Abstract 14173: Incidence and Burden of "Missed Primary Prevention ICDs" Among Out-of-Hospital Cardiac Arrests
Introduction: While the high societal burden of primary prevention ICDs is recognized, the burden of underutilization--failure to implant appropriate primary prevention ICDs--has not been investigated. The percentage of out-of-hospital cardiac arrest (OHCA) that could be prevented by primary prevention ICD implantation, and how the resource burden of arrest due to “missed primary prevention” (“MPP”) compares to elective implantation, is unknown.
Methods: Charts were reviewed of patients brought to Yale-New Haven Hospital with OHCA, and of patients undergoing elective primary prevention ICD implantation for standard indications, between 6/09 and 3/12. “MPP” cases were defined as OHCA due to pulseless VT, VF, or asystole, and documented pre-arrest EF≤35%.
Results: Of 121 OHCA, 94 had VT/VF/asystole. Of these, 12 (13%) had a known pre-existing EF≤35%, meeting the definition of MPP. Elective ICD implantation was performed in 153 patients. There was no significant difference between the MPP- OHCAs vs electives in age, (68±3.5 vs 64±0.9 years), EF (30±1.5 % vs 28±0.4%) or NYHA class (2.4±0.2 vs 2.3±0.05). More MPP-OHCAs were female (53% vs 25%, p <0.02).
The average length of stay (LOS) for MPP-OHCAs was 9.8±0.5 days vs 1.2±0.1 days for electives (p <0.0001 vs all MPP-OHCAs). Of the MPP-OHCAs, 100% had a left heart catheterization, transthoracic echocardiogram, and head CT, 50% received hypothermia, 92% mechanical ventilation, 50% EEG, 67% central venous access, 58% arterial line, 17% temporary pacing, and 75% pressor support. Acute kidney injury occurred in 42%, with 17% requiring hemodialysis and 33% suffering sustained renal injury. Recurrent arrest occurred in 33%, AF in 42%, and ICU delirium in 42%. Infections included 42% with aspiration pneumonias, 17% ventilator-associated pneumonias, and 17% UTIs. Disposition included 42% to home, 33% nursing facility, and 25% died. None of these procedures or complications occurred in the electives.
Conclusion: From 2009-12 at this tertiary care center, 13% of arrhythmic OCHAs admitted alive could have been prevented through appropriate primary prevention ICD implantation. LOS, complications, and use of procedures and therapies were higher in these MPP-OHCAs compared to elective implants.
- © 2013 by American Heart Association, Inc.