Position paper for management of elderly patients with pacemakers and implantable cardiac defibrillators: Groupe de Rythmologie et Stimulation Cardiaque de la Société Française de Cardiologie and Société Française de Gériatrie et Gérontologie.
Despite the increasingly high rate of implantation of pacemakers (PMs) and implantable cardioverter defibrillators (ICDs) in elderly patients, data supporting their clinical and cost-effectiveness in this age stratum are ambiguous and contradictory. We reviewed the data regarding the applicability, safety and effectiveness of conventional pacing, ICDs and cardiac resynchronization therapy (CRT) in elderly patients. Although periprocedural risk may be slightly higher in the elderly, the implantation procedure for PMs and ICDs is still relatively safe in this age group. In older patients with sinus node disease, the general consensus is that DDD pacing with the programming of an algorithm to minimize ventricular pacing is preferred. In very old patients presenting with intermittent or suspected atrioventricular block, VVI pacing may be appropriate. In terms of correcting potentially life-threatening arrhythmias, the effectiveness of ICD therapy is similar in older and younger individuals. However, the assumption of persistent ICD benefit in the elderly population is questionable, as any advantageous effect of the device on arrhythmic death may be attenuated by higher total non-arrhythmic mortality. While septuagenarians and octogenarians have higher annual all-cause mortality rates, ICD therapy may remain effective in selected patients at high risk of arrhythmic death and with minimum comorbidities despite advanced age. ICD implantation among the elderly, as a group, may not be cost-effective, but the procedure may reach cost-effectiveness in those expected to live more than 5-7years after implantation. Elderly patients usually experience significant functional improvement after CRT, similar to that observed in middle-aged patients. Management of CRT non-responders remains globally the same, while considering a less aggressive approach in terms of reinterventions (revision of left ventricular [LV] lead placement, addition of a right ventricular or LV lead, LV endocardial pacing configuration). Overall, physiological age, general status and comorbidities rather than chronological age per se should be the decisive factors in making a decision about device implantation selection for survival and well-being benefit in elderly patients.
CHU Trousseau, université François-Rabelais, 37044 Tours, France. Electronic address: lfau@med.univ-tours.fr.
Laurent
L
Fauchier
Clinique Ambroise-Paré, 92200 Neuilly-sur-Seine, France.
Christine
C
Alonso
Rouen University Hospital, 76031 Rouen, France.
Frederic
F
Anselme
Institut Lorrain du Cœur et des Vaisseaux, CHU de Nancy, 54500 Vandœuvre-lès-Nancy, France.
Hugues
H
Blangy
CHU Haut Lévêque, Bordeaux, 33600 Pessac, France.
Pierre
P
Bordachar
Clinique Pasteur, 31300 Toulouse, France.
Serge
S
Boveda
CHU Trousseau, université François-Rabelais, 37044 Tours, France.
Nicolas
N
Clementy
CHU Michallon, 38700 Grenoble, France.
Pascal
P
Defaye
CHU La Timone, 13385 Marseille, France.
Jean-Claude
JC
Deharo
Centre hospitalier, 41016 Blois, France.
Patrick
P
Friocourt
Nouvelles cliniques nantaises, 44202 Nantes, France.
Daniel
D
Gras
Hôpital privé de Parly 2, 78150 Le Chesnay, France.
Franck
F
Halimi
CHRU de Lille, 59000 Lille, France.
Didier
D
Klug
Brest University Hospital, 29200 Brest, France.
Jacques
J
Mansourati
CHU La Timone, 13385 Marseille, France.
Benjamin
B
Obadia
CHU Arnaud-de-Villeneuve, 34090 Montpellier, France.
Jean-Luc
JL
Pasquié
CHU Pontchaillou, 35000 Rennes, France.
Dominique
D
Pavin
Institut Lorrain du Cœur et des Vaisseaux, CHU de Nancy, 54500 Vandœuvre-lès-Nancy, France.
Nicolas
N
Sadoul
Centre hospitalier, 13616 Aix-en-Provence, France.
Jerome
J
Taieb
Centre cardiologique du Nord, 93200 Saint-Denis, France.
Olivier
O
Piot
Hôpital Broca, 75013 Paris, France.
Olivier
O
Hanon
D000368:Aged; D001145:Arrhythmias, Cardiac / Q000628:therapy*; D058406:Cardiac Resynchronization Therapy / Q000592:standards*; D002309:Cardiology / Q000592:standards*; D017147:Defibrillators, Implantable; D019468:Disease Management; D005602:France; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D010138:Pacemaker, Artificial; D012955:Societies, Medical
Cardiac pacing; Cardiac resynchronization therapy; Défibrillateur automatique implantable; Elderly; Implantable cardioverter defibrillator; Pacemaker; Resynchronisation cardiaque; Sujet âgé