John Libbey Eurotext

Gériatrie et Psychologie Neuropsychiatrie du Vieillissement

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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 Volume 14, issue 3, Septembre 2016

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Authors
1 CHU Trousseau et Université François Rabelais, Tours, France
2 Clinique Ambroise Paré, Neuilly-sur-Seine, France
3 CHU de Rouen, Rouen, France
4 Institut Lorrain du cœur et des vaisseaux, CHU Nancy, France
5 CHU Haut Lévêque, Bordeaux, France
6 Clinique Pasteur, Toulouse, France
7 CHU Michallon Grenoble, France
8 CHU La Timone, Marseille, France
9 Centre hospitalier, Blois, France
10 Nouvelles cliniques nantaises, Nantes, France
11 Hôpital privé de Parly 2, Le Chesnay, France
12 CHRU Lille, Lille, France
13 Brest University Hospital, Brest, France
14 CHU Arnaud-de-Villeneuve, Montpellier, France
15 CHU Pontchaillou, Rennes, France
16 Centre hospitalier, Aix-en-Provence, France
17 Centre Cardiologique du Nord, Paris, France
18 Hôpital Broca, Paris, France
* Tirés à part
a senior coauthors

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.