NEW YORK (Reuters Health) – Octogenarians with heart failure have a higher risk of in-hospital death after defibrillator or pacemaker placement, compared to younger patients, new research shows.

The study “raises the issue of whether or not the approach of implanting defibrillators and other devices in the elderly is appropriate,” senior author Dr. Paul J. Hauptman from St. Louis University School of Medicine told Reuters Health by phone.

The results also show it’s not uncommon for octogenarians to receive these devices – even though most clinical trials excluded patients in that age group. “People may be surprised about the proportion of patients getting implantable cardiac devices that are over the age of 80,” Dr. Hauptman said.

As he and his associates reported April 12 in the Archives of Internal Medicine, they studied 26,887 adults who were hospitalized with heart failure in 2004 or 2005 and who had cardiac devices implanted – either a cardioverter defibrillator (ICD) alone, or a cardiac resynchronization therapy (CRT) device with a defibrillator (CRT-D) or without one (CRT-P).

The patients were predominantly white males with a median age of 70. The 4694 men and women who were 80 years or older accounted for 17.5% of the device implantation procedures. This group included 992 patients (21.1%) who were older than 85 and 309 (6.6%) who were 89 or older.

In-hospital mortality rose from 0.7% among patients younger than 80 years old to 1.2% in patients ages 80 to 85, and 2.2% in those older than 85 (p < 0.001).

Age 80 or older was an independent predictor of in-hospital mortality, as was an elevated comorbidity score, inotrope use and procedure-related complications.

The older patients also had slightly more complications related to the device procedure, the authors note.

“The one gratifying finding was that the older the patient, the more likely they were to receive the biventricular pacer (CRT-P) not the ICD,” Dr. Hauptman said. “Why is that relevant? I think there is general consensus that those devices may really improve symptoms, which should be the major driver in octogenarians.”

Dr. Hauptman also made the point that the cost-effectiveness argument in favor of cardiac device therapy was derived from clinical trials in patients averaging 58 to 67 years old, with some trials having upper age limits of 80 years old.

“So not only do we not know the effectiveness from a clinical standpoint in the elderly, we don’t know the cost-effectiveness,” Dr. Hauptman said. “And since these are big-ticket items, one would really posit that it’s time that we critically look at whether we are doing patients a service by implanting these devices in octogenarians.”

There seems to be a “sweet spot for these devices,” Dr. Hauptman said. For example, the MADIT-2 trial showed a U-shaped mortality curve, such that a patient of very low risk or moderate to high risk (for any number of reasons) of dying of heart failure did not get a benefit of the device.

Also, he said, there’s evidence that beta-blockers are underutilized in elderly heart failure patients. “Beta-blockers for sure reduce the risk of sudden death and improve cardiac function in a large percentage of patients and we published a paper just last month showing a marked under-utilization of beta-blockers in patients undergoing a device procedure.”

Dr. Hauptman and his colleagues call for more research into the appropriateness of these devices for older patients, “as well as the merits of less invasive options.”

Reference:
Arch Intern Med 2010;170:631-637.