Comment on: Benefit of primary and secondary prophylactic implantable cardioverter defibrillator in elderly patients

Abstract

To the Editor, The article by Lewenhardt et al. stated that in primary prevention the proportion of patients who benefited from implantable cardioverter defibrillator (ICD) implantation decreased with increasing age, and there were no patients who benefited from ICD therapy in the group of patients >80 years. 1 We would like to discuss the possible impact of frailty on the study results.Frailty is a progressive age-related deterioration in physiological systems that results in extreme vulnerability to stressors and increases the risk of a range of adverse outcomes including care dependence and death. 2,3 It is a common geriatric syndrome.The prevalence of frailty in high-income countries at age 50-64 years is around 4%, increasing to 17% in people older than 65 years. 4 We suppose that frailty in some patients included in the study may have affected the results and led to negative results in the group of patients >80 years. For example, the recent trial showed that revascularization reduces the primary endpoint (composite of myocardial infarction, need for urgent revascularization, stroke, and death) in patients with non-ST-segment elevation acute coronary syndrome (ACS) aged ≥80 years, 5 while the trial, which included only frail patients, showed no beneficial effect of revascularization. 6 Finally, frailty is associated with a significantly higher risk of all-cause mortality and readmission in patients with acute ACS. 7,8 In our view, subanalysis of the current trial in frail and nonfrail cohorts should be performed if it is possible.

Reply: How well can frailty predict no benefit from ICD therapy?

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We would like to thank Zakiev et al 1 for their interest in our study.Zakiev et al 1 emphasized the importance of frailty in elderly patients when considering whether ICD implantation might have a benefit.We agree with their comment on key points.A meta-analysis on this topic was published a few years ago by Chen et al Despite the lack of a clear definition of frailty, the metaanalysis questioned the benefit of primary prophylactic ICD therapy in elderly frail patients. 2 More recently, Segar et al published a subgroup analysis of the SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial) from 2005, which demonstrated no benefit of ICD therapy in frailer patients.

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“…Zakiev et al 1 emphasized the importance of frailty in elderly patients when considering whether ICD implantation might have a benefit.…”