META-ANALYSIS: AGE AND EFFECTIVENESS OF PROPHYLACTIC IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS

Title: Meta-Analysis: Age and Effectiveness of Prophylactic Implantable Cardioverter-Defibrillators
Date Posted: December 1, 2010
Authors: Santangeli P, Di Biase L, Russo AD, et al.
Citation: Ann Intern Med 2010;153:592-599.

Study Question:
Do implantable cardioverter-defibrillators (ICDs) improve survival in elderly patients when used for primary prevention of sudden death?

Methods:
This was a meta-analysis of five primary prevention randomized ICD trials (MADIT-II, DINAMIT, DEFINITE, SCD-HeFT, and IRIS) that included 5,783 patients with an ejection fraction ≤40% and a primary prevention indication for an ICD. Elderly patients (defined as ages >60-65 years) accounted for 44% of the overall study population. The primary endpoint was the survival benefit of prophylactic ICD therapy compared to optimal medical therapy.

Results:
In patients <60-65 years of age, ICD therapy was associated with a significant decrease of 35% in all-cause mortality. In contrast, the decrease in mortality with ICD therapy in elderly patients was 19% and not statistically significant.

Conclusions:
The authors concluded that prophylactic ICD therapy does not improve survival in elderly patients to the same extent as in younger patients.

Perspective:
None of the primary prevention ICD trials was designed to determine whether age influences the extent to which ICD therapy improves survival. Nevertheless, it is noteworthy that post-hoc analysis of the MADIT-II trial showed no significant difference in ICD survival benefit between patients older and younger than 75 years of age. The results of the present study are provocative and should stimulate further evaluation of the interaction between age and prophylactic ICD therapy. However, it would be inappropriate to stop implanting ICDs in elderly patients based only on the results of this meta-analysis, particularly when the definition of ‘elderly’ was an age cut-off of only 60-65 years.

Author(s):
Fred Morady, M.D., F.A.C.C.

POSTED BY STEVEN ALMANY, MD

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The Milwaukee Journal Sentinel (12/14, Fauber) "Health & Science Today" blog reported that "deaths from cardiovascular disease dropped 28% from 1997 to 2007 and stroke death declined by 45%, according the latest statistics compiled by the American Heart Association." But, "during that same period the number of cardiovascular procedures and operations increased by 27%."

HeartWire (121/15, Nainggolan) reported, "Similar to last year's figures, a third of Americans have high blood pressure (this rises to 44% in African Americans), 15% have total-cholesterol levels of 240 mg/dL or higher, almost a quarter of men and 18% of women smoke, two-thirds of the adult population is overweight and a third obese, while 20% of children aged six to 11 are obese."

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Reuters (12/16) reports that Dr. Veronique Roger, who led the study, said, "We need to energize our commitment to strategies that can prevent disease in the first place." WebMD (12/15, Woznicki) reported that "the findings appear online in Circulation: Journal of the American Heart Association."

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Bloomberg News (12/15, Lauerman, Waters) reports that "the torn aorta that led to the death of Richard Holbrooke, the U.S. envoy for Afghanistan and Pakistan, is an uncommon disorder that isn't always recognized, doctors said."

USA Today (12/15, Rubin) reports that approximately "3,000 Americans die each year from an aortic dissection, although the actual number probably is higher." USA Today adds that the book With Love and Laughter, by John Ritter's widow, Amy Yasbeck, "devotes chapter 24, titled 'From the Heart,' to the topic of aortic aneurysms. The chapter includes the 'Ritter Rules,' named for her late husband and based on new guidelines about the diagnosis and treatment of aortic aneurysms from the American Heart Association and the American College of Cardiology." The Los Angeles Times (12/14, Forgione) "Booster Shots" blog also covered the story.

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