Early Post-ICD-Implant Follow-up Visit Prolongs Survival in NCDR Registry

June 25, 2013

WASHINGTON, DC — Patients who complete a follow-up clinic visit two weeks to three months after receiving an implantable cardioverter defibrillator (ICD), with or without biventricular pacing, have significantly greater survival over the following year than those who don't have such an in-person visit, although they are more likely to be readmitted for cardiovascular causes, suggests an analysis based on a large US registry [1]. The analysis also suggested that the increased hospitalizations weren't as much for heart failure as for arrhythmias.

Quality-improvement initiatives that encourage such early device follow-up on a routine rather than selective basis, as recommended in a transatlantic expert consensus statement in 2008 [2], should be considered, given its apparent significant impact on mortality, according to the authors of the current analysis, led by Dr Paul L Hess (Duke Clinical Research Institute, Durham, NC).

There have been no data to support a survival effect for that part of the expert consensus statement, "until now," Hess told heartwire . "This is really the first study to really look at this question." The group's findings, based on data from 2005 to 2008 from Medicare and the National Cardiovascular Data Registry (NCDR) ICD Registry, were published online June 14, 2013 in Heart Rhythm.

The analysis included patients who survived without hospitalization for at least 12 weeks after discharge, while they were tracked for follow-up visits. The 30 256 patients who had their initial in-person follow-up visit within that time, compared with the 43 060 who didn't have such a follow-up, were on average older and more likely to be white, have nonischemic cardiomyopathy and more advanced heart failure, and have a defibrillating cardiac resynchronization therapy (CRT-D) device.

Hazard Ratio* (95% CI) for One-Year Outcomes for Initial Post-ICD-Implantation Follow-up Visit at 2–12 Weeks, Compared With No Such Visit, in the NCDR-ICD Database

End point

HR (95% CI)

p

Death

0.93 (0.88–0.98)

0.005

Cardiovascular readmission

1.04 (1.01–1.08)

0.012

Heart-failure readmission

1.00 (0.95–1.04)

0.843

Device-related infection

1.21 (0.98–1.49)

0.083

*Adjusted for age, race, insurance, reason for admission, atrial fibrillation/flutter, type of implanted device, prior MI, diabetes, hypertension, heart failure, NYHA class, cardiomyopathy etiology, cerebrovascular disease, primary valvular disease, end-stage renal disease, LV ejection fraction, chronic lung disease, and systolic blood pressure.

Within 12 months of the end of that 12-week tracking period, those with the recommended early follow-up fared better for survival and had more cardiovascular rehospitalizations in adjusted analyses. But their heart-failure readmissions weren't increased. Rather, the jump in CV hospitalizations appeared due to readmission for arrhythmias, especially atrial fibrillation or flutter or paroxysmal tachycardia.

"The reasons for that are largely speculative, but we theorize that perhaps the physicians who followed up the devices were often electrophysiologists and [so] more aware of arrhythmias," according to Hess. Or, perhaps, arrhythmias were revealed at device interrogation at in-person visits or by remote monitoring.

Why an early follow-up as endorsed by the consensus document would improve outcomes is also largely speculative, but "it is plausible that clinic visits lead to prompt identification and correction of problems," write Hess et al. "Previously subclinical life-threatening ventricular arrhythmias captured by newly implanted devices may lead to the initiation or uptitration of life-saving therapies like beta-blockers. Stroke-related death may be reduced by the detection of atrial fibrillation and the initiation of an anticoagulant." Or, they propose, tweaking pacing parameters, especially for CRT, during a follow-up visit could improve outcomes.

The study was primarily funded by the National Heart, Lung, and Blood Institute. Lee had no disclosures. Disclosures for the coauthors are listed in the paper.

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