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Older patients have a good survival rate, but are more likely to be hospitalized or to enter a nursing facility, after getting an implantable cardioverter defibrillator (ICD) to prevent

sudden cardiac death, according to a U.S. registry study.

With scarce data on the outcomes of the elderly receiving ICDs for secondary prevention, investigators accessed the National Cardiovascular Data Registry ICD registry and found a 21.8%

2-year mortality rate for those over 65.

Patients in their 80s at implantation were twice as likely to die in the subsequent 2 years when compared with their peers in their 60s (28.9% versus 14.7%, adjusted RR 2.01, 95% CI

1.85-2.33), Frederick A. Masoudi, MD, MSPH, of University of Colorado in Aurora, and colleagues found.

Still, both rates were better than the 35% mortality seen among patients at least 75 years of age in the original randomized trials comparing defibrillator therapy with antiarrhythmic

therapy, the researchers noted in their study in the Jan. 24 issue of the Journal of the American College of Cardiology.

The rate of hospitalization with an ICD was 65.4% overall, with patients in their 80s again more likely to be hospitalized (71.5% versus 60.5%, adjusted RR 1.27, 95% CI 1.19-1.36). This

group was also more likely to be admitted to a nursing facility within 2 years (31.9% versus 13.1%, adjusted RR 2.67, 95% CI 2.37-3.01), and was particularly vulnerable in the first 30 days.

"High hospitalization and skilled nursing facility admission rates, particularly among the oldest patients, identify substantial care needs after device implantation," Masoudi's group

suggested.

"The reasons for the use of a skilled nursing facility undoubtedly vary widely and may initially represent short stays following hospitalization, but the increasing rate over time may

reflect the loss of functional independence," the authors wrote. "These high rates of skilled nursing facility use are indicative of patients with advancing frailty and substantial

healthcare needs who receive a therapy principally aimed at prolonging life."

"Whether an older patient should receive a secondary prevention ICD has evolved into a difficult and complex decision for the clinical cardiologist, patient, and caregivers," according to an

accompanying editorial by Sumeet Chugh, MD, of Cedars-Sinai Medical Center in Los Angeles, and two colleagues.

"On the basis of the available evidence, any mortality benefit of secondary prevention ICDs in patients over 80 years of age remains uncertain. In fact, we cannot rule out the possibility of

adverse effects on the elderly patient, especially in terms of hospitalization and admission to skilled nursing facilities."

"In either scenario, the significant costs to the healthcare system may not be justifiable," the editorialists commented.

"There are important knowledge gaps that continue to thwart evidence-based secondary prevention of sudden cardiac death in the elderly patients ... This conundrum can potentially be solved

by refining the clinical guidelines on the basis of evidence from a prospective randomized trial in a carefully selected subgroup of the elderly population at risk."

For the study, Masoudi and colleagues included 12,420 Medicare beneficiaries who underwent first-time secondary prevention ICD implantation between 2006 and 2009. This group had had

documented episodes of tachycardic arrest; sustained monomorphic ventricular tachycardia; or sustained polymorphic ventricular tachycardia.

Participants were at least 65 years of age; average age was 75 years at the time of implantation.

Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Masoudi reported a contract with the American College of Cardiology as the Chief Science Officer of the National Cardiovascular Data Registries.

Co-authors declared ties with Atria, Mobile Sense, Philips, Biotronik, the Department of Defense, the National Institutes of Health, the National Science Foundation, Bristol-Myers Squibb,

TrygFonden, Helsefonen, and The Laerdal Foundation.