Many May Get Unneeded Implantable
TUESDAY, Jan. 4 (HealthDay News) -- About 20 percent of U.S.
patients who receive an implantable cardioverter-defibrillator
(ICD) may not need it, a new study finds.
Patients who receive out-of-guideline ICDs are put at higher
risk of death and serious complications than patients who meet the
criteria for the life-saving device, the researchers say in the
Jan. 5 issue of the
Journal of the American Medical Association.
"Our findings highlight the importance of enhancing health-care practitioners' adherence to evidence-based practice," said lead researcher Dr. Sana M. Al-Khatib, an associate professor of medicine at the Duke Clinical Research Institute.
"There is a tremendous opportunity for improvement in site performance," she added.
For patients with advanced systolic heart failure, an ICD can
prevent sudden cardiac death. However, guidelines recommend against
its use in patients recovering from a heart attack or bypass
surgery or those with severe heart failure symptoms or a recent
diagnosis of heart failure, the researchers explained.
To determine how many ICDs are implanted outside the guidelines,
Al-Khatib and colleagues analyzed records from the National
Cardiovascular Data Registry's ICD Registry between January 2006
and June 2009.
During that time, 111,707 ICDs were implanted, of which 25,145
(22.5 percent) did not meet current criteria, the researchers
Among patients who received out-of-guideline implants, 36.8
percent had had a heart attack and 62.1 percent suffered from heart
Slightly more in-hospital deaths occurred among the
out-of-guideline group than among those whose ICD met the
guidelines (0.57 percent versus 0.18 percent) and their risk for
complications was also higher (3.23 percent versus 2.41 percent),
the research team found.
Overall, most ICDs were implanted by electrophysiologists (66.6
percent), followed by nonelectrophysiologist cardiologists (24.8
percent), thoracic surgeons (2.6 percent) and other specialists
(6.1 percent), the study authors noted.
But electrophysiologists prescribed the smallest proportion of
the possibly unneeded ICDs, the researchers found. Most were
implanted by thoracic surgeons and nonelectrophysiologist
Dr. Alan Kadish, president and chief executive officer of Touro
College in New York City and author of an accompanying journal
editorial, said some of the so-called unneeded ICDs were probably
implanted for good reason.
"There are some people where the guidelines are gray, where implantation is probably appropriate," he said. "But there are still a significant number of people who receive ICDs who don't need them based on current criteria," he added.
Kadish suggested several reasons for the unnecessary ICD
implants: lack of knowledge about the guidelines or gray areas of
the guidelines where an ICD might improve patient outcome despite
not being spelled out in the criteria.
"There may be some physicians who are just inappropriately putting them in," Kadish said, "but I think that's a minority of the out-of-guideline implantations."
Money is not really an incentive for doctors to implant ICDs, he
said. The procedure can cost $50,000 or more, most of which covers
the cost of the device and hospital fees. Only a small portion goes
to the doctor, he said.
If your doctor wants to prescribe an ICD, Kadish advises asking
if its use meets guidelines or if it is the right thing to do even
though it doesn't meet guidelines.
Dr. Gregg Fonarow, an American Heart Association spokesman and
professor of cardiology at the University of California, Los
Angeles, said the findings point to "the need to enhance
evidence-based care and quality feedback to health-care providers"
regarding ICD use.
Feedback to hospitals can improve adherence to the guideline
recommendations, which would eventually reduce unnecessary health
costs and benefit patients' health, the authors stated.
For more information on ICDs, visit the
U.S. National Heart, Lung and Blood
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