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June 23/30, 2015

Underutilization of Implantable Cardioverter-Defibrillators in Older Patients

Author Affiliations
  • 1Minneapolis Heart Institute, Abbott Northwestern Hospital, Allina Health, Minneapolis, Minnesota
JAMA. 2015;313(24):2429-2430. doi:10.1001/jama.2015.6408

Clinical trials have demonstrated that sudden cardiac death after an acute myocardial infarction (MI) can be prevented in patients at high risk by inserting an implantable cardioverter-defibrillator (ICD). Guidelines from the American Heart Association (AHA), American College of Cardiology (ACC), and the Heart Rhythm Society (HRS) state that ICD therapy is indicated for patients with left ventricular ejection fraction (EF) less than or equal to 35% due to prior MI who are at least 40 days after MI and are in New York Heart Association Class (NYHA) II or III or in patients who have an EF less than or equal to 30% and are in NYHA Class I.1 These indications are supported by the highest levels of evidence (Level A) and based in part on major clinical trials like the Multicenter Automatic Defibrillator Implantation Trial II2 and Sudden Cardiac Death in Heart Failure Trial,3 which showed that ICD therapy in high-risk individuals with coronary artery disease results in a relative risk reduction for total mortality of between 20% and 30%. In a subsequent article published by the AHA, ACC, and HRS and endorsed by the American Geriatrics Society, the only age-specific comorbidity that would make a primary prevention ICD “rarely appropriate” was if a patient 90 years or older was in NYHA Class I.4