title: 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 et Société française de gériatrie et gérontologie.
abstract: Despite the increasingly high rate of implantation of pacemakers (PM) and cardioverter-defibrillators (ICD) 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 the conventional pacing, ICD and cardiac resynchronization therapy (CRT) in elderly patients. Although peri-procedural risk may be slightly higher in the elderly, the procedure of implantation of PMs and ICDs is still relatively safe in this age group. In older patients with sinus node disease, a general consensus is that dual chamber pacing, along with the programming of an algorithm to minimise ventricular pacing is preferred. In very old patients presenting with intermittent or suspected AV block, VVI pacing may be appropriate. In terms of correcting potentially life-threatening arrhythmias, the effectiveness of ICD therapy is comparable in older and younger individuals. However, the assumption of persistent ICD benefit in the elderly population is questionable, as any advantage of the device on arrhythmic death may be attenuated by a 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 >5-7 years after implantation. The elderly patients usually experience a 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 re interventions (revision of LV lead placement, addition of a RV or LV lead, LV endocardial pacing configuration). Overall, age, comorbidities and comprehensive geriatric assessment should be the decisive factor in making a decision on device implantation selection for survival and well-being benefit in elderly patients.
authors.affiliation: CHU Trousseau et Université François Rabelais, Tours, France.
authors.forename: Laurent
authors.initials: L
authors.lastname: Fauchier
authors.affiliation: Clinique Ambroise Paré, Neuilly-sur-Seine, France.
authors.forename: Christine
authors.initials: C
authors.lastname: Alonso
authors.affiliation: CHU de Rouen, Rouen, France.
authors.forename: Frédéric
authors.initials: F
authors.lastname: Anselme
authors.affiliation: Institut Lorrain du cœur et des vaisseaux, CHU Nancy, France.
authors.forename: Hugues
authors.initials: H
authors.lastname: Blangy
authors.affiliation: CHU Haut Lévêque, Bordeaux, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Bordachar
authors.affiliation: Clinique Pasteur, Toulouse, France.
authors.forename: Serge
authors.initials: S
authors.lastname: Boveda
authors.affiliation: CHU Trousseau et Université François Rabelais, Tours, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Clementy
authors.affiliation: CHU Michallon Grenoble, France.
authors.forename: Pascal
authors.initials: P
authors.lastname: Defaye
authors.affiliation: CHU La Timone, Marseille, France.
authors.forename: Jean-Claude
authors.initials: JC
authors.lastname: Deharo
authors.affiliation: Centre hospitalier, Blois, France.
authors.forename: Patrick
authors.initials: P
authors.lastname: Friocourt
authors.affiliation: Nouvelles cliniques nantaises, Nantes, France.
authors.forename: Daniel
authors.initials: D
authors.lastname: Gras
authors.affiliation: Hôpital privé de Parly 2, Le Chesnay, France.
authors.forename: Franck
authors.initials: F
authors.lastname: Halimi
authors.affiliation: CHRU Lille, Lille, France.
authors.forename: Didier
authors.initials: D
authors.lastname: Klug
authors.affiliation: Brest University Hospital, Brest, France.
authors.forename: Jacques
authors.initials: J
authors.lastname: Mansourati
authors.affiliation: CHU La Timone, Marseille, France.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Obadia
authors.affiliation: CHU Arnaud-de-Villeneuve, Montpellier, France.
authors.forename: Jean-Luc
authors.initials: JL
authors.lastname: Pasquié
authors.affiliation: CHU Pontchaillou, Rennes, France.
authors.forename: Dominique
authors.initials: D
authors.lastname: Pavin
authors.affiliation: Institut Lorrain du cœur et des vaisseaux, CHU Nancy, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Sadoul
authors.affiliation: Centre hospitalier, Aix-en-Provence, France.
authors.forename: Jérôme
authors.initials: J
authors.lastname: Taieb
authors.affiliation: Centre Cardiologique du Nord, Paris, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Piot
authors.affiliation: Hôpital Broca, Paris, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Hanon
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017147:Defibrillators, Implantable / Q000592:standards*; D005260:Female; D005602:France; D006331:Heart Diseases / Q000150:complications / Q000453:epidemiology / Q000628:therapy*; D006801:Humans; D008297:Male; D010138:Pacemaker, Artificial / Q000592:standards*; D010346:Patient Care Management / Q000592:standards*
keywords: cardiac pacing; cardiac resynchronization therapy; elderly; implantable cardioverter defibrillator