Implantable cardioverter defibrillators (ICDs) have been demonstrated to improve survival for both primary and secondary prevention of sudden cardiac arrest. However, studies suggest that ICD therapy is underused in appropriate candidates. Sex and racial disparities in ICD use have been suggested. We sought to characterize the referral patterns of high-risk patients for the primary prophylaxis of sudden cardiac arrest at a tertiary academic medical center serving a diverse population in an urban US setting. Electronic hospital databases were retrospective reviewed for patients meeting criteria for prophylactic ICD implantation. We evaluated the association of gender, age, race, and primary language with the referral and subsequent implantation of an ICD. We identified 1,055 patients satisfying prophylactic ICD criteria: 600 men, mean age 62.6 years, 27.6% black, 19.3% white, 23.3% Hispanic, and 49.8% primary language of English. Of the 673 patients (63.7%) referred for ICD evaluation, 345 underwent implantation, 125 declined, and 203 had significant co-morbidities that precluded implantation. Gender, race, and primary language were not associated with referral for ICD or with decision to proceed with implantation. Patients of increased age were less likely to be referred for ICD and were more likely to refuse implantation. ICD therapy was not considered in 146 patients eligible for prophylactic implantation. In conclusion, referral rates for ICD consideration were higher at our institution than in previous reports. Nonetheless, 14% of appropriate patients were not considered. This argues for the importance of increased education for patients and referring physicians.
The implantable cardioverter defibrillator (ICD) has been demonstrated to be an effective therapy for both the primary and secondary prevention of sudden cardiac arrest (SCA). Although ICD implantation for the primary prevention of SCA is a class I indication by multiple national and international organizations, this therapy is underused. A review of the American Heart Association’s Get With the Guidelines—Heart Failure quality improvement program showed that only 35% of patients underwent ICD implantation by discharge. This and other studies have demonstrated that gender and race may influence utilization of ICDs. We examined the referral pattern for primary prevention ICD therapy at an academic, tertiary care center serving a racially diverse urban population.
Methods
The Institutional Review Board of Albert Einstein College of Medicine-Montefiore Medical Center approved the protocol. The electronic medical record database was queried for patients satisfying clinical parameters for the implantation of a primary prophylaxis ICD (i.e., New York Heart Association class II to III heart failure with a left ventricular ejection fraction [LVEF] ≤35% despite ≥3 months of decongestive therapy or an ischemic cardiomyopathy with an LVEF ≤30%). The adequacy of medical therapy was determined by reviewing both medications prescribed and documentation by the provider. Records were reviewed for a 3-year period (July 1, 2005 to June 30, 2008). This period was chosen because awareness and demand for ICD therapy was likely to be high following the Food and Drug Administration’s approval of ICD therapy for the primary prophylaxis of SCA. Patient demographics were obtained in patients meeting implant criteria. Patient records were reviewed for referral for ICD therapy and subsequent implantation. Continuous data were analyzed using the Student’s t test. Categorical data were analyzed using the chi-square test. A p value ≤0.05 was considered significant.
Results
We identified a cohort of 1,055 patients (56.9% men, mean age 62.6 ± 19 years). The 3 most commonly self-reported races were black (27.6%), white (19.3%), and Hispanic (23.3%). The primary language was English in 49.8% and Spanish in 29.0%. Figure 1 illustrates a flowchart of patient referrals.
Referral for ICD evaluation occurred in 673 patients ( Table 1 ). Patient gender, race, and primary language were not associated with referral (p = 0.29, p = 0.66, p = 0.45, respectively). Patients referred were younger than those not referred (57.8 ± 17 vs 71.2 ± 18 years, respectively, p <0.0001). Referrals were more commonly made when ≤80 years and more commonly not made when >80 years.
| Variable | Referred for ICD | |
|---|---|---|
| Yes (n=673) | No (n=382) | |
| Sex | ||
| Male | 391 (58.1%) | 209 (54.7%) |
| Female | 282 (41.9%) | 173 (45.3%) |
| Age (years) | ||
| ≥ 85 | 22 (3.3%) | 128 (33.5%) |
| 81-85 | 41 (6.1%) | 44 (11.5%) |
| 75-80 | 72 (10.7%) | 25 (6.5%) |
| 60-74 | 162 (24.1%) | 82 (21.5%) |
| 50-59 | 174 (25.9%) | 50 (13.1%) |
| 40-49 | 88 (13.1%) | 28 (7.3%) |
| 30-39 | 66 (9.8%) | 15 (3.9%) |
| < 30 | 48 (7.1%) | 10 (2.6%) |
| Race | ||
| Black | 188 (27.9%) | 103 (27.0%) |
| White | 126 (18.7%) | 78 (20.4%) |
| Hispanic | 162 (24.1%) | 84 (22.0%) |
| Multiracial | 95 (14.1%) | 52 (13.6%) |
| Asian | 68 (10.1%) | 36 (9.4%) |
| Other | 7 (1.0%) | 8 (2.1%) |
| Declined | 27 (4.0%) | 21 (5.5%) |
| Primary Language | ||
| English | 328 (48.7%) | 197 (51.6%) |
| Spanish | 202 (30.0%) | 104 (27.2%) |
| Albanian | 21 (3.1%) | 10 (2.6%) |
| Italian | 34 (5.1%) | 12 (3.1%) |
| Other | 33 (4.9%) | 19 (5.0%) |
| Declined | 55 (8.2%) | 40 (10.5%) |
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