Target Audience (click to view)
This activity is designed to meet the needs of physicians.
Learning Objectives(click to view)
Upon completion of the educational activity, participants should be able to:
- Discuss the findings of a retrospective study that evaluated the incidence and hospital variation of 1-year implantable cardioverter-defibrillator implantation after myocardial infarction among potentially eligible Medicare beneficiaries with an ejection fraction of 35% or lower.
Method of Participation(click to view)
Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation. A statement of credit will be available upon completion of an online evaluation/claimed credit form at http://akhcme.com/akhcme/lessons/6. You must participate in the entire activity to receive credit. If you have questions about this CME/CE activity, please contact AKH Inc. at firstname.lastname@example.org.
Credit Available(click to view)
CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.
AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Commercial Support(click to view)
There is no commercial support for this activity.
Disclosures(click to view)
It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.
Disclosure of Unlabeled Use & Investigational Product(click to view)
This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer(click to view)
This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.
Faculty & Credentials(click to view)
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH planners and reviewers have no relevant financial relationships to disclose.
Complete the Post Test(click to view)
According to current estimates, more than 350,000 people experience sudden cardiac death in the United States each year. Patients with low ejection fraction (EF) are at risk for sudden cardiac death, and clinical trials have established that implantable cardioverter-defibrillators (ICDs) improve survival for these individuals. Guidelines recommend ICDs as primary prevention for patients with an EF of 35% or lower if they do not improve after being treated with optimal medical therapy for at least 40 days after a myocardial infarction (MI).
Studies suggest that ICDs are underutilized in routine clinical practice, especially after a patient suffers an MI. The incidence of MI and the resulting sequelae from these events increase with age. The benefit of ICDs as primary prevention is controversial among older patients because this population is underrepresented in clinical trials. Clinicians may be uncertain about the efficacy of ICDs in an older patient population and must also consider treatment goals and procedural risks. These factors may discourage the use of ICDs among older adults.
A Closer Look
In a retrospective study published in JAMA, Sean D. Pokorney, MD, MBA, and colleagues examined data from Medicare beneficiaries with an EF of 35% or less after MI. Participants were treated at 441 U.S. hospitals between 2007 and 2010, but were excluded if they had a prior ICD implant. The investigators evaluated the incidence and hospital variation of 1-year ICD implantation after MI among potentially eligible patients. They also examined factors that were linked to 1-year ICD implantation and compared 2-year mortality between patients with and without ICDs.
The study was unique in that it evaluated the use and timing of ICD implantation in the post-MI setting. By using a large, national acute MI registry linked to Medicare data, the analysis addressed an understudied older-aged population that is at high risk of cardiac adverse outcomes but is often undertreated. “Our intent was to identify opportunities to optimize the consideration and use of ICDs after older patients had an MI,” adds Dr. Pokorney.
According to the study results, the cumulative 1-year ICD implantation rate among more than 10,000 older MI patients with an EF of 35% or lower was 8.1%. “This means that less than one in 10 Medicare patients with a low EF after an acute MI received an ICD within a year of their hospital discharge,” says Dr. Pokorney. Patients who received ICDs were more likely to have prior CABG procedures, higher peak troponin levels, in-hospital cardiogenic shock, and cardiology follow-up within 2 weeks after discharge when compared with those who did not receive an ICD within 1 year (Table).
The analysis also revealed that study patients who received an ICD had lower 2-year mortality rates than those who did not receive an ICD. The 2-year mortality rate was 15.3 events per 100 patient-years for those receiving ICDs, compared with 26.4 events per 100 patient-years for those not receiving the devices. These findings remained after adjusting for differences in baseline characteristics, in-hospital revascularization status, and post-discharge MI or heart failure readmissions.
“We also found that patients who had more contact with the healthcare system—with early cardiology follow-up or readmissions for MI or heart failure—had a higher likelihood of ICD implantation,” Dr. Pokorney says. “Patients with recurrent heart failure and recurrent MI were also more likely to get ICDs.”
Previous research has shown that older patients have lower rates of ICD use than their younger counterparts. This may be due to the perception that older patients derive less benefit from ICDs. The study showed that patients who have these characteristics and do not receive an ICD had a 1.7-fold higher proportion of death. The magnitude of this association is consistent with the relative risk reductions that have been seen in other research.
Individualized shared decision making is critical because ICD therapy may shift death from a sudden event to a more gradual and comorbid process. “We need to take into account each patient’s quality of life, treatment goals, and preferences,” Dr. Pokorney says. “Our data suggest that age alone should not be considered a contraindication when considering candidates for ICDs.”
Additional research is needed to determine evidence-based approaches that can increase rates of ICD implantation among eligible patients. “Close clinical follow-up is necessary to optimize medical therapy prior to implanting ICDs,” says Dr. Pokorney. “Transitions in care after MI are points of vulnerability that may be helped with quality improvement interventions. Systematic interventions must be developed to encourage close outpatient follow-up, improve communication and implementation of long-term care plans, and enhance patient education. Such interventions may help us identify more effective ways to optimize ICD use among older patients.”
Readings & Resources (click to view)
Pokorney SD, Miller AL, Chen AY, et al. Implantable cardioverter-defibrillator use among Medicare patients with low ejection fraction after acute myocardial infarction. JAMA. 2015;313:2433-2440. Available at: http://jama.jamanetwork.com/article.aspx?articleid=2338252.
Steinbeck G, Andresen D, Seidl K, et al; IRIS Investigators. Defibrillator implantation early after myocardial infarction. N Engl J Med. 2009;361:1427-1436.
Miller AL, Gosch K, Daugherty SL, et al. Failure to reassess ejection fraction after acute myocardial infarction in potential implantable cardioverter/defibrillator candidates: insights from the Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients’ Health Status (TRIUMPH) registry. Am Heart J. 2013;166:737-743.
Chan PS, Nallamothu BK, Spertus JA, et al. Impact of age and medical comorbidity on the effectiveness of implantable cardioverter-defibrillators for primary prevention. Circ Cardiovasc Qual Outcomes. 2009;2:16-24.