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The Mode of Death in Implantable Cardioverter-Defibrillator and Cardiac Resynchronization Therapy With Defibrillator Patients: Results From Routine Clinical Practice
Study Questions:
What is the mode of death in patients undergoing implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) in clinical practice?
Methods:
This was a retrospective analysis of a single-center prospectively collected database of all patients undergoing ICD and/or CRT-defibrillator (CRT-D) therapy at Leiden University Medical Center for primary and secondary prevention according to guidelines. Cause of death was categorized as cardiac death, noncardiac death, and sudden death.
Results:
There were 2,859 patients undergoing device implant who were followed a median 3.4 years. Patients in the CRT-D group were older with lower ejection fractions. Cumulative mortality over 2, 4, and 8 years was 10%, 20%, and 39.9%, respectively. Mortality in the primary prevention group was 14% (n = 107), and 35% (n = 37) of these patients died of heart failure, 7% (n = 7) of sudden death, and 33% (n = 35) of noncardiac causes. Mortality in the secondary prevention group was 28% (n = 253), with 28% (n = 71) of deaths due to heart failure and 38% (n = 95) from noncardiac causes. In the CRT-D group, 25% (n = 302) of patients died. Heart failure was the mode of death in 43% (n = 131) and 30% (n = 92) died of noncardiac causes. Overall, the 8-year cumulative incidence (95% confidence interval) of death from heart failure was 8.6% (7.1-12%) in the primary prevention group, 9.6% (7.1-12%) in the secondary prevention group, and 22.6% in the CRT-D group. Sudden death occurred in 7% (n = 49) of patients with an 8-year cumulative incidence of 2.1% (0.3-4.0%), 3.2% (1.6-4.8%), and 3.6% (1.8-5.3%) in the primary, secondary, and CRT-D groups, respectively.
Conclusions:
The authors concluded that most patients undergoing ICD or CRT-D implant die of heart failure or noncardiac causes.
Perspective:
The authors demonstrated that patients in a clinical setting have lower annual mortality rates in general and lower heart failure mortality rates than those enrolled into major clinical trials of ICD and CRT-D therapy. While patients undergoing ICD implant for secondary prevention had higher ejection fractions at baseline, they had a rate of heart failure death similar to that of patients undergoing device implant for primary prevention. The CRT-D group had the worst outcomes, but also had sicker clinical characteristics at baseline (e.g., older age, lower ejection fraction, worse renal function).
Keywords: Heart Diseases, Cause of Death, Incidence, Defibrillators, Cardiac Pacing, Artificial, Heart Failure, Death, Sudden, Cardiac, Defibrillators, Implantable, Primary Prevention, Cardiac Resynchronization Therapy
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