Our patients are sicker than ever. Obesity, diabetes, and cardiovascular disease is increasingly prevalent in the US today. Even with the challenges of an aging population, we are doing a much better job diagnosing and treating cardiovascular disease in the year 2012 as compared to decades ago. Life prolonging therapies are commonplace and death rates from CV disease are declining (particularly in men). Advanced technologies such as LVADs and ICDs have been developed specifically to prolong life. Healthcare costs have skyrocketed and healthcare reform is at the forefront of almost any political campaign.
As an EP physician, I am often asked by my colleagues to make difficult decisions about the implantation of life saving ICDs in an aging population. How do you decide how old is too old? Is this all about chronologic age or does so called “biologic age” play a role? Is this all about applying the data from multiple ICD trials (with a patient population that may not represent your patient exactly)? Should we as physicians be unofficially “rationing” healthcare?
These are difficult questions, and I think, only represent the tip of the iceberg in this debate. In my opinion, we must take a multifaceted approach to making these decisions. When asked to consult on a patient who is elderly and asked if the patient would benefit from an ICD, I do just that-I provide consultation. I provide a thoughtful consideration of the data supporting what we do, the patient’s age and overall condition (including co-morbidities) and, most importantly, the patient’s feelings about the risks and benefits of proceeding. Most device trials have excluded patients over 80 years old so we really have no specific data in this population. Despite this fact, national database registry information indicates that nearly one fifth of ICD or CRT devices are implanted in this age group. When we examine the guidelines, there are almost no absolute age-specific contraindications for ICD therapy but as the patient age advances very careful consideration of alternatives should be entertained and disclosed in discussions with patient and family.
In a article by Swindle, et al in Archives of Internal Medicine in 2010, the outcomes of ICD implantation in elderly patients was examined. In the study, the median age was 70 years old and almost 18% were more than 80. When the study cohort was compared to younger patients, those more than 80 years old were more likely to receive CRT pacing therapy without ICD. In hospital mortality increased from .7% to 1.2% in patients older than 80 and to 2.2% in patients older than 85. In another study by Panotopoulos et al published in JACC in 1997, the implantation of ICDs in patient older than 75 was examined and found that mortality rates in this pateint population was increased 3 fold as compared to younger cohorts. Data from studies involving mainly younger patients and ICDs may over estimate benefit in elderly populations and conversely studies involving a large population of elderly patients may under-estimate that benefit in younger cohorts.
Obviously there is no consensus at this time as how to best handle elderly patients meeting criteria for ICD or CRT therapy. Our best practice should involve a careful assessment of the patient, the disease and co-morbidities as well as a detailed discussion of risks and benefits with patient and family. There is no right answer in these cases. There is no well designed RCT in this age group to to guide our decision making. Certainly there are times and situations where I believe that CRT therapy without ICD is appropriate and have advocated this approach in many of my elderly patients. I have also implanted ICDs in many patients over the age of 80. In all cases, the most important factor in making this decision has been thoughtful discussion with the patient. Ultimately we must individualize care and help the patient make an informed decision that is best for their own personal situation and belief system. Certainly, just because we CAN, doesn’t mean we SHOULD.