Dr. Goldfinger is resident, internal medicine, Mount Sinai Medical Center, New York, NY.

Dr. Choi is resident, internal medicine, Mount Sinai Medical Center.

Dr. Adler is assistant professor, division of cardiology, Mount Sinai Medical Center.

ABSTRACT

Heart failure primarily affects older adults, but these patients are underrepresented in clinical trials. Implantable cardiac defibrillators have been shown in large trials to reduce mortality through primary and secondary prevention of cardiac arrest. It is not clear, however, whether older patients derive the same mortality benefit as younger patients. Cardiac resynchronization therapy improves exercise tolerance and quality of life, and decreases mortality and hospitalizations for younger and older patients with heart failure. Each of these devices is underused in older patients, especially in women and minorities. Physician recommendation for device placement requires a discussion of indication, risks, and benefits, as well as plans for deactivation in end-stage disease.

Goldfinger JZ, Choi AD, Adler ED. Implantable cardiac defibrillators and cardiac resynchronization therapy for heart failure in older adults. Geriatrics. 2009;64(8):20-29.

Key words: implantable cardiac defibrillators, cardiac resynchronization therapy, biventricular pacing, sudden cardiac death

Heart failure is predominantly a disease of older adults. Prevalence is between 2% and 3% at age 65 but rises to 80% for patients more than 80 years old.¹ Incidence increases with age. Compared to adults aged 65 to 74 years, the annual rates of new heart failure events are 2-fold greater among those aged 75 to 84 years and 3-fold greater for those more than 85 years of age.² Heart failure incidence and prevalence are rising because of increased rates of diabetes and hypertension, improved survival after myocardial infarction (MI), and better medical management of heart failure.^3,4 The 5.7 million Americans living with heart failure and the 550,000 Americans newly diagnosed each year face a heavy symptom burden, increased rates of depression,⁵ worse quality of life,⁶ and yearly mortality that exceeds that of breast cancer, lung cancer, prostate cancer, and HIV/AIDS combined.²

Patients with heart failure have increased rates of health care use compared with patients with other diseases.⁷ Heart failure is the most common cause of hospital admission for adults over age 65, and patients experience high readmission rates, with as many as two-thirds being readmitted within 1 year.^8-10 Heart failure is a frequent cause of emergency department ⁴ and outpatient visits, with patients logging more than 3 million yearly visits to their providers.²

Although older Americans are the face of heart failure in the community, they are underrepresented in clinical trials of heart failure.^11,12 Still, guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) recommend the same management for older patients with heart failure as for younger patients, albeit with the caveat that older patients may require individualized consideration of medication metabolism and tolerability.¹

The ACC/AHA heart failure management guidelines include medications and devices that can improve either or both symptom control and survival. In this paper, we will review the evidence and guidelines for implantable cardiac defibrillators (ICD) and cardiac resynchronization therapy (CRT) in older patients. We will also examine the data on use of these devices in older patients and discuss the role for device deactivation in patients with end-stage heart failure.