CRT-D in the Elderly:
Although current guidelines rarely provide recommendations on the selection of patients for CRT-D and CRT-P, an older age, multiple comorbidity and frail patient is inclined to receive a CRT-P across the centers generally. Our work supported this clinical practice by verifying the non-significant difference of all-cause mortality in the elderly (≥75 years) between CRT-D and CRT-P. With the progression of HF, pump-failure represents the most frequent cause of death [13,42]. In addition, the risk of death caused by non-cardiac diseases in older patients will increase due to more comorbidities and frailty. Assuming pump-failure and non-cardiac death as a competing risk of SCD, the benefits of additional ICD therapy would be attenuated in the elderly. Furthermore, a multicenter observational study by Barra et al including 3008 subjects reported an association of CRT-D and increased occurrence of late complications (a complication occurring or diagnosed following hospital discharge and which had not been seen to occur during the index hospitalization), especially the complication of device-related infection [43]. It may result in a potential increase in admissions and long-term mortality. Meanwhile, Liang et al reported a 5.9% incidence of inappropriate shock in CRT-D patients, which may affect quality of life and increase the risk of death [33]. As our work indicated that an additional ICD seems to have no advantage in mortality in aged patients, we should not only take clinical index (LVEF, QRS duration) into consideration in aspect of individual device selection, but also patient’s age, comorbidities and life expectancy.