Elsevier

American Heart Journal

Volume 156, Issue 2, August 2008, Pages 322-328
American Heart Journal

Clinical Investigation
Congestive Heart Failure
Short-term mortality and cost associated with cardiac device implantation in patients hospitalized with heart failure

https://doi.org/10.1016/j.ahj.2008.04.003Get rights and content

Background

The use of implantable cardiac devices in the management of heart failure has increased, but patient selection and inhospital outcomes in clinical practice have not been critically explored. Therefore, we evaluated the inhospital mortality and costs associated with patients with heart failure who received an implantable cardioverter defibrillator, cardiac resynchronization device, or device lead.

Methods

We analyzed admissions with International Classification of Diseases, Ninth Revision, procedure codes for implantation/revision of cardioverter defibrillator or cardiac resynchronization device and a primary or secondary diagnosis code for heart failure in a prospective hospital database from 2004 to 2005. Odds ratios were calculated to quantify risk for mortality. Average accumulated costs over time were calculated before and after day of first device implant procedure.

Results

Among 27,907 hospitalizations, inhospital mortality varied based on day of device implantation and use of intravenous inotropic therapy. Mortality was 0.3% for patients who did not require inotropic drugs versus 3.3%, 6.6%, and 15.2% for patients who required initiation of drug before, on the day of, or after device implantation, respectively. Logistic regression demonstrated that the most potent risk for inhospital mortality was the use of inotropic drugs. Similar trends were observed for any vasoactive therapy. There was a marked increase in costs associated with these admissions.

Conclusions

Implantation of cardiac devices during a hospitalization for heart failure may be associated with significant inhospital mortality if patients require intravenous vasoactive therapy. Risk stratification methodology that incorporates ongoing/anticipated need for these drugs will likely improve clinical decision making.

Section snippets

Methods

We used PREMIER's Perspective Comparative Database for calendar years 2004 and 2005. PREMIER is a hospital performance improvement alliance created and owned by several hundred hospitals and health systems.33 Data validation and audits are performed by PREMIER to ensure quality. The database incorporates detailed patient level data from acute care hospitals in a large national sample organized by discharge month (n = 240 hospitals).

Variables within PREMIER include patient demographic

Results

The number of hospitalizations with ICD-9 procedure codes for an implantable cardiac device and a primary or secondary ICD-9 diagnosis for HF was 27,907. Patients were predominantly male, white, and older (mean [SD] age 68.4 [12.0] years, median age 70.0 years) (Table I). The most common non-HF primary ICD-9 diagnosis code was paroxysmal ventricular tachycardia (427.1, 11.0%). The most common secondary ICD-9 diagnoses included hypertension (54.1%), diabetes (35.3%), and chronic obstructive lung

Discussion

A major transformation in the care of patients with HF occurred with the advent of transvenous ICDs followed by the introduction of cardiac resynchronization devices alone or in combination with ICD technology. The clinical trials that formed the basis for regulatory approval of these devices did not in general enroll patients with advanced HF; when these patients were included, they tended to be ambulatory.28 Furthermore, the language used in clinical practice guidelines of major professional

References (49)

  • M.R. Mehra et al.

    Cardiac resynchronization therapy: caveat medicus

    J Am Coll Cardiol

    (2004)
  • Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators

    N Engl J Med

    (1991)
  • Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group

    N Engl J Med

    (1987)
  • M. Packer et al.

    The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. US Carvedilol Heart Failure Study Group

    N Engl J Med

    (1996)
  • A. Hjalmarson et al.

    Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group

    JAMA

    (2000)
  • M. Packer et al.

    Effect of carvedilol on survival in severe chronic heart failure

    N Engl J Med

    (2001)
  • B. Pitt et al.

    The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators

    N Engl J Med

    (1999)
  • A.L. Taylor et al.

    Combination of isosorbide dinitrate and hydralazine in blacks with heart failure

    N Engl J Med

    (2004)
  • H.M. Krumholz et al.

    Readmission after hospitalization for congestive heart failure among Medicare beneficiaries

    Arch Intern Med

    (1997)
  • S.S. Rathore et al.

    Sex-based differences in the effect of digoxin for the treatment of heart failure

    N Engl J Med

    (2002)
  • M.S. Cuffe et al.

    Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial

    JAMA

    (2002)
  • J.D. Sackner-Bernstein et al.

    Risk of worsening renal function with nesiritide in patients with acutely decompensated heart failure

    Circulation

    (2005)
  • J.D. Sackner-Bernstein et al.

    Short-term risk of death after treatment with nesiritide for decompensated heart failure: a pooled analysis of randomized controlled trials

    JAMA

    (2005)
  • A.E. Buxton et al.

    A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators

    N Engl J Med

    (1999)
  • Cited by (0)

    The study is supported in part by National Institutes of Health RO1-AG021515 (Dr P Hauptman).

    Dr Hauptman: Grant support from the National Institutes of Health; local site coinvestigator on the SCD-HeFT trial. Mr Swindle: No relevant financial relationships. Dr Burroughs: No relevant financial relationships. Dr Schnitzler: No relevant financial relationships.

    View full text