Are ICDs Being Implanted in the Wrong Patients?

national database of nearly 28,000 patients from 240 hospitals between the years 2004-2005. The researchers looked at in-hospital mortality rates of patients who received a cardiac resynchronization device (a biventricular pacemaker) to coordinate the contractions of the heart, implantable cardioverter defibrillator (ICD) to prevent sudden cardiac death, or both, to identify which patients are poor candidates for the procedure. The researchers subsequently identified two "red flags” that were associated with higher risk of in-hospital mortality. The first of these was the that patients who received inotropic therapy--drugs that alleviate the symptoms of advanced HF by making the heart pump more vigorously--before or after the procedure were at the highest risk for in-hospital mortality. Another red flag was the timing of the procedure. Most patients received the devices on the first day of their hospitalization, indicating that it was an elective procedure. However, patients who received the devices after an extended hospitalization, indicating the procedure was likely non-elective, were at risk for in-hospital mortality. According to the researchers, these red flags need to be considered when deciding whether a patient is a good candidate for the devices, and should help doctors decide which patients should receive them, helping to make HF care more cost-effective. The study was published in the June 2008 issue of the American Heart Journal (AHJ).

"Implantable cardiac devices were not intended for, or studied as 'rescue therapy' for very ill hospitalized patients with heart failure,” said senior author Paul Hauptman, M.D., a professor of internal medicine. "Overuse of these devices is a disservice to patients, because it puts them through unnecessary procedures and creates unrealistic expectations for the device.”

"In our analysis, 24.1% of patients who receive inotropic drugs, whether or not they received a cardiac device, die before leaving the hospital,” added Dr. Hauptman. "Clearly, patients who need or will likely need inotropic therapy are very ill and unlikely to receive long-term benefit from these devices. Future guidelines regarding the appropriate use of these devices should incorporate the ongoing or anticipated need for inotropic therapy.”


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