ESC Congress 2017 In Review – Focus on Arrhythmias - 16

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He reported findings from an updated meta-analysis
of 5 randomised controlled trials including 2,992 patients
which re-examined the benefit of ICD therapy in this
setting [Wolff G et al. Clin Res Cardiol. 2017]. The data
showed that ICD device therapy significantly reduced
patient mortality compared with usual clinical care (OR,
0.77; 95% CI, 0.64 to 0.93; P = .006). It also significantly
reduced SCD (OR, 0.43; 95% CI, 0.27 to 0.69; P = .0004),
said Dr Wolff, but had no significant reduction in CV death
or noncardiac death compared with usual clinical care.
To rule out any influence of amiodarone therapy on
all-cause mortality, Dr Wolff and colleagues performed a
stratified analysis to control for any potential confounding effect of the drug. They found that amiodarone therapy did not affect the overall results, and ICD therapy still
provided a significant benefit over usual clinical care.
These findings demonstrate that ICD therapy confers a
survival benefit in the primary prevention setting, reducing SCD, said Dr Wolff. He explained that the results of
the DANISH trial suggest an increase in the numberneeded-to-treat to prevent any death in patients with
ICDs compared with guideline-directed therapy.
Dr Wolff concluded that ICD therapy should therefore remain the standard therapy for primary prevention of SCD in DCM until new data allow clinicians to
use risk stratification methods to customise treatment
recommendations according to patient characteristics.
Device Implantation in Elderly Patients
ICD and CRT-D implantation is also effective in preventing SCD in elderly patients, and current guidelines recommend that clinicians should consider this treatment
in patients with an estimated survival of at least 1 year.
However, Ines Aguiar-Ricardo, MD, University of
Lisbon, Lisbon, Portugal, noted that because the guidelines do not specify any age limits for this therapy, cli-

nicians face challenging decisions about whether to
implant ICDs in elderly patients, especially because of
patients' diminished life expectancy and the frequent
presence of associated comorbid conditions.
Because differences in device generator longevity vary according to manufacturer [Alam MB et al.
Europace. 2014], Dr Aguiar-Ricardo and colleagues conducted a retrospective single-centre study to investigate
whether the expected survival rate in elderly patients
should influence clinicians' selection of a device based
on its longevity [Aguiar-Ricardo I et al. Eur Heart J.
2017]. Their study included 249 generator implantations
in 210 patients aged ≥ 75 years, from 1995 to 2016.
The median long-term survival of these patients was
5.7 years (95% CI, 3.7 to 7.7), said Dr Aguiar-Ricardo.
However, there was no significant difference in median survival between patients with ICDs and those with CRT-Ds.
The investigators found that patient median survival
time was lower than the longevity of the ICD generators. The first generator was still functioning at the end
of follow-up in only 56% of patients, and 20 patients
underwent replacement of at least one generator
(Figure 1).
And although the longevity of CRT-D generators was
also greater than patients' median survival time, the
first generator was still functioning at the end of followup in only 60% of patients, said Dr Aguiar-Ricardo, and
13 patients underwent at least 1 generator replacement.
This means that as many as 40% of elderly patients
with ICDs or CRT-Ds may need to undergo generator replacement during follow-up, she stressed, so it
does not make sense to provide generators of shorter
longevity for this patient population. It seems most
cost-effective to use devices with increased generator
longevity for elderly patients to avoid the need for additional replacement, she emphasised.

Figure 1. Patient Survival and ICD Longevity After ICD Implantation
Mean follow-up in the elderly population is still
relatively short: 4 years

1.0

ICD generator
longevity

Cumulative Survival

0.8

0.6

56% (n = 59) of the patients have the first ICD
generator still functioning at the end of follow-up

Survival of the elderly
ICD carriers

20 patients underwent at least one generator
replacement*
> 5 patients underwent two generator
replacements
> 1 patient underwent three replacements

0.4

0.2

Maintaining the current ICD generator
longevity, as much as 40% of the elderly ICD
carriers may need to undergo generator
replacement during follow-up

0.0
0

In general, survival of the elderly patients is lower
than longevity of ICD generators

Time (years)

* 2 replacements occurred in the context of device
upgrade and 3 in the context of device extraction

ICD, implantable cardioverter-defibrillator.
Reproduced with permission from I Aguiar-Ricardo, MD.

October 2017

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Table of Contents for the Digital Edition of ESC Congress 2017 In Review – Focus on Arrhythmias