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Defibrillator Use After Myocardial Infarction in Older Adults

Defibrillator Use After Myocardial Infarction in Older Adults

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...
ICDs: Analyzing Patient Perception & Physician Communication

ICDs: Analyzing Patient Perception & Physician Communication

Implantable cardioverter-defibrillators (ICDs) have changed the way patients with cardiac arrhythmias are evaluated and treated. Asymptomatic patients often receive ICDs as part of a primary prevention strategy, but there is potential for post-implantation complications, most notably anxiety and psychosocial changes. In addition, ICD recipients are typically older and have comorbidities that serve as competing risks for mortality. Primary prevention strategies are indicated for patients who have not had a sudden death event or symptoms of life-threatening arrhythmias. In secondary prevention, patients have already experienced life-threatening events. Survival benefits are more likely to occur when ICDs are implanted for secon-dary rather than primary prevention. An important problem, however, is that currently available screening modalities to identify patients at risk for sudden death are lacking. “Making the decision to get an ICD is clearly a life-changing event for patients,” explains Paul J. Hauptman, MD. “Physicians need to explicitly discuss the benefits of these devices with patients and also educate them about risks beyond those of the implantation procedure itself.” Few studies, however, have addressed the information exchange between physicians and patients on pertinent issues with ICDs. These include discussions on the risks and benefits as well as potential consequences for quality of life (QOL). Exploring Information Exchange on ICDs Dr. Hauptman and colleagues had a study published in JAMA Internal Medicine that examined patient–physician communication at the time decisions were made to implant ICDs. Focus groups with recipients of ICDs were conducted to address the nature of pre-implantation discussions. The content and style of communication from cardiologists was observed when they met with standardized patients—people who were trained to act as...
Updated Guidelines for Heart Failure

Updated Guidelines for Heart Failure

Recently, the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) jointly released an expanded clinical practice guideline for the management of patients with heart failure (HF). The update, published in the Journal of the American College of Cardiology was designed to assist clinicians in selecting the best management strategies for patients. “The guideline updates definitions and classifications for HF, increases the emphasis on patient-centric outcomes, and introduces ‘guideline- directed medical therapy’ (GDMT),” explains Clyde W. Yancy, MD, MSc, FACC, who chaired the ACCF/AHA writing committee. Descriptions & Classifications of Heart Failure The ACCF/AHA guideline update provides a more focused approach on dilated cardiomyopathies and the appropriate evaluation of patients. This includes family and genetic screening and counseling. “The guidelines once again endorse four stages of disease progression: Stages A thru D,” explains Dr. Yancy. “Stage A patients are those with positive risk factors, whereas Stage B patients have existing but still asymptomatic left ventricular function.” “The expectations are highest for hospitalized patients with HF because of their vast resource consumption from initial admissions to subsequent readmissions.” Stage C is the classic patient with congestive HF, but importantly, Dr. Yancy says this patient group is now well dichotomized as having HF with reduced ejection fraction (EF) or HF with preserved EF. “Best therapies are aligned with each stage, specifically risk factor modification, pre-emptive medical and device therapies for asymptomatic left ventricular dysfunction, and classic evidence-based therapies for symptomatic HF patients with reduced EF,” he says. “The guidelines also provide a treatment algorithm for Stage C HF patients with reduced EF [Figure]. The algorithm, known as GDMT, can...
Devices for Cardiac Rhythm Abnormalities: A Guideline Update

Devices for Cardiac Rhythm Abnormalities: A Guideline Update

According to recent estimates, about 400,000 pacemakers and implantable cardioverter defibrillators (ICDs) are surgically implanted each year in the United States. In 2008, the American College of Cardiology Foundation (ACCF), American Heart Association (AHA), and the Heart Rhythm Society (HRS) released guidelines for using device therapy to manage cardiac rhythm abnormalities. Since the release of the 2008 guidelines, many clinical research advances relating to device-based therapies have emerged, says Andrew E. Epstein, MD, FAHA, FACC, FHRS. “In an effort to help clinicians keep pace with these advances, the ACCF, AHA, and HRS jointly released updated guidelines in 2012 for the use of device-based therapy in treating heart rhythm disorders. The guidelines can help in clinical decision making in most circumstances.” The 2012 update writing group included experts in device therapy, cardiovascular care, internal medicine, cardiovascular surgery, and pediatric and adult electrophysiology. The guidelines were also developed in collaboration with the American Association for Thoracic Surgery, Heart Failure Society of America, and Society of Thoracic Surgeons. Building on Earlier Cardiac Device Guidelines For the 2012 update, the writing group began by reviewing the 2008 recommendations. The latter are largely unchanged for standard pacing and ICD indications. However, given new data on cardiac resynchronization therapy (CRT), the 2008 guidelines were updated with CRT as its focus, especially with regard to expanding indications for this treatment (Figure 1). “CRT can significantly improve quality and quantity of life by delaying or avoiding worsening heart failure.” —Andrew E. Epstein, MD, FAHA, FACC, FHRS “Despite our improvements in managing patients with device-based therapies, it can still be challenging for physicians to select patients in whom...

Primary Prevention ICDs Yield Survival Benefits

Among eligible patients, those who undergo implantable cardioverter-defibrillator (ICD) implantation appear to benefit from a significantly decreased mortality rate when compared with those who do not undergo implantation, according to a retrospective analysis. The authors noted that vigilance is required to ensure that patients eligible for primary prevention ICDs are appropriately referred and assessed. Abstract: Circulation: Arrhythmia and Electrophysiology, August...
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