Outcomes of Implantable Cardioverter-Defibrillator Use in Patients With Comorbidities Results From a Combined Analysis of 4 Randomized Clinical Trials

被引:73
作者
Steinberg, Benjamin A. [1 ,2 ]
Al-Khatib, Sana M. [1 ,2 ]
Edwards, Rex [2 ]
Han, JooYoon [3 ]
Bardy, Gust H. [4 ,5 ]
Bigger, J. Thomas [6 ]
Buxton, Alfred E. [7 ]
Moss, Arthur J. [8 ]
Lee, Kerry L. [2 ]
Steinman, Richard [9 ]
Dorian, Paul [10 ,11 ]
Hallstrom, Alfred [3 ]
Cappato, Riccardo [12 ]
Kadish, Alan H. [13 ]
Kudenchuk, Peter J. [5 ]
Mark, Daniel B. [1 ,2 ]
Inoue, Lurdes Y. T. [3 ]
Sanders, Gillian D. [2 ]
机构
[1] Duke Univ, Dept Med, Med Ctr, Durham, NC USA
[2] Duke Univ, Duke Clin Res Inst, Durham, NC USA
[3] Univ Washington, Dept Stat, Seattle, WA 98195 USA
[4] Seattle Inst Cardiac Res, Seattle, WA USA
[5] Univ Washington, Div Cardiol, Seattle, WA 98195 USA
[6] Columbia Univ, Dept Med, New York, NY USA
[7] Beth Israel Deaconess Med Ctr, Cardiovasc Div, Boston, MA 02215 USA
[8] Univ Rochester, Med Ctr, Heart Res Follow Program, Rochester, MN USA
[9] Columbia Univ, Irving Inst Clin & Translat Res, New York, NY USA
[10] Univ Toronto, St Michaels Hosp, Dept Med, Toronto, ON, Canada
[11] Univ Toronto, St Michaels Hosp, Dept Cardiol, Toronto, ON, Canada
[12] IRCCS Policlin San Donato, Milan, Italy
[13] Northwestern Univ, Feinberg Sch Med, Dept Med, Chicago, IL 60611 USA
基金
美国国家卫生研究院; 美国医疗保健研究与质量局;
关键词
comorbid illness; implantable cardioverter-defibrillator; outcomes; randomized trials; PRIMARY PREVENTION; MYOCARDIAL-INFARCTION; COST-EFFECTIVENESS; IMPROVED SURVIVAL; HEART-FAILURE; RISK; CARDIOMYOPATHY; ARRHYTHMIA; MORTALITY; DISEASE;
D O I
10.1016/j.jchf.2014.06.007
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
OBJECTIVES The aim of this study was to determine if the benefit of implantable cardioverter-defibrillators (ICDs) is modulated by medical comorbidity. BACKGROUND Primary prevention ICDs improve survival in patients at risk for sudden cardiac death. Their benefit in patients with significant comorbid illness has not been demonstrated. METHODS Original, patient-level datasets from MADIT I (Multicenter Automatic Defibrillator Implantation Trial I), MADIT II, DEFINITE (Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation), and SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial) were combined. Patients in the combined population (N = 3,348) were assessed with respect to the following comorbidities: smoking, pulmonary disease, diabetes, peripheral vascular disease, atrial fibrillation, ischemic heart disease, and chronic kidney disease. The primary outcome was overall mortality, using the hazard ratio (HR) of time to death for patients receiving an ICD versus no ICD by extent of medical comorbidity, and adjusted for age, sex, race, left ventricular ejection fraction, use of antiarrhythmic drugs, beta-blockers, and angiotensin-converting enzyme inhibitors. RESULTS Overall, 25% of patients (n = 830) had <2 comorbid conditions versus 75% (n = 2,518) with significant comorbidity (>= 2). The unadjusted hazard of death for patients with an ICD versus no ICD was significantly lower, but this effect was less for patients with >= 2 comorbidities (unadjusted HR: 0.71; 95% confidence interval: 0.61 to 0.84) compared with those with <2 comorbidities (unadjusted HR: 0.59; 95% confidence interval: 0.40 to 0.87). After adjustment, the benefit of an ICD decreased with increasing number of comorbidities (p = 0.004). CONCLUSIONS Patients with extensive comorbid medical illnesses may experience less benefit from primary prevention ICDs than those with less comorbidity; implantation should be carefully considered in sick patients. Further study of ICDs in medically complex patients is warranted. (C) 2014 by the American College of Cardiology Foundation.
引用
收藏
页码:623 / 629
页数:7
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