AICD usage for primary prevention at Mercy Hospital: successes, challenges and next steps

1. AICD usage for primary prevention at Mercy Hospital: successes, challenges and next steps Mohammad Tahir PGY-3

2. Automatic Implantable Cardioverter Defibrillator • AICD: shock therapy in the event of VT/VF • Indicated for prevention of suddent cardiac death (SCD) • Secondary prevention: resuscitation after VT/VF arrest • Primary prevention: high risk for development of VT/VF

3. Background • MADIT-I Trial1: mortality benefit in post MI, NSVT & LVEF <35% • MADIT-II Trail2: mortality benefit in post MI & LVEF <30% • ACC/AHA 20023: for LVEF <30% (class IIa) • SCD-HeFT Trial4: mortality benefit in ischemic & non-ischemic CM, LVEF <35% 1Moss AJ et al.N Engl J Med 1996;335:1933-1940 2Moss AJ et al. N Engl J Med. 2002 Mar 21;346:877-83. 3ACC/AHA/NASPE 2002 Guideline Update Circulation 2002;106;2145-2161. 4Bardy GH et al.N Engl J Med 2005;352:225-237.

4. Adapted from: ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities J. Am. Coll. Cardiol. 2008;51;e1-e62; May 15, 2008.

5. Background (contd…) • ACC/AHA 2008: LVEF <35% • Post MI (after 40 days), NYHA II/III (class I) • Non-Ischemic NYHA II/III (class I) • Cost effective: QALY, Hospitalization ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities J. Am. Coll. Cardiol. 2008;51;e1-e62; May 15, 2008.

6. Objectives • To determine the proportion of eligible patients receiving or referred to AICD implantation • To analyze the factors affecting the referral

7. Methodology • Retrospective Chart review • IRB Approval: consent waived • Duration: Jan-July 2008 • Data Abstracted on • Demographics • Duration of CHF • Ischemic/ Non-ischemic Cardiomyopathy, • History of • coronary artery disease, • diabetes, • hypertension, • chronic kidney disease, • pacemaker implantation, • CABG or PCI

8. Methodology (contd…) • Baseline rhythm: sinus rhythm/ atrial fibrillation, • QRS complex duration • Use of medications including • beta blocker, • ACE inhibitor, • digoxin, • anti-arrhythmic drugs (amiodarone), • anti-coagulation with Coumadin, • New York Heart Association (NYHA) class for CHF • Pedal edema • Acute myocardial infarction (AMI) during current hospital admission

9. Inclusion criteria • All hospital discharges with a primary or secondary diagnosis of Heart Failure or Cardiomyopathy • Evidence of LVEF <35% • Echocardiography • Nuclear stress test • MUGA Scan • Left Ventriculography

10. Exclusion Criteria • In-hospital death • AICD previously implanted (in-situ) • Discharge to hospice services • Comfort measures only

11. Data Analysis • Variables abstracted in MS excel • Analysis software: SPSS & Epi Info • Chi-square test: Categorical Variables • Independent sample t-test: Continuous variables • Statistical significance: p <0.05.

12. Results

13. Total patients with LVEF ≤ 35% 208 In-Hospital Death 15 AICD previously implanted 35 Hospice/comfort care 13 Study Population N=145 Referred Group 77 (53%) Unreferred Group 68 (47%)

14. Referred Group (n=77) Out-patient evaluation for AICD 16 (21%) Patient refusal for AICD 9 (12%) AICD deferred in view of risk vs. benefit 3 (4%) Re-evaluation after optimization of therapy 8 (10%) AICD implanted during hospitalization 41 (53%)

15. Clinical Variables of ‘referred’ (n=77) and ‘unreferred’ (n=68) groups

16. Clinical Variables of ‘referred’ (n=77) and ‘unreferred’ (n=68) groups

17. Clinical Variables of ‘referred’ (n=77) and ‘unreferred’ (n=68) groups

18. Clinical Variables of ‘referred’ (n=77) and ‘unreferred’ (n=68) groups

19. Imaging/ EKG variables of ‘referred’ (N=77) and ‘unreferred’ (N=68) groups

20. Imaging/ EKG variables of ‘referred’ (N=77) and ‘unreferred’ (N=68) groups

21. Limited F/U data • Cross sectional • One patient from each group was found to have AICD implanted in the interim period before second hospitalization.

22. Discussion • Only 53% of eligible patients had documentation of such discussion • AICD implantation: 53% of those referred • Referred Patients: • Younger • Lower EF

23. Discussion (contd..) • Most of the patients with severe Aortic Stenosis: in unreferred group • The need of aortic valve replacement evaluation being of paramount importance. • Not considered immediate candidates • Such documentation was missing.

24. Discussion (contd..) • Coronary Angiogram: 36.4 % in referred group vs. 12 % in unreferred group • Patients undergoing coronary angiogram more likely to have a discussion about the AICD. • Acute presentation • Consultative assistance

25. Discussion (contd..) • Significant difference in the mean LVEDD: • likely an incidental finding • Sicker patients with lower EF. • Also noted that, recommendations made after procedures such as coronary angiograms were more likely to be followed by the team.

26. Conclusions • AICD referral in only 53 % • Need for improvement. • Hospitalization provides an opportunity: • Greater amount of time spent by patients • Make an in-depth assessment • Involve cardiovascular specialist • Referral/ recommendations. • Likely to be followed as out-patient as in CHF1 1Reibis R, Dovifat C, Dissmann R, et al. Clin Res Cardiol. 2006 Mar;95(3):154-61.

27. Limitations • Retrospective review type • Cross sectional • Dependence on documented medical information.

28. Recommendation • Despite limitations: • A real life patient care outcome report • Insight for the need to improve. • Creation of ‘centralized recommendation’ from points of diagnostic procedures • Echocardiogram • Radionuclide cardiac imaging • Left ventriculography. • Importance of medical records documentation • Continued education of all the providers

29. Acknowledgement • Dr. Aravind Herle • Dr. Syed J Noor • Dr. Khalid J Qazi • CHS IRB Team • HIM Staff

30. Questions

31. Thank You