The Providence VA Medical Center - Rhode Island Medical Society

THE WARREN ALPERT MEDICAL SCHOOLOF BROWN UNIVERSITYDivision of GeriatricsDepartment of MedicineGERIATRICS FOR THEPRACTICING PHYSICIANSudden Cardiac Death and Implantable CardioverterDefibrillations (ICD) and the Older AdultSudden cardiac arrest (SCA) usually results from a hemodynamicallyunstable heart rhythm-ventricular fibrillation or ventriculartachycardia. Failure or absence of resuscitation results insudden cardiac death (SCD). There are 450,000 cases of SCDannually in the United States. Rate of survival following SCAhas not changed over the past three decades. 1 Survival afterhospital discharge, however, has improved, partly due to thedevelopment of implantable cardioverter defibrillators (ICDs).In 2005, the Centers for Medicaid and Medicare Services estimatedthat 500,000 Medicare beneficiaries were candidates forICD placement. 2 ICD prescription in elderly patients entailsparticular considerations, given common co-morbidities andhigher rates of non-cardiac mortality. ICD implantation shouldnot be regarded as routine in elders; each case should be consideredindividually. Geriatricians and other primary care physiciansplay a key role in the judicious selection of candidates forthis potentially life-saving therapy.RISK OF SCD IN ELDERLYThe prevalence of coronary artery disease (CAD) increaseswith age, along with risk of SCD. The proportion of CADdeaths attributed to SCD, however, decreases with age. In theFramingham study, 62% in men aged 45-54 years old whodied of CAD experienced SCD. 3 This percentage fell to 58%in men aged 55-64 years and to 42% in men aged 65-74 years.Congestive heart failure is responsible for a higher proportionof deaths in the elderly population. Advanced age, however, isassociated with a poor outcome following cardiac arrest. In areview of 5,882 cases of out-of-hospital cardiac arrest, octogenariansexperienced a hospital discharge rate of 9%, comparedto 19% in a younger group. 4 In a second series of 12,000patients treated by emergency medical service personnel forSCA, every one-year increase in age was associated with a significantlylower likelihood of survival. 1Omar Hyder, MD, and Ohad Ziv, MDQuality Partners of RIEDITED BY ANA TUYA FULTON, MDINDICATIONS FOR ICD PRESCRIPTIONOver the past two decades, studies identified ICDs as an effectiveprevention strategy of SCD. In survivors of SCA, ICDs arethe secondary prevention strategy of choice. 5,6 Patients at highriskalso benefit from prophylactic ICD implantation. TheMADIT II and MUSTT studies demonstrated a survival benefitin patients with reduced ejection fraction (