Elsevier

International Journal of Cardiology

Volume 314, 1 September 2020, Pages 64-69
International Journal of Cardiology

Prognostic value of Charlson Comorbidity Index in the elderly with a cardioverter defibrillator implantation

https://doi.org/10.1016/j.ijcard.2020.03.060Get rights and content

Highlights

  • 5-year survival rate was 29% in elderly with Charlson Comorbidity Index ≥ 4.

  • Elderly with Charlson Comorbidity Index ≥ 4 had the lowest cumulative incidence of appropriate therapy.

  • Survival was not different between elderly with Charlson Comorbidity Index 0–1 and youngers.

  • Appropriate therapy rates were not different between those 2 groups.

  • Charlson Comorbidity Index score is helpful to better select elderly candidates for ICD implantation.

Abstract

Background

Elderly patients are often underrepresented in implantable cardioverter defibrillator (ICD) trials, and ICD implantation in patients ≥75 years consequently remains controversial. We aimed to evaluate mortality, appropriate ICD therapy rates and survival gain in an elderly population after risk stratification according to the Charlson Comorbidity Index (CCI).

Methods

This monocentric retrospective study included elderly ICD patients ≥75 years. They were subdivided according to their CCI score into 3 categories (0–1, 2–3 or ≥4 points). Elderly patients were matched 1:2 with younger control ICD patients on gender, type of prevention (primary or secondary) and type of device (associated cardiac resynchronization therapy or not).

Results

Between January 2009 and July 2017, 121 elderly patients (mean age 78 ± 3; 83% male) matched with 242 controls (mean age 66 ± 5) were included. At 5 year follow-up after ICD implantation, overall survival was 78%, 57%, and 29% (P = 0.002) in the elderly with a CCI score of 0-1, 2-3 and ≥4 respectively, and 72% in controls. There was no significant difference regarding ICD appropriate therapy between the 3 subgroups despite a trend towards lower rates of therapy in CCI ≥ 4 points patients (34.2%, 39.7% and 22.8% respectively; P = 0.45). Median potential survival gain after an appropriate therapy was >5, 4.7 and 1.4 years, with a CCI score of 0-1, 2-3 and ≥4 respectively (P = 0.01).

Conclusion

Elderly patients with CCI score ≥ 4 had the lowest survival after ICD implantation and little survival gain in case of appropriate defibrillator therapy. More than age alone, the burden of comorbidities assessed by the CCI could be helpful to better select elderly patients for ICD implantation.

Introduction

Even though by now, the benefits of implantable cardioverter defibrillator (ICD) have been clearly established in many indications, potential overuse of this therapy has been pointed out by different studies and its cost-effectiveness is also being debated [1,2].

In elderly patients, comorbidities have a meaningful impact on life expectancy, which may increase competing risk with arrhythmic death and therefore reduce overall effectiveness of ICD therapy [3]. Moreover, there is a lack of evidence-based data regarding the benefit of ICD therapy in elderly patients, since most individuals enrolled in large randomized trials have been <70 years old [4,5]. This selected population contrasts with real-life older comorbid patients, who may theoretically be eligible for an ICD implantation [6].

Several studies have identified variables of interest to stratify non-sudden cardiac death and while different scores have been published, they are not used in clinical practice, due to their complexity or lack of external validity [4,[7], [8], [9]]. The Charlson Comorbidity Index (CCI) is a simple standardized score used to predict mortality with respect to the weight of comorbidities in diverse pathologies [10,11].

This study aimed to assess whether the CCI, a simple standardized score, could be valuable to stratify ICD therapy usefulness regarding survival, occurrence of appropriate shock and potential survival gain in elderly patients ≥75 years old.

Section snippets

Study design

This retrospective single-center registry included consecutive elderly patients who were referred to our institution for ICD implantation between January 2009 and July 2017. Inclusion criteria were: i) Patient ≥75 years at the time of implantation; and ii) De novo primary or secondary prevention ICD implantation (including up-grading from pacemaker to defibrillator therapy).

To obtain a point of comparison, these elderly patients were matched with control adult patients, aged <75 years at the

Population characteristics

A total of 121 patients (mean age 78.0 ± 2.6 years; 83% males) ≥ 75 years-old at the time of ICD implantation were enrolled in this study. Of them, 89 (74%) were implanted for primary prevention of sudden cardiac death and 62 (51%) had cardiac resynchronization therapy. Baseline characteristics of elderly patients are detailed in Table 1. Age, sex, body mass index and NYHA class were not statistically different between the 3 subgroups. As expected, numerous differences were found, with many

Discussion

The current study assessed the triage value of CCI regarding mortality, appropriate therapy rates and survival gain after therapy in ICD recipients ≥75 years. The main findings can be summarized as follows: i) Prognosis after ICD implantation in the elderly population is heterogeneous; ii) For elderly with few comorbidities (CCI 0–1 point), survival after ICD implantation was not significantly different than in the control group, of which the mean age was 66 ± 5 years); and iii) a high

Conclusion

In this community-based of elderly patients, comorbidities were found to have a major impact on prognosis after defibrillator implantation. A CCI score ≥ 4 was significantly associated with higher mortality rates and limited survival gain despite appropriate therapy. In order to better detect elderly subjects who may derive less benefit of ICD implantation, a comorbid burden assessment using the CCI appears simple and relevant.

The following are the supplementary data related to this article.

CRediT authorship contribution statement

Pierre Poupin: Data curation, Investigation, Writing - original draft, Writing - review & editing. Claire Bouleti: Writing - original draft, Writing - review & editing. Bruno Degand: Investigation, Data curation, Validation, Writing - original draft. Marc Paccalin: Validation, Writing - original draft. François Le Gal:Investigation, Data curation, Writing - original draft. Marie-Laure Bureau: Investigation, Writing - original draft. Benjamin Alos: Data curation, Writing - original draft. Pierre

Acknowledgment

The authors thank Jeffrey Arsham for rereading the manuscript.

Grant support

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

Dr. Garcia received consulting fees from St. Jude Medical and Boston Scientific. Dr. Le Gal and Dr. Degand received consulting fees from Sorin Group, St. Jude Medical and Boston Scientific. The other authors have no conflict of interest.

References (26)

  • D.G. Katritsis et al.

    Sudden cardiac death and implantable cardioverter defibrillators: two modern epidemics?

    Europace

    (2012)
  • S. Barra et al.

    Implantable cardioverter-defibrillators in the elderly: rationale and specific age-related considerations

    Europace

    (2015)
  • G.H. Bardy et al.

    Amiodarone or an implantable cardioverter–defibrillator for congestive heart failure

    N. Engl. J. Med.

    (2005)
  • Cited by (11)

    • Participation in Sports and Physical Activities After Total Joint Arthroplasty

      2023, Journal of Arthroplasty
      Citation Excerpt :

      Demographic information such as age, sex, body mass index (BMI), primary TJA date, and laterality of TJA were obtained from our institutional arthroplasty database, which collects data prospectively. Nonage adjusted Charlson Comorbidity Index (CCI) was obtained from our institutional database [16]. For patients who did not have a recorded CCI in the database, electronic medical records were manually reviewed to calculate the CCI.

    • The Impact of Charlson Comorbidity Index on De Novo Cardiac Implantable Electronic Device Procedural Outcomes in the United States

      2022, Mayo Clinic Proceedings
      Citation Excerpt :

      Other studies have focused on specific types of devices (eg, ICD), despite well-recognized differences in the complexity of procedures between CIED types, or certain outcomes (eg, composite in-hospital complications or 1-year mortality), which does not inform operators about the impact of CCI score on specific postprocedural outcomes.18-21,23 Furthermore, many studies have included de novo and upgrade CIED procedures despite the different procedural risks of each procedure type.20,21,23 In our analysis, a significant number of patients undergoing CIED implantation are classed as having severe comorbidity burden as measured by the CCI score (CCI≥3), with the lowest (36.0%) and highest prevalence (60.8%) being among those undergoing dual-chamber PPM and CRT-D, respectively.

    View all citing articles on Scopus
    1

    This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

    View full text