Implantable Cardioverter-Defibrillator Use Among Medicare Patients With Low Ejection Fraction After Acute Myocardial Infarction

Sean D Pokorney, Amy L Miller, Anita Y Chen, Laine Thomas, Gregg C Fonarow, James A de Lemos, Sana M Al-Khatib, Eric D Peterson, Tracy Y Wang
JAMA: the Journal of the American Medical Association 2015 June 23, 313 (24): 2433-40

IMPORTANCE: Implantable cardioverter-defibrillators (ICDs) are not recommended within 40 days of myocardial infarction (MI); thus, ICD implantation might not be considered during the post-MI care transition.

OBJECTIVE: To examine ICD implantation rates and associated mortality among older MI patients with low ejection fraction (EF).

DESIGN, SETTING, AND PARTICIPANTS: Retrospective observational study of Medicare beneficiaries with an EF of 35% or less after MI, treated at 441 US hospitals between 2007 and 2010, excluding patients with prior ICD implantation. Follow-up data were available through December 2010.

EXPOSURES: ICD implantation within 1 year of MI vs no ICD implantation within 1 year of MI.

MAIN OUTCOMES AND MEASURES: Patient characteristics associated with receiving an ICD within 1 year after discharge and 2-year mortality associated with ICD implantation.

RESULTS: Among 10,318 MI patients with EF of 35%or lower, the cumulative 1-year ICD implantation rate was 8.1% (95%CI, 7.6%-8.7%). Patients with ICD implantation were more likely to have prior coronary artery bypass graft procedures, higher peak troponin levels, in-hospital cardiogenic shock, and cardiology follow-up within 2 weeks after discharge relative to patients who did not receive an ICD within 1 year. Implantation of ICD was associated with lower 2-year mortality (15.3 events per 100 patient-years [128 deaths in 838 patient-years] vs 26.4 events per 100 patient-years [3033 deaths in 11 479 patient-years]; adjusted HR, 0.64; 95%CI, 0.53-0.78). [table: see text]

CONCLUSIONS AND RELEVANCE: In this large registry study of older patients who experienced MI from 2007-2010, fewer than 1 in 10 eligible patients with low EF received an ICD within 1 year after MI, although ICD implantation was associated with lower risk-adjusted mortality at 2 years. Additional research is needed to determine evidence-based approaches to increase ICD implantation among eligible patients.

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MUST and MADIT criteria could help this problem. However, holding therapy do to Federal Guidelines and not knowledge based medical guidelines makes all physicians uncomfortable. Therefore, the advent of the Life-Vest industry.


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