaluated on 1-year mortality. Advancing age was a powerful independent predictor of 1-year mortality after ICD placement, with mortality rising from 7% in the lowest age quartile to 32% in the highest age quartile.
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