Decision‐making regarding primary prevention implantable cardioverter‐defibrillators among older adults

Abstract

Most implantable cardioverter defibrillators (ICDs) are implanted for the purpose of primary prevention of sudden cardiac death among older patients with heart failure with reduced ejection fraction. Shared decision‐making prior to device implantation is guideline‐recommended and payer‐mandated. This article summarizes patient and provider attitudes toward device placement, device efficacy and effectiveness, potential periprocedural complications, long‐term events such as shocks, quality of life, costs, and shared decision‐making principles and recommendations. Most patients eligible for an ICD anticipate more than 10 years of survival. Physicians are less likely to offer an ICD to patients ≥80 years of age given a perceived lack of benefit. There is a dearth of data from randomized clinical trials addressing device efficacy among older patients; there is a need for more research in this area. However, currently available data support the use of ICDs irrespective of age provided life expectancy exceeds 1 year. Advanced age is independently associated with complications at the time of device placement but not the risk of device infection. The risk of inappropriate shock may be comparable or lower than that of younger patients. While quality of life is generally not adversely impacted by an ICD, a subset of patients experience post‐traumatic stress disorder. ICDs are cost‐effective from societal and health care sector perspectives; however, out‐of‐pocket costs vary according to insurance type and level. Shared decision‐making encounters may be incremental and iterative in nature. Providers are encouraged to partner with their patients, providing them counsel tailored to their values, preferences, and clinical presentation inclusive of age.

Patient perspectives on the need for implanted device information: Implications for a post‐procedural communication framework

“… 18 Further, shared decision‐making encounters may be both incremental and iterative. 32 Patient preferences remain relevant after implantation of a device, especially due to the longitudinal course of implanted devices. Patients may need replacement of their implanted device due to its natural ageing or a problem.…”

Downgrade of cardiac defibrillator devices to pacemakers in elderly heart failure patients: clinical considerations and the importance of shared decision-making

“…In the last 10 years, however, this part of HF management has received increasing attention, and in the current ESC HF guidelines of 2016, palliative care and discussions on end-of-life decisions and deactivation of ICDs have also been included [ 1 ]. Initiating the discussion regarding a deactivation of an ICD, or downgrading a pacemaker device, may be very difficult, whereby patients’ insufficient knowledge about the disease and about the value of an ICD plays an important role [ 9 , 12 , 15 , 29 ]. The issue of a (possible, future) downgrade should be addressed early and, ideally, this should be tackled when an ICD is first implanted.…”

“…In addition to these issues regarding the efficacy of the ICD, a small but significant proportion (9% at 5 years in a recent study) [ 8 ] deliver inappropriate shocks, which may be very stressful for patients. In the light of these findings, implantation of an ICD in elderly HF patients has become less automatic [ 9 ], and this is also true in patients who have an ICD (or CRT device with ICD function, CRT-D) in which the battery is approaching its end-of-life. In the last few years, a large study has been conducted in the Netherlands, which examines outcome measures and appropriate shocks of ICD therapy in HF patients [ 10 ], and the results of this trial are eagerly awaited.…”

“…In these discussions in elderly patients, clearly, not only medical considerations play a role, but all aspects of care for these patients must be integrated into what is called palliative care (which is certainly not the same as terminal or end-of-life care) [ 12 ]. Indeed, there is increased awareness that in elderly HF patients advanced care planning [ 13 ] but also shared decision-making with the patient [ 9 , 14 , 15 ] play an important role, also when considering device replacement.…”

Implantable cardioverter‐defibrillators for primary prevention of sudden cardiac death: what are the barriers to implementation in the ‘real world’?

“…1 International guidelines, based on randomized controlled trials, have since firmly established indications for primary ICD implantation in patients with left ventricular systolic dysfunction and heart failure and broader patient populations. [2][3][4][5] However, implementation of ICD therapy for primary prevention is still challenging for a series of reasons and prominent among these are low referral rates and financial issues. 2,4 In this issue of Journal, Schrage et al 6 provide a sub-analysis of the SwedeHF Registry, undertaken from 2011-2018.…”