Delaying Follow-up With ICD Patients Is Associated With Increased Mortality Risks

May 29, 2014

TORONTO, ON — Patients treated with implantable cardioverter defibrillators (ICDs) who do not receive follow-up within 12 weeks have a significantly increased risk of mortality, according to a new study[1].

The analysis also suggested that the type of physician seen in follow-up is important, with researchers reporting that early follow-up with a primary-care physician did not translate into improved survival. In fact, there was a trend toward a higher risk of all-cause mortality among those seen within 12 weeks by a primary-care physician and a significantly increased risk of out-of-hospital death.

"We found that the benefit does seem to be specific to the cardiac specialists," senior investigator Dr Douglas Lee (University of Toronto, ON) told heartwire . "When the first follow-up was done by primary-care doctors, there was no mortality benefit. I think it's the electrophysiologists' skills and the potential recognition of warning signs. Also, electrophysiologists are cardiologists, so they're probably also aware of other cardiac issues that might not be apparent to someone who doesn't have specialized training."

The new study is published online May 29, 2014 in the Canadian Journal of Cardiology.

Guidelines Recommend Early Follow-up

The clinical-practice guidelines for ICD care recommend a postimplant follow-up for early surveillance between two and 12 weeks. To heartwire , Lee said a lot of the focus with an ICD is on in-hospital care, but there are limited data on the type and timeliness of follow-up the patient receives after hospital discharge. One US study did show that early follow-up was associated with a slight decrease in mortality, but a higher rate of hospital readmissions.

"We wanted to look at this question in the Canadian context," said Lee. "In terms of electrophysiology care, it's slightly different because we're more centralized, with designated hospitals in Ontario as ICD centers. A lot of the decision making and follow-up is done by people board certified in electrophysiology. And obviously our healthcare system is very different as well."

The analysis included 8096 individuals who received an ICD in Ontario between 2007 and 2011. Of those treated with an ICD, 1145 patients (14%) received a follow-up visit outside of 12 weeks. The most common indication for the ICD was primary prevention (53.2%) and ischemic cardiomyopathy was the most prevalent underlying disease etiology (65.5%).

During follow-up, 5.8% of patients who received delayed follow-up died compared with 2.9% of patients who received follow-up within 12 weeks. In a multivariate-adjusted model, including adjustment for distance to the ICD center and postdischarge primary-care visits, those who had early follow-up had a 31% lower all-cause-mortality risk than those with delayed follow-up. Patients with early ICD follow-up also had a 48% lower risk of out-of-hospital mortality.

Secondary-prevention ICD patients with early follow-up had a statistically significant 61% lower risk of overall mortality compared with those who had late follow-up. For primary-prevention ICD patients and those receiving replacement devices, there was a trend toward lower overall mortality, but the reduction was not statistically significant.

Compared with the US study, the Canadian investigators did not observe an increase in the rate of hospitalizations among those who received early follow-up. They did observe that patients who lived farther away from the ICD center, those who had myocardial ischemia or impaired renal function, and those who received a replacement device or who underwent implantation for secondary prevention were all more likely to receive delayed follow-up care.

To heartwire , Lee said the data showing a difference in mortality risk among patients followed up by a cardiologist vs those followed by a primary-care doctor provide evidence in support of the recommendation that patients are seen by a cardiologist in an ICD center. During follow-up, the cardiologist typically will check the settings of the ICD and the integrity of system, making sure there is no dislodgement. In addition, an examination is also done to make sure there are no clinical signs of potential cardiovascular problems.

The research is supported by an operating grant from the Canadian Institutes of Health Research and the Ontario Ministry of Health and Long-Term Care. Lee reports no conflicts of interest. Disclosures for the coauthors are listed in the paper.

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