Over one-fifth of US patients with ICDs lack suitable indication
MedWire News: More than 20% of US patients recently fitted with an implantable cardioverter-defibrillator (ICD) received the device for a non-evidence-based indication, study findings show.
The research, published in JAMA, also shows a significantly higher, albeit modestly so, risk for in-hospital mortality and postprocedure complications among patients with non-evidence-based ICDs compared with those with evidenced-based ICDs.
"Although the absolute difference in complications between the two groups is modest, these complications could have significant effects on patients' quality of life and healthcare use, including length of hospital stay and costs," explain the authors, led by Sana Al-Khatib from Duke Clinical Research Institute in Durham, North Carolina, USA.
They add: "While a small risk of complications is acceptable when a procedure has been shown to improve outcomes, no risk is acceptable if a procedure has no demonstrable benefit."
Al-Khatib and colleagues analyzed the stated indications for 111,707 ICD implantations recorded in the National Cardiovascular Data Registry-ICD registry from January 2006 through June 2009. They found that 25,145 (22.5%) of ICDs were implanted for non-evidence-based indications, namely acute myocardial infarction (8.2%), recent coronary revascularization (0.7%), New York Heart Association (NYHA) class IV heart failure (HF; 2.7%), and newly diagnosed HF (14.0%).
As national evidence-based guidelines do not recommend ICD implantation for these conditions, the researchers say that "more efforts should focus on enhancing adherence to evidence-based practice."
On analysis of post-ICD implantation patient outcomes, Al-Khatib and colleagues found that patients with non-evidence-based ICDs had higher rates of both in-hospital mortality and postprocedure complications (eg, death, pneumothorax, and infection) than those with evidence-based ICDs, at 0.57% versus 0.18% and 3.23% versus 2.41%, respectively (p<0.001 for both).
Of note, non-evidence-based ICDs were implanted by non-electrophysiologists significantly more often than by electrophysiologists.
This suggests that "physicians require further education to understand the rationale for the guidelines and potential alternative approaches when a patient does not meet guidelines for ICD implantation," Alan Kadish and Jeffrey Goldberger, both from Northwestern University in Chicago, Illinois, USA, wrote in an accompanying editorial.
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By Lauretta Ihonor