Frequency and Determinants of Implantable Cardioverter Defibrillator Deployment Among Primary Prevention Candidates With Subsequent Sudden Cardiac Arrest in the Community

Abstract

Background-The prevalence rates and influencing factors for deployment of primary prevention implantable cardioverter defibrillators (ICDs) among subjects who eventually experience sudden cardiac arrest in the general population have not been evaluated. Methods and Results-Cases of adult sudden cardiac arrest with echocardiographic evaluation before the event were identified from the ongoing Oregon Sudden Unexpected Death Study (population approximately 1 million). Eligibility for primary ICD implantation was determined from medical records based on established guidelines. The frequency of prior primary ICD implantation in eligible subjects was evaluated, and ICD nonrecipients were characterized. Of 2093 cases (2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012), 448 had appropriate pre-sudden cardiac arrest left ventricular ejection fraction information available. Of these, 92 (20.5%) were eligible for primary ICD implantation, 304 (67.9%) were ineligible because of left ventricular ejection fraction >35%, and the remainder (52, 11.6%) had left ventricular ejection fraction ≤35% but were ineligible on the basis of clinical guideline criteria. Among eligible subjects, only 12 (13.0%; 95% confidence interval, 6.1%-19.9%) received a primary ICD. Compared with recipients, primary ICD nonrecipients were older (age at ejection fraction assessment, 67.1±13.6 versus 58.5±14.8 years, P=0.05), with 20% aged ≥80 years (versus 0% among recipients, P=0.11). Additionally, a subgroup (26%) had either a clinical history of dementia or were undergoing chronic dialysis. Conclusions-Only one fifth of the sudden cardiac arrest cases in the community were eligible for a primary prevention ICD before the event, but among these, a small proportion (13%) were actually implanted. Although older age and comorbidity may explain nondeployment in a subgroup of these cases, other determinants such as socioeconomic factors, health insurance, patient preference, and clinical practice patterns warrant further detailed investigation. Key Words: death, sudden ◼ epidemiology ◼ heart arrest ◼ implantable defibrillators ◼ population ◼ utilization © 2013 American Heart Association, Inc.Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.113.002539Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz. Received March 11, 2013; accepted August 21, 2013. From The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (K.N., K.R., A.U.-E., C.T., H.C., E.M., S.S.C.); and Departments of Pathology (K.G.) and Emergency Medicine (J.J.), Oregon Health and Science University, Portland, OR.Correspondence to Sumeet S. Chugh, MD, Cedars-Sinai Medical Center, The Heart Institute, AHSP Suite A3100, 127 S. San Vicente Blvd., Los Angeles, CA 90048, Los Angeles, CA 90048. E-mail sumeet.chugh@cshs.org be significantly underused in the community for both primary and secondary prevention. [13][14][15] However, the extent of deployment of the primary ICD amon...

Disparity Between Indications for and Utilization of Implantable Cardioverter Defibrillators in Asian Patients With Heart Failure

“…In fact, ICD recipients were older and had a greater comorbidity burden compared with nonrecipients. Of note, the mean age of our older Asian ICD recipients (63 years) was comparable to the younger Western ICD recipients (61 to 67 years) reported, 41,42 emphasizing the growing concern that HF afflicts Asians at a younger age than their Western counterparts. 13,43 A high proportion (79.1%) of ICDeligible patients were male, and among ICD recipients, an even higher proportion (83.5%) were male.…”

Natural History and Implantable Cardioverter‐Defibrillator Implantation After Revascularization for Stable Coronary Artery Disease With Depressed Ejection Fraction

“…Their retrospective population-based evaluation found that only 13% of previously ICD-eligible individuals who suffered sudden cardiac arrest had received ICD therapy for primary prevention. 9 The experience in our study demonstrates that although the allocation of ICD therapy may be far from perfect for the population at large, ICD use is more efficient in the higher-risk population of known CAD and persistently depressed LVEF.…”

Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Cardiac Death

“…So in response to the second question, although initiatives that increase ICD use in patients who meet present guidelines have the potential to save lives, the data by Narayanan et al 6 illustrate the potential ceiling to the absolute number of lives that can be saved with this approach. To further influence mortality from SCA, we need to focus effort, research, and resources on multiple strategies aimed at SCA prevention at earlier stages and in populations at all levels of risk.…”