Prognostic value of Charlson Comorbidity Index in the elderly with a cardioverter defibrillator 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.
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- 1
This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.