The mortality analysis of primary prevention patients receiving a cardiac resynchronization defibrillator (CRT-D) or implantable cardioverter-defibrillator (ICD) according to guideline indications in the improve SCA study

BACKGROUND

In primary prevention (PP) patients the utilization of implantable cardioverter-defibrillators (ICD) and cardiac resynchronization therapy-defibrillators (CRT-D) remains low in many geographies, despite the proven mortality benefit.

PURPOSE

The objective of this analysis was to examine the mortality benefit in PP patients by guideline-indicated device type: ICD and CRT-D.

METHODS

Improve sudden cardiac arrest was a prospective, nonrandomized, nonblinded multicenter trial that enrolled patients from regions where ICD utilization is low. PP patient's CRT-D or ICD eligibility was based upon the 2008 ACC/AHA/HRS and 2006 ESC guidelines. Mortality was assessed according to guideline-indicated device type comparing implanted and nonimplanted patients. Cox proportional hazards methods were used, adjusting for known factors affecting mortality risk.

RESULTS

Among 2618 PP patients followed for a mean of 20.8 ± 10.8 months, 1073 were indicated for a CRT-D, and 1545 were indicated for an ICD. PP CRT-D-indicated patients who received CRT-D therapy had a 58% risk reduction in mortality compared with those without implant (adjusted hazard ratio [HR]: 0.42, 95% confidence interval [CI]: 0.28-0.61, p < .0001). PP patients with an ICD indication had a 43% risk reduction in mortality with an ICD implant compared with no implant (adjusted HR: 0.57, 95% CI: 0.41-0.81, p = .002).

CONCLUSIONS

This analysis confirms the mortality benefit of adherence to guideline-indicated implantable defibrillation therapy for PP patients in geographies where ICD therapy was underutilized. These results affirm that medical practice should follow clinical guidelines when choosing therapy for PP patients who meet the respective defibrillator device implant indication.

Significant regional variation in use of implantable cardioverter-defibrillators in Denmark

AIMS

Implantable cardioverter-defibrillator (ICD) treatment prevents sudden cardiac death in high-risk patients. This study examined geographical variation in ICD implantation rates in Denmark and potential causes of variation.

METHODS AND RESULTS

We obtained numbers of ICD implantations in the 5 Danish regions and 98 municipalities during 2007-13 from the Danish Pacemaker and ICD Registry. Standardized implantation rates (SIRs) were computed as ICD implantations per 1 000 000 person-years, and age- and gender-standardized to the Danish population. We examined associations of the municipal SIR with mean age and Charlson Comorbidity Index score of ICD recipients, percentage of implantations with primary prophylactic indication, and distance from patient residency to ICD implanting centre. Based on 7192 ICD implantations, the nationwide SIR was 186 [95% confidence interval (CI) 182-190], ranging from 170 (95% CI 158-183) in the North Denmark Region to 206 (95% CI 195-218) in the Region of Zealand. Municipalities with higher patient comorbidity scores, higher percentages of implantations with primary prophylactic indication, and shorter distances to ICD implanting centres, had higher SIRs [differences between SIRs of municipalities in highest and lowest quartiles 22 (95% CI 10-34), 45 (95% CI 33-58), and 35 (95% CI 24-47), respectively]. Regional differences in SIRs decreased over time and had become insignificant during 2011-13.

CONCLUSION

Implantable cardioverter-defibrillator implantation rates in Denmark varied significantly between regions but variation decreased during 2007-13. Geographical variation was associated with differences in patient comorbidity score, variation in use of primary prophylactic ICD treatment, and distance to ICD implanting centre.

Consideration for primary prevention implantable cardioverter defibrillators differ between specialities

PURPOSE

Implantable cardioverter defibrillator (ICD) implantation rates remain variable despite established guideline recommendations. This study aims to assess whether being managed by a cardiologist has an impact on whether patients are considered for an ICD for primary prevention of sudden cardiac death.

DESIGN/METHODS

Single-centre, retrospective, observational study of patients identified to have severe left ventricular systolic dysfunction (LVSD) on echocardiography (n = 129) between 1 and 30 June 2016 with cross-sectional assessment at 1 year. An assessment of ICD consideration at 1 year following the echocardiogram was documented, in addition to the specialty of the managing physician (group 1-electrophysiologist/heart failure specialist; group 2-all other cardiologists; group 3-non-cardiologist).

RESULTS

129/1173 (11%) transthoracic echocardiographies (s) were identified to have severe LVSD. 52 (40%), 37 (29%) and 40 (31%) were managed by group 1, group 2 and group 3, respectively. Mean age was 74.7 (±12.6) years with a predominance of male gender (70.5%). An ICD was not considered in 47.3%. Those managed by a cardiologist were more likely to be considered for an ICD than a non-cardiologist (63.9% vs 30.0%; OR 4.0, 95% CI 1.8 to 8.8, p = 0.001) with a greater survival at 1 year (89.9% vs 52.5%, OR 8.1 95% CI 3.2 to 20.4, p < 0.001). Group 1 were more likely to consider ICD than group 2 cardiologists (75.0% vs 45.9%; OR 3.5; 95% CI 1.4 to 8.7, p = 0.005).

CONCLUSION

There is significant variation between cardiologists and non-cardiologists, as well as within different cardiology subspecialists, when considering the option of ICD therapy for primary prevention.

Temporal Trends of Cardiac Implantable Electronic Device Implantations: a Nationwide Population-based Study

Background and Objectives

Implantation of cardiac implantable electronic devices (CIED), including permanent pacemakers (PM), implantable cardioverter-defibrillators (ICD), and cardiac resynchronization therapy (CRT) devices, has increased significantly over the past several years. However, limited data exists regarding temporal trends of CIED implantations in Asian population. This study aimed to investigate temporal trends of CIED treatment in Korea.

Methods

Using the National Health Insurance Service database of the entire Korean adult population, temporal trends of CIED procedures between 2009 and 2016 were evaluated. Additionally, temporal changes in the prevalence of patients' comorbidities were evaluated.

Results

A total of 35,421 CIED procedures (new implantations: 27,771, replacements: 7,650) were performed during the study period. The mean age of new CIED recipients and the prevalence of comorbidities, including hypertension, diabetes mellitus, heart failure, stroke, and atrial fibrillation, increased substantially with time. Compared to 2009, the number of new implantations of PM, ICD, and CRT devices increased by 2.0 (1,977 to 3,910), 3.6 (230 to 822), and 4.9 (44 to 217) times in 2016, respectively. The annual new implantation rate of CIED also increased accordingly (5.1 to 9.3 for PM, 0.6 to 1.9 for ICD, and 0.1 to 0.5 for CRT devices, per 100,000 persons).

Conclusions

The number of CIED implantation increased substantially from 2009 to 2016 in Korea. Also, the patients with CIED have been changed to be older and have more comorbidities. Therefore, the burden of health care cost in patients with CIED would be expected to increase in the future.

Five year trends (2008-2012) in cardiac implantable electrical device utilization in five European nations: a case study in cross-country comparisons using administrative databases

Aims

Common methodologies for analysis of analogous data sets are needed for international comparisons of treatment and outcomes. This study tests using administrative hospital discharge (HD) databases in five European countries to investigate variation/trends in pacemaker (PM) and implantable cardioverter defibrillator (ICD) implant rates in terms of patient characteristics/management, device subtype, and initial implantation vs. replacement, and compares findings with existing literature and European Heart Rhythm Association (EHRA) reports.

Methods and results

HD databases from 2008 to 2012 in Austria, England, Germany, Italy and Slovenia were interrogated to extract admissions (without patient identification) associated with PM and ICD implants and replacements, using direct cross-referencing of procedure codes and common methodology to compare aggregate data. 1 338 199 records revealed 212 952 PM and 62 567 ICD procedures/year on average for a 204.4 million combined population, a crude implant rate of about 104/100 000 inhabitants for PMs and 30.6 for ICDs. The first implant/replacement rate ratios were 81/24 (PMs) and 25/7 (ICDs). Rates have increased, with cardiac resynchronization therapy (CRT) subtypes for both devices rising dramatically. Significant between- and within-country variation persists in lengths of stay and rates (Germany highest, Slovenia lowest). Adjusting for age lessened differences for PM rates, scarcely affected ICDs. Male/female ratios remained stable at 56/44% (PMs) and 79/21% (ICDs). About 90% of patients were discharged to home; 85-100% were inpatient admissions.

Conclusion

To aid in policymaking and track outcomes, HD administrative data provides a reliable, relatively cheap, methodology for tracking implant rates for PMs and ICDs across countries, as comparisons to EHRA data and the literature indicated.

The Atlantic divide in coronary heart disease: Epidemiology and patient care in the US and Portugal

INTRODUCTION AND OBJECTIVES

We aimed to compare access to new health technologies to treat coronary heart disease (CHD) in the health systems of Portugal and the US, characterizing the needs of the populations and the resources available.

METHODS

We reviewed data for 2000 and 2010 on epidemiologic profiles of CHD and on health care available to patients. Thirty health technologies (16 medical devices and 14 drugs) introduced during the period 1980-2015 were identified by interventional cardiologists. Approval and marketing dates were compared between countries.

RESULTS

Relative to the US, Portugal has lower risk profiles and less than half the hospitalizations per capita, but fewer centers per capita provide catheterization and cardiothoracic surgery services. More than 70% of drugs were available sooner in the US, whereas 12 out of 16 medical devices were approved earlier in Portugal. Nevertheless, at least five of these devices were adopted first or diffused faster in the US. Mortality due to CHD and myocardial infarction (MI) was lower in Portugal (CHD: 72.8 vs. 168 and MI: 48.7 vs. 54.1 in Portugal and the US, respectively; age- and gender-adjusted deaths per 100000 population, 2010); but only CHD deaths exhibited a statistically significant difference between the countries.

CONCLUSIONS

Differences in regulatory mechanisms and price regulations have a significant impact on the types of health technologies available in the two countries. However, other factors may influence their adoption and diffusion, and this appears to have a greater impact on mortality, due to acute conditions.

Investigating Regional Variation of Cardiac Implantable Electrical Device Implant Rates in European Healthcare Systems: What Drives Differences?

Despite established efficacy for cardiac implantable electrical devices (CIEDs), large differences in CIED implant rates have been documented across and within countries. The aim of this paper is to investigate the influence of socio-economic, epidemiological and supply side factors on CIED implant rates across 57 Regions in 5 EU countries and to assess the feasibility of using administrative data for this purpose. A total of 1 330 098 hospitalizations for CIED procedures extracted from hospital discharge databases in Austria, England, Germany, Italy and Slovenia from 2008 to 2012 was used in the analysis. Higher levels of tertiary education among the labour force and percent of aged population are positively associated with implant rates of CIED. Regional per capita GDP and number of implanting centres appear to have no significant effect. Institutional factors are shown to be important for the diffusion of CIED. Wide variation in CIED implant rates across and within five EU countries is undeniable. However, regional factors play a limited part in explaining these differences with few exceptions. Administrative databases are a valuable source of data for investigating the diffusion of medical technologies, while the choice of appropriate modelling strategy is crucial in identifying the drivers for variation across countries. © 2017 The Authors. Health Economics published by John Wiley & Sons, Ltd.

Is There a Role for Genetics in the Prevention of Sudden Cardiac Death?

The identification of patients at risk for sudden cardiac death (SCD) is fundamental for both acquired cardiovascular diseases (such as coronary artery diseases, CAD) and inherited arrhythmia syndromes (such as the long-QT syndrome, LQTS). Genetics may play a role in both situations, although the potential to exploit this information to reduce the burden of SCD varies among these two groups. Concerning acquired cardiovascular diseases, which affect most of the general population, preliminary data suggest an association between genetics and the risk of dying suddenly. The maximal utility, instead, is reached in inherited arrhythmia syndromes, where the discovery of monogenic diseases such as LQTS tracked the way for the first genotype-phenotype correlations. The aim of this review is to provide a general overview focusing on the current genetic knowledge and on the present and future applicability for prevention in these two populations at risk for SCD.

Implant rates of cardiac implantable electrical devices in Europe: A systematic literature review

BACKGROUND

In recent years, indications for cardiac implantable electrical devices (CIEDs) have broadened; however, budget constraints can significantly impact patient access to these life-saving health technologies.

OBJECTIVE

To perform a systematic literature review on the implant rates of pacemakers, cardioverter-defibrillators, and cardiac resynchronization therapy devices in Europe over the last decade to provide insight into the possible reasons for differences across regions or countries.

METHODS

Four electronic databases were searched to find studies describing CIED implant rates in Europe. Fifty-eight studies were included.

RESULTS

An overview showed a recent rise in CIED implants, with large geographic differences. The ratio between the regions with the highest and lowest implant rates within the same country ranged between 1.3 and 3.4 for pacemakers and between 1.7 and 44.0 for defibrillators. The ratio between the countries with the highest and lowest implant rates ranged between 2.3 and 87.5 for pacemakers, between 3.1 and 1548.0 for defibrillators, and between 4.1 and 221.0 for resynchronization therapy devices. Implant rate variability appears to be influenced by health care, economic, demographic, and cultural factors.

CONCLUSION

Publications on CIED implant rates in Europe show a wide variability within and across countries, the determinants of which are only partially investigated. Policy making should improve regarding equity of access to better care.

Sudden cardiac death risk stratification

Arrhythmic sudden cardiac death (SCD) may be caused by ventricular tachycardia/fibrillation or pulseless electric activity/asystole. Effective risk stratification to identify patients at risk of arrhythmic SCD is essential for targeting our healthcare and research resources to tackle this important public health issue. Although our understanding of SCD because of pulseless electric activity/asystole is growing, the overwhelming majority of research in risk stratification has focused on SCD-ventricular tachycardia/ventricular fibrillation. This review focuses on existing and novel risk stratification tools for SCD-ventricular tachycardia/ventricular fibrillation. For patients with left ventricular dysfunction or myocardial infarction, advances in imaging, measures of cardiac autonomic function, and measures of repolarization have shown considerable promise in refining risk. Yet the majority of SCD-ventricular tachycardia/ventricular fibrillation occurs in patients without known cardiac disease. Biomarkers and novel imaging techniques may provide further risk stratification in the general population beyond traditional risk stratification for coronary artery disease alone. Despite these advances, significant challenges in risk stratification remain that must be overcome before a meaningful impact on SCD can be realized.

Using quality indicators to compare outcomes of permanent cardiac pacemaker implantation among publicly and privately funded patients

BACKGROUND

Funding source/insurance status has been associated with disparity in the management and outcomes of cardiovascular disease, with poorer outcomes among disadvantaged groups.

AIM

Using proposed quality indicators for permanent pacemaker (PPM) implantation and administrative data, this study aimed to determine whether quality indicator-based outcomes of PPM implantation were comparable for publicly and privately funded patients within Australia's two-tier health system.

METHODS

A population-based cohort study of adults implanted with a PPM between 1995 and 2009 in Western Australia. The association of funding outcomes derived from linked administrative data was tested in multivariate logistic regression models.

RESULTS

There were 9748 PPMs implanted, 48% being among privately funded patients. The mean age was 75 years for both public and private patients. Private patients had better health status (fewer with cardiac conditions and lower non-cardiac comorbidity scores), were less likely to be an emergency admission (33% vs 60%, P < 0.001) and more likely to have dual- or triple-chamber pacing. Mean length of stay was significantly greater for private patients (4.3 (standard deviation 6.3) vs 5.1 (6.8) days <0.001), related to longer elective admissions. Crude mortality was lower for private patients in-hospital (0.7 vs 1.3%), 30-day post-procedure (1.3 vs 2.1%) and at 1 year (7.3 vs 9.5%). Emergency admission, comorbidity and other demographic and clinical factors, not funding source, were significant predictors of these outcomes.

CONCLUSIONS

There was no difference between publicly and privately funded patients in study outcomes, after adjustment for demographic and clinical factors. The exception was longer hospital stay for elective PPM among privately funded patients.

The usual suspects in sudden cardiac death of the young: a focus on inherited arrhythmogenic diseases

Up to 14,500 young individuals die suddenly every year in Europe of cardiac pathologies. The majority of these tragic events are related to a group of genetic defects that predispose the development of malignant arrhythmias (inherited arrhythmogenic diseases [IADs]). IADs include both cardiomyopathies (hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, dilated cardiomyopathy) and channelopathies (long QT syndrome, short QT syndrome, Brugada syndrome and catecholaminergic polymorphic ventricular tachycardia). Every time an IAD is identified in a patient, other individuals in his/her family may be at risk of cardiac events. However; if a timely diagnosis is made, simple preventative measures may be applied. Genetic studies play a pivotal role in the diagnosis of IADs and may help in the management of patients and their relatives.

Current use of implantable electrical devices in Sweden: data from the Swedish pacemaker and implantable cardioverter-defibrillator registry

AIMS

The National Swedish Pacemaker and Implantable Cardioverter-Defibrillator (ICD) Registry collects prospective data on all pacemaker and ICD implants in Sweden. We aimed to report the 2012 findings of the Registry concerning electrical devices implantation rates and changes over time, 1 year complications, long-term device longevity and patient survival.

METHODS AND RESULTS

Forty-four Swedish implanting centres continuously contribute implantation of pacemakers and ICDs to the Registry by direct data entry on a specific website. Clinical and technical information on 2012 first implants and postoperative complications were analysed and compared with previous years. Patient survival data were obtained from the Swedish population register database. In 2012, the mean pacemaker and ICD first implantation rates were 697 and 136 per million inhabitants, respectively. The number of cardiac resynchronization therapy (CRT) first implantations/million capita was 41 (CRT pacemakers) and 55 (CRT defibrillators), with only a slight increase in CRT-ICD rate compared with 2011. Most device implantations were performed in men. Complication rates for pacemaker and ICD procedures were 5.3 and 10.1% at 1 year, respectively. Device and lead longevity differed among manufacturers. Pacemaker patients were older at the time of first implant and had generally worse survival rate than ICD patients (63 vs. 82% after 5 years).

CONCLUSION

Pacemaker and ICD implantation rates seem to have reached a level phase in Sweden. Implantable cardioverter-defibrillator and CRT implantation rates are very low and do not reflect guideline indications. Gender differences in CRT and ICD implantations are pronounced. Device and patient survival rates are variable, and should be considered when deciding device type.

Sudden cardiac death: a critical appraisal of the implantable cardioverter defibrillator

IMPORTANCE

Approximately 350,000 Americans still die of sudden cardiac death each year. This exceeds the number of patients who die annually from stroke, lung cancer, breast cancer and AIDS combined.

OBJECTIVE

This review aims to trace the history of implantable cardioverter defibrillators (ICD) with reference to landmark trials and their influence on the formulation of Medicare guidelines for ICD implantation criteria. This paper will also discuss the cost-effectiveness of ICDs and the quality of life after implantation. The reasons for the disparity between guidelines for implantation and actual clinical practice will be elucidated, with suggestions for improving overall clinical performance.

RESULTS AND CONCLUSION

The ICD has been shown to be cost-effective in reducing sudden cardiac death and all-cause mortality. However, the existing recommendations for ICD implantation have yet to translate completely into clinical practice. Barriers to implementation of existing guidelines include knowledge gaps in the referring physician practices, lack of validated screening tools to assess patient candidacy for the device and patient understanding of the need for the device. Future strategies to increase compliance with the existing guidelines and improve clinical performance are areas of potential research focus.

["Is it possible to do less?" The current state of the debate in Sweden]

The question "Is it possible to do less?" and the claim "Less is more!" can be answered and construed in different ways. One possible interpretation, which is well established in the Swedish health system, is "Accomplishing more (of the things that are important) by doing less (of the things that are dispensable)". Essentially, this is the basis of prioritisation in Swedish health care. While the concept of prioritisation is very well established in Sweden, the discussion about prioritising in Germany has always been difficult. It is, from a Swedish perspective, unclear why, of all things, health care should be exempted from prioritisation which otherwise is a necessity concerning all aspects of human and societal life. Some conditions complicate prioritisation in German health care, including the system of private and statutory health insurance and economic incentives which do not reward procedures based on indications. It will be argued that the Swedish health care system is more effective than the German not at least because of the system of prioritisation that allows for providing more necessary and essential health care instead of offering unnecessary and dubious procedures, thereby also improving patient outcome. (As supplied by publisher).

Assessing the outcomes of implantable cardioverter defibrillator treatment in a real world setting: results from hospital record data

BACKGROUND

A plethora of clinical studies have assessed the benefits of implantable cardioverter defibrillators (ICDs) and supported their use in clinical practice. However, evidence on the safety and efficacy of ICDs appears insufficient to support expansion of their use in clinical practice, and more information on their impact in real life settings is warranted. This paper aims to investigate the impact of ICDs using a large administrative dataset reflecting actual clinical practice.

METHODS

Data were obtained from the hospital discharge database of the Friuli Venezia Giulia region in Italy containing patient-level information on 169,488 cases. Data on mortality outside hospital were obtained from regional sources. Exact matching method was used to estimate the outcomes associated with ICDs: mortality, length of stay, re-hospitalization and regional expenditure. The method was applied in two steps. First, patients with ICDs were matched with those without using the following: age class (by 5 years), gender, year of admission, type of admission (day hospital vs. ordinary) and primary diagnosis. In the second step, matching included also Charlson Comorbidities Index. Exact matching average treatment effect on the treated (ATT) was used as a main measure of impact.

RESULTS

Compared with matched controls, treatment with ICDs was associated with lower mortality (absolute risk reduction 10.6% at 1 year and 8.3% at 2 and 8.4% at 3 years, p < 0.001 and hazard ratio 0.80, p < 0.001), greater regional expenditure at index hospitalization (ATT: €9459.64, p < 0.001) and during follow up (ATT: €1707.29, p < 0.001) and higher re-hospitalization rate (ATT: 0.53, p < 0.001). No significant difference was found for length of stay (9.07 vs. 8.86 days). The results were maintained after more restrictive matching was applied.

CONCLUSIONS

Assessing the impact of innovative, expensive medical technologies on the basis of real world data is warranted, especially when there are barriers to implementation. Hospital administrative datasets can be of great value when a technology such as the ICD is implemented in a relatively small sample of patients, to allow use of exact matching techniques.

Risk stratification for prevention of sudden cardiac death

OPINION STATEMENT

Sudden cardiac death (SCD) is a very prevalent cause of death in the United States. The majority of individuals who experience SCD do not survive the episode. Although there are ongoing efforts to improve resuscitation (ie, training in cardiopulmonary resuscitation, easy access to automatic external defibrillators), the primary modality addressing this public health problem is prevention by identification and treatment of high-risk cohorts. Current screening techniques have focused on identifying patients for primary prevention of ventricular tachyarrhythmias. Primary prevention therapies include medications, such as beta-blockers, statins, and angiotensin-converting enzyme inhibitors, and the implantable cardioverter defibrillator (ICD), whose use is currently focused on only the highest-risk subpopulations. The high-risk groups that are currently screened for consideration of an ICD for either primary or secondary prevention of SCD include those with a variety of cardiomyopathies, those with a history of previous aborted SCD, and those with genetic predispositions. In patients with ischemic cardiomyopathy and nonischemic dilated cardiomyopathy, the primary screening parameter to identify the highest-risk group (which is then subsequently screened for consideration of an ICD) is left ventricular ejection fraction (LVEF). Various other clinical factors and noninvasive test results are often combined with this information, but the optimal way in which this should be done has not been established. The array of noninvasive tests available includes those focusing on depolarization abnormalities, repolarization abnormalities, disturbed autonomic responses, and imaging. Unfortunately, current risk-stratification paradigms do not identify the majority of patients who will experience SCD. The fundamental reason for this is that the risk of SCD is truly lower in those without high-risk features such as depressed LVEF; however, the much larger number of patients with these lower-risk features translates into a larger absolute number of SCDs in this lower-risk group. In order to widen the scope of risk stratification, careful clinical study will be needed to develop appropriate testing strategies that can reliably identify patients at significant risk for ventricular tachyarrhythmias in the broader population.

Adoption of Transcatheter Aortic Valve Implantation in Western Europe

Transcatheter aortic valve implantation (TAVI) is a novel therapeutic option for patients with severe symptomatic aortic stenosis (AS) at excessive or high surgical risk for conventional surgical aortic valve replacement. First commercialised in Europe in 2007, TAVI growth has been exponential among some Western European nations, though recent evidence suggests heterogeneous adoption of this new and expensive therapy. Herein, we review the evidence describing the utilisation of TAVI in Western Europe.