REPLACE DARE (Death After Replacement Evaluation) Score

Transcription

REPLACE DARE (Death After Replacement Evaluation) Score
DOI: 10.1161/CIRCEP.114.001671
REPLACE DARE (Death After Replacement Evaluation) Score:
Determinants of All-Cause Mortality After Implantable Device Replacement
Or Upgrade from the REPLACE Registry
Running title: Chung et al.; Mortality after CIED Replacements
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
Mina K. Chung, MD1; Richard G. Holcomb, PhD2; Suneet Mittal, MD
D3; Jonathan
Jona
Jo
nath
na
than
th
an S
S.. Steinberg,
Sttein
ein
Kevi
Ke
vinn Mi
vi
Mitc
Mitchell,
tche
tc
h ll RN7;
he
MD3; Marye J. Gleva, MD4; Theofanie Mela, MD5; Daniel Z. Uslan, MD6; Kevin
JJeanne
Je
an
anne
nn E
E.. Po
Poole,
oole,
e, M
MD
D8 ffor
orr tthe
h R
he
REPLACE
EPLA
LA
LACE
ACE Investigators*
Inv
nves
esti
es
tiga
g tors
ga
rs*
s*
1
Cleveland
landd Clinic,
Clin
Cl
in
nic
ic, Cleveland,
C ev
Cl
e ellan
a d,
d OH;
OH; 2Mi
Minnetonka,
M
nnet
nn
e oonnkaa, MN
et
MN;
N; 3Va
Valley
V
llley Health
lley
Hea
ealt
ltth System
Syst
Sy
stem
st
em
m and
and Columbia
Col
olum
u b
4
Washington
shhin
ingt
gton U
gt
University,
niversit
i
ity,
it
y S
St.
t. L
Louis,
University
College
y Colle
l ge off Physicians
Phhysiiciians & Surgeons,
Surgeons, New
New York,
Yorkk, NY;
NY; Wa
Massachusetts
M
sett
se
ttss General
tt
Gene
Ge
nera
ne
r l Ho
Hosp
Hospital
sppit
ital
al & Harvard
Har
arva
vard
va
rd Medical
Med
e ic
ical
a School,
al
Sch
choo
oo
ol,
l, Boston,
Bos
osto
ton,
to
n, MA;
MA
A;; 6Division of
MO; 5Massachuse
BIOTRONIK,
BIOTRO
BIOT
OTRO
OT
RO
Infectious Diseases,
Geffen
Diseases
D
isea
is
ease
sess David
Dav
avid
id G
effe
ef
fenn School
fe
Scho
Sc
hool
ho
ol of
of Medicine
Medi
Me
dici
di
cine
ci
ne at
at UCLA,
UCLA
UC
LA Los
Los Angeles,
Angeles
Ange
An
gele
less CA;
le
CA; 7BI
8
Lake Oswego, OR; University of Washington, Seattle, WA
*List of Investigators provided in supplemental material.
Correspondence:
Mina K. Chung, MD
Department of Cardiovascular Medicine, Cleveland Clinic
9500 Euclid Avenue, J2-2
Cleveland, OH 44195
Tel: 216-444-2290
Fax: 216-636-6951
E-mail: [email protected]
Journal Subject Code: [120] Pacemaker, [22] Ablation/ICD/surgery
1
DOI: 10.1161/CIRCEP.114.001671
Abstract:
Background - Identifying factors predictive of mortality may be important to decrease risk
associated with cardiac implantable electrical device (CIED) replacement procedures. This study
aimed to determine whether clinical factors and complications independently associate with
death and to develop a mortality risk prediction tool after CIED replacement.
Methods and Results - The prospective REPLACE Registry determined 6-month complication
and mortality rates after CIED replacement with or without planned lead addition or revision.
Vital status was collected. Kaplan-Meier survival and multivariable Cox proportional hazards
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regression analyses were performed to identify patient, procedural, or complication
variables
p
predictive of death. The REPLACE DARE (Death After Replacement Ev
Evaluation)
score
was
Eval
alua
al
uati
ua
tion
ti
on)) sc
on
sco
ore wa
ore
a
constructed using hazard ratios, reflecting relative risk contributions off each
variable,
combined
h va
vari
riab
ri
ab
ble
le,, co
comb
m
into an additive
died.
d ve mortality
ditive
mort
mo
r al
rt
a ityy risk
r sk score equation. At 6 months
ri
months 70/1744(4.0%)
70/17444(4.
4..0%) patients had died
d Cox
regression analysis
found
major
anaalysis foun
nd noo significant
sig
ig
gni
nifi
fiicant association
asssocia
iatiion between
ia
beetwe
w en
we
nm
ajjor ccomplications
o pllicatio
om
tio
ions
n aand
ns
ndd ddeath.
eaath
h
However, rec
failure
NYHA
class
III/IV,
antiarrhythmic
drug
rrecent
cen
ent heart
rtt fa
ailuree aadmission,
dm
mis
issi
s onn, NY
N
HA
A cla
asss II
II/IV
II/
II
V, ant
tiaarrhhytthm
mic
ic dru
rugg us
ru
use,
cerebrovascular
disease,
and
chronic
disease
were
independently
with 6c ar diseas
cula
a e,, an
as
nd chroni
niic kidney
nic
y dis
issea
e se
se st
sstage
ag
ge we
w
re inde
deepe
penden
en
entl
nt y as
associated w
month mortality.
r i y. The
rtalit
Th REPLACE
RE
EPL
PLAC
ACE
AC
E DARE
DA
ARE score was 22.0±1.4
.00±1.44 iinn survivors
surrvi
v vors
rss versus 33.5±1.8
.5±
5±11.8 in non5±
n
survivors (p<0.001)
Risk
pp<0.001)
<0
0.0
.001
01)) with
wiith
t predictive
pre
redi
d ct
di
ctiv
i e ROC
ROC value=0.758
valu
va
lue=
e 00..75
7588 (p<0.001).
(p<0
(p
<0.0
<0
.0001
01).
). R
iissk off death
dea
eath
th
h was
was 1.0%
1.0
.0%
% for
f
DARE=0 and 55.6% for DARE=7. The hazard ratio was 1.8 for each change of 1 DARE unit.
Conclusions - Comorbidities, but not complications, were significantly associated with mortality
after CIED replacement. The REPLACE DARE Score is a novel tool which can identify patients
with substantial mortality risk. Such patients should have the relative risk and benefit of their
procedure considered carefully.
Clinical Trial Registration - clinicaltrials.gov; Unique Identifier: NCT00395447.
Key words: implantable cardioverter-defibrillator, pacemaker, risk prediction, risk score,
mortality
2
DOI: 10.1161/CIRCEP.114.001671
Cardiac implantable electronic device (CIED) replacements encompass a broad spectrum of
patients with variable comorbidities. Most patients with pacemakers (PMs) and implantable
cardioverter defibrillators (ICDs) will undergo one or more generator replacements. However,
certain patients with multiple comorbidities being considered for replacement or upgrade
procedures may face prohibitive risk or limited prognosis negating potential benefits. Similar
clinical judgment is reflected in the mandate to withhold primary prevention ICD implantation if
life expectancy is estimated to be under one year.1
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Few studies have evaluated mortality and associated risk factors
rs followingg CIED
D
replacement or upgrade procedures. Advanced age, comorbid conditions,
ons, and
andd procedure
pro
roce
ceddure
du e related
rel
complications
o s might
ons
migh
mi
ghtt contribute
gh
c nttribute to mortality. The RE
co
REPL
REPLACE
P ACE regis
registry,
stry,, a prospective multice
multicenter
e
study that evaluated
eva
eva
valuated patients
patieents undergoing
underg
un
rggoingg device
dev
evicee replacement
repllaccem
men
nt w
with
itth
th or wi
with
without
hou
out pl
planned
lan
a need le
lead
ead
addition orr revision,
revis
isiion
is
on,
n provided
p ovid
pr
id
ded
d a uniqu
unique
quue oppo
opportunity
ort
r unnit
ity to
to examine
exa
xami
xa
mine
mi
ne thi
this
hiss question.
hi
questionn.2 T
qu
The
he obj
objectives
bjecti
bj
tiv
ti
i
of
the current analys
analyses
y es wer
were
re to iidentify
d ntif
de
ifyy cl
if
clinical
liniicall or pr
pprocedural
ocedural
d l ffactors
actorss tthat
hat ar
aaree associ
associated
iatted
dw
with
ith aallcause 6-month
mortality
mortality
DARE
onth
nth
th mortalit
rttalit
lit and
ndd tto develop
ddee elop
lo a mortalit
rttalit
lit risk
riiskk tool,
ttooll designated
desii atted
d tthe
he RE
REPLACE
REPL
PLAC
ACE
E DA
(Death After Replacement Evaluation) risk score.
Methods
The prospective multicenter REPLACE Registry2 determined 6-month complication rates after
CIED replacement without (Cohort 1) or with (Cohort 2) planned transvenous lead addition or
revision. Patients with anticipated life expectancy of <6 months or those undergoing a planned
lead extraction procedure were excluded. Major and minor complications were pre-specified and
independently adjudicated.2 All deaths during the 6-month follow-up were identified. Although
procedure-related death was a major complication for the original analysis, it was not considered
a complication for the purposes of this analysis, since only a complication that occurred prior to
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DOI: 10.1161/CIRCEP.114.001671
death qualified as a potential risk factor for mortality. The mortality analysis considered each
cohort separately as well as in combination. The REPLACE study was approved by the ethics
committee of each participating institution; all patients provided written informed consent.
Mortality analyses
The primary outcome for this analysis was 6-month all-cause mortality. Vital status was
collected for 100% of subjects. Univariable analyses examining the association of factors with
6-month all-cause mortality were performed, using Chi-squared or Fisher’s exact tests for
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categorical and two-group Student's t-tests for continuous variables.
Variables considered for mortality analysis included age, sex, race, bo
mass
index,
bbody
dy m
dy
asss in
as
inde
dex
de
New York Hea
Heart
eart
ea
rt A
Association
s oc
ss
o iaati
t on (NYHA) functional class,
cla
lasss, heart failure
failur
u e ho
hhospitalization
spitalization within the
previous 12
months,
ejection
fraction
coronary
2m
onths, left ventricular
venttric
icular
ar eject
cttio
on fra
acttionn ((LVEF),
LV
VEF
F),, PM
M dependence,
dep
pende
d nce, pprior
de
rior
or co
oroon
artery bypass
disease,
ass graft
grraf
aftt (C
((CABG)
ABG)
AB
G) or valvee su
surgery,
y pperipheral
e iphe
er
iph ral ar
art
artery
tery ddisease,
isea
is
e se, cerebr
ea
cerebrovascular
broovascula
br
l r di
dis
recent myocardial
infarction,
myocardial
infarction,
chronic
obstructive
o dia
ocard
i l infa
f rccti
tion, remote myo
y carddia
i l inf
farcti
tion,
i
chroni
h niic ob
obst
structive pulmonary
st
p lm
pu
mon
onaryy
disease (COPD),
diabetes
(CKD)
OPD)
OP
D) di
ab
bett mellitus,
mellit
elli
llitt s chronic
ch
h nii kidney
kid
ki
kidne
dn disease
dis
(CK
CKD)
D) stage
ta as defined
defi
fi d bby the
the
National Kidney Foundation classification3, liver disease, smoking, medications, anticoagulants,
surgical time, any major complication, and any minor complication. Additional analyses of age
were also performed in device subgroups.
Device type variables considered were: implanted generator type (single or dual chamber
PM, single or dual chamber ICD, cardiac resynchronization therapy PM (CRT-P) and/or ICD
(CRT-D), and intended upgrade type (single to dual chamber PM or ICD, PM or ICD to CRT-P
or CRT-D).
Cumulative survival rates were calculated according to the Kaplan-Meier method. Event
times were measured from the time of the study replacement procedure. The significance of
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DOI: 10.1161/CIRCEP.114.001671
differences in survival between variables considered was assessed with the log-rank test. As the
last follow-up at 6 months was ±4 weeks, Kaplan-Meier curves are displayed to 210 days.
Univariable associations of baseline and patient factors to mortality were examined to identify
candidate predictors (factors with univariable p-value<0.2). Multivariable Cox proportional
hazards regression modeling used both backward elimination and forward stepwise Cox
regression analyses to validate the robustness of significant predictor variables with an adjusted
p<0.05 needed for entry into the model and an adjusted p>0.1 for removal at any stage. Relative
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risks were expressed as hazard ratios with associated confidence intervals.
vals.
Baseline values for all candidate predictor variables used in thee survival
surv
rviv
i all analyses
iv
ana
naly
lysees were
ly
w
determined
d att time
tiime zero
zer
ero (date
(d
date of original replacement
replacemen
ent procedure),, including
en
inclluding complications. The
presence orr ab
absence
complications
included
baseline
bsence of com
omplliccatio
ons were
weree includ
udded
d on
on the
the same
ssaamee basis
basiss as other
otther ba
base
elinee
predictors, sincee al
replacement
alll study
studdy complications
comp
mpli
l cati
tion
ti
ons were
on
re those
tho
h se adjudicated
ho
adj
djud
dj
udic
ud
icat
ic
ated
at
ed to
to be
be related
rellated
ed to
to the
th
he replacem
repl
lacem
procedure andd were assum
assumed
um
med
d to ha
hhave
ve an onset coin
coincident
cide
id nt with
wit
ithh the
th
he procedure,
p occed
pr
edure, regardless
reg
gardl
dles
dl
e s of when
es
symptoms associated
iattedd with
iith
th tthe
he complications
pli
licati
tio were
ere reported.
reported
rtted
d
Results were considered significant at p<0.05. Values are reported as mean±standard
deviation, unless otherwise specified. Statistical analyses were performed with SPSS statistical
software (Version 18, SPSS/IBM, Inc.).
Mortality Risk Prediction Score
Using the subject factors found to be predictive of mortality in the multivariable Cox regression
analysis, the REPLACE DARE mortality risk prediction score was developed. Hazard ratios
reflected the relative risk contribution of each variable and were combined in a final additive
score equation:
Mortality Risk Score = ((3.097^ HF) + (1.959^NYHA) + (1.425^(CKD-1)) + (1.901^AAD) +
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DOI: 10.1161/CIRCEP.114.001671
(1.801^CEREB) + (1.238^(AGE - 1))) - 6.
The six variables identified to be predictive of survival included: 1) HF [admitted for
heart failure in previous 12 months (0=No; 1=Yes)]; 2) NYHA [NYHA Class (0=0,I, II;
1=III,IV)]; 3) CKD [chronic kidney disease stage (1-5)]; 4) AAD [Class I or III antiarrhythmic
drug use (0=No; 1=Yes)]; 5) CEREB [history of cerebrovascular disease (0=No; 1=Yes)]; 6)
AGE [age quartiles (1= <63; 2= 63-72; 3=73-79; 4=80+].
A value of "1" was subtracted from CKD stage and age quartiles for scaling purposes; the
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equation was standardized so that a subject with no risk factors, lowestt CKD stage,
youngest
stage
g , and
d yo
you
age quartile had a value of zero.
To evaluate
robustness
eva
vaalu
luat
atee th
thee ro
obustness of the predictorss used
used in the REPLACE
RE
EPL
LAC
A E DARE Score, a
bootstrapping
estimating
intervals
ing validation was
in
was pperformed
erfoormed
d est
tim
mattin
ng the
th variability
vari
va
riaabilitty andd confidence
ri
conf
n iden
nf
nce
c int
ntervvals
va
associated with
predictors
10,000
sampling
w h th
thee pr
pred
dic
i tors bbased
ased
d oon
n 10,0
000 ssimulated
imullated
ted
d trials
tri
rial
alss created
crrea
eate
t d bby
y sam
ampl
am
pling with
ith
h
replacement
the
original
REPLACE
Study
patients.
n from
nt
f
th
he or
rig
gin
i all R
EPLA
EP
LA
ACE
ES
tudy
d ppopulation
dy
oppulattion off 11744
7444 pa
74
pati
tiients.
Results
REPLACE enrolled 1744 subjects undergoing CIED replacement into Cohort 1 (N=1031) and
Cohort 2 (N=713).2 The previously reported complication rates in Cohort 1 included 134 total
major plus minor complications in 111 patients (10.8% patient level complication rate). Of these,
51 major complications occurred in 41 patients (4.0%) and 83 minor complications in 76 patients
(7.4%). In Cohort 2, 227 total major plus minor complications occurred in 149 patients (20.9%
patient complication rate). These included 163 major complications in 109 patients (15.3%) and
64 minor complications in 54 patients (7.6%).
Mortality after CIED replacement
At 6 months, 70 patients had died (4.0%), 37(3.6%) in Cohort 1 and 33(4.6%) in Cohort 2,
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DOI: 10.1161/CIRCEP.114.001671
p=0.32. Mean time from CIED replacement procedure to death was 100.3±62.3 days (median
100.5 days, range 3-212; interquartile range, 49-151 days). No deaths occurred during the actual
replacement procedure. Fifteen deaths occurred by 30 days (30-day total mortality 0.9%) of
which 8 were adjudicated as a major complication due to the procedure in the original analysis.2
Among patients who had a major complication, 10/190(5.2%) patients died and among patients
who had a minor complication, 1/130(0.8%) patients died.
Relationship of Patient Characteristics to 6-Month Mortality
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Baseline patient characteristics and univariable analyses by 6-month survival
urvival status (Table
(Taabl
blee 1)
showed that patients who died were older, more likely to have diabetess me
mellitus,
ell
llit
itus
it
us, COPD,
COPD
CO
PD,,
PD
c la
cula
larr di
ddisease,
seeas
ase, pperipheral
eripheral vascular disease,
disease
se, CKD,
se
CKD, prior CABG
C BG
CA
B or valve surgery, prior
p
cerebrovascular
forr heart failure
failurre within
wiith
hin the
the pas
a t 122 months,
monnth
hs, and
nd hhigher
iiggherr NYHA
NYHA
HA ffunctional
unctio
io
onal cclass
lasss (a
a
admission fo
past
(all
Averag
ag
ge ag
age was ap
approximat
atel
at
ely 4 ye
year
rs higher
h gh
hi
her iin
n su
ubj
bjeccts who
whho died
die
iedd (p=0.023).
(p=0
(p
0.023
023
2 ).
)
p<0.05). Average
approximately
years
subjects
144% (N=248)
(N=2
(N
=2
2488) off sub
bje
jects iin
n the
h R
E LA
EP
ACE
E Registry
Reg
gistr
trry had
had been
b en hhospitalized
be
ospi
pita
pi
tali
ta
l ze
li
z d for
f
Although onlyy 14%
subjects
REPLACE
re within
iithin
thiin tthe
th
he preceding
di 112
2 months
nth
ths th
these patients
ti ts accounted
acco nt
nted
ted
d for
f 43%
43% (N=30)
((N
N 30
30)) off tthe
th
h 70
heart failure
months,
observed deaths. Patients who died were also more likely to be on an antiarrhythmic drug and on
diuretics. Defibrillation testing was not significantly associated with higher mortality (p=0.40).
Kaplan-Meier survival curves by clinical characteristics are shown in Supplemental Figures 1
and 2. There was also a significant and consistent increase in the risk of death associated with
CKD stage from 2.3% (5/215 patients) for stage 1 to 16.0% (4/25 patients) for stage 5
(Supplemental Figure 2A).
Relationship of CIED Type and Replacement Procedure to 6-Month Mortality
In univariate analyses of survival status at 6 months (Table 1), patients with a CRT-P or CRT-D
implanted had a higher observed mortality than those receiving a PM or ICD (CRT 6.2%, PPM
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DOI: 10.1161/CIRCEP.114.001671
2.8%, ICD, 2.7%; between groups, p=0.003). Kaplan-Meier survival analyses (Figure 1),
confirmed worse survival in patients who had CRT devices implanted compared with PMs or
ICDs without CRT (p<0.001) and in patients upgraded to a CRT device (p=0.003). A significant
difference by cohort was not demonstrated (p=0.27).
Relationship of Complications to 6-Month Mortality
Univariable associations of complications with mortality (Supplemental Table 1A) showed sixmonth mortality was 4.0% in patients without any major or minor complications during the study
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
and 4.3% in those who experienced any complications (p=0.73). Of the
he 146 patients
p tients with
pa
witth one
o or
more major complication, 6.8% of patients died. In contrast, among the
1598
patients
who
he 159
5998 pa
pati
tien
ti
entts
ts w
ho did
not experience
major
(p=0.08).
least
e ce a m
ence
ajor
aj
or ccomplication,
omplication, 3.8% died (p
om
p=0
=0.08). Of the 1300 ppatients
atients who had at le
e
one minor complication,
with
1614
with
complication, 0.8%
0.8%
% diedd compared
comp
mparred w
ith 44.3%
.3%
3%
% ooff 16
6144 ppatients
atien
ntss w
ith nno
o mi
minorr
complications
Deaths
with
complications
shown
Supplemental
o (p=0.06).
ons
(p=
(p
=0.06).
) D
eatths in patients
paati
tients w
ithh major
it
majo
j r co
jo
com
mpli
l cati
li
tion
ti
ons are sh
on
how
own in S
uppllem
m
Table 1B. Kapl
Kaplan-Meier
survival
analysis
major
complications
shown
plan-Me
pl
M ie
ierr survi
ivall analy
lysiis by occurrence off majo
ly
j r comp
jo
mp
pliicatiions iiss sh
show
o n in
Figure 1D and
in
Figure
ndd bby any
an ((major+minor)
majj +miin ) complications
li ti
in Supplemental
S pplemental
pll
tall Fi
Fig re 33.
Cox Proportional Hazards Regression Analysis
Candidate variables associated with mortality with univariable p<0.2 were considered in Cox
regression models. A total of 26 baseline variables were identified as candidates for inclusion in
the multivariable models. As this was a large set of potential predictors relative to the number of
mortality events, attention was paid to the direction and consistency of the effect of individual
variables across sets of predictor variables. Both forward and backward stepwise elimination was
used to confirm a robust set of predictors. Cox multivariable regression (Table 2) identified 5
significant predictors of survival time: admission for heart failure in the prior 12 months, NYHA
class III/IV, antiarrhythmic drug use, cerebrovascular disease, and CKD stage. Although there
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DOI: 10.1161/CIRCEP.114.001671
was some statistical evidence that the effect of these baseline predictors were time-dependent in
an examination of the proportional hazards assumption, the interactions of time with the
predictors had associated hazard ratios nearly equal to unity in each case (0.99 – 1.01) and were
not included in the final model. Age and CKD were highly correlated (p<0.001) with a linear
regression predicted age increase of 5.88 years per increase of each CKD stage. Age in quartiles
met model parameter retention criteria and was retained in the final model (p=0.065) for risk
score generation. Notably, neither the occurrence of a prior major or minor complication was a
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significant multivariate predictor of mortality. None of the following factors were retained
retaine
nedd in the
ne
final Cox regression model: prior major complications, prior major or min
minor
nor ccomplications,
ompl
plic
licat
atio
ionns
io
ns
upgrade to CR
CRT,
RT, upgrade
uppgr
g ad
adee to
t an ICD, or device typee iimplanted.
mplanted.
Analyses of
Age
Device
Subgroups
of A
ge in Devic
ice Su
Sub
bgro
roups
ro
Additional analyses
performed
whether
significant
analy
lyse
ly
sess of age were perf
se
rfor
rf
ormedd to
or
to determine
determiine wh
de
det
whet
ethher ad
et
advanced
d aage
g was a si
ge
igni
predictor off mortali
CIED
mortality
lity
li
ty iinn cohort
cohort or CI
IED ssubgroups.
ubgr
bg oups
p . Age
Ag di
ddistribution
isttribu
b tiion by
by cohort
coho
h rtt iiss shown
show
sh
ownn in
ow
Supplemental
ntal
nt
tall Figure
Fig re 4A.
Fi
4A Kaplan-Meier
Kaplan
K
apll M
Meier
eii ssurvival
r i all analyses
anal
all ses (Supplemental
(S pplemental
pll
tall Figure
Fig re 4B-J)
Fi
4B JJ)) showed
sho
sh
h
that age was a significant univariate predictor of mortality in patients with implanted CRT
devices (p=0.019). Multivariable Cox regression analyses (Supplemental Table 2) showed that
age in quartiles was a significant predictor of mortality in the implanted CRT, upgrade to CRT,
upgrade to CRT or ICD, and Cohort 2 subgroups, though not a significant predictor of mortality
in the upgrade to ICD subgroup.
The REPLACE DARE Mortality Risk Score
Using the subject factors found to be predictive of survival in the multivariable Cox regression
analysis in the total cohort, a mortality risk prediction score was developed. Included for
analyses were 1662 subjects with complete data. The analysis included 95% of all patients and
9
DOI: 10.1161/CIRCEP.114.001671
96% of all deaths (67 of 70 patient deaths). Eighty-two subjects (5%) with missing GFR were
excluded. The observed REPLACE DARE Mortality Risk Score had a mean value of
2.056±1.409 (range 0-7.32). Frequency distribution of the risk scores is shown in Figure 2A.
Results of bootstrapping the Cox regression analyses in 10,000 simulated trials of the full
REPLACE Study population (N=1744 patients) (Supplemental Tables 3A and 3B) demonstrated
negligible bias of the originally estimated REPLACE DARE Score components (<4%), nearly
identical p-values for statistical significance, and comparable coverage of the associated 95%
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
confidence intervals for the estimated hazard ratios.
The performance of the derived mortality risk score (ability to predi
predict
dictt survival)
di
sur
urvi
viiva
val)
l) was
was
examined in
number
i a nu
numb
mber
mb
er off eevaluations.
valuations. First, mean vvalues
alues among ssurvivors
urvi
viivors and deaths (Table
(Tabb 3A)
demonstrated
significant
(p<0.001)
with
near
doubling
ted a highly sign
te
gnifiicaant difference
diifferrence
ce (p<0
<0.001
01) wi
w
th a ne
ear do
ear
oubbliing off the
t e risk
th
riisk score
scorr
between non-survivors
survivors.
Next,
REPLACE
o urv
on-su
rviv
iv
ivors
v andd surviv
i orss. N
ext, tthe
he RE
REPL
PL
LAC
ACE
E DARE
DARE Score
Score variable
var
aria
ar
iaable was entered
entte
into a stepwise
Cox
regression
the
wise Co
C
x regr
gres
gr
e siion with
wit
i h th
he variables
variiab
bles pr
ppreviously
evio
i usly
l iidentified
ly
d nt
de
ntif
ifiedd as
if
a ppredictors
redi
d ctorss (Table
di
(Taable 3B).
(T
After adjustment
variable,
stment
st
t ntt for
f the
the REPLACE
REP
EPLA
LACE
CE DARE
DAR
ARE
E Score
S
ariable
iabl
bl none off tthe
he other
th predictors
dictt were
er
retained. The REPLACE DARE Score variable was uniquely selected with either a forward
stepwise or backward elimination approach.
A third observation was that the score behaved in a monotonic fashion over the range of
risk. [Figure 2B] The score values were rounded to simple integers for illustration, although
using the score values rounded to the first decimal, in practice, could provide further resolution.
Thus, for a subject at lowest risk (Score=0), the observed mortality in the REPLACE Study was
1.0% while mortality increased to 55.6% for a Score=7. The hazard ratio associated with the
REPLACE-DARE Score was 1.795 for each change of one unit. The associated Kaplan-Meier
survival graph by REPLACE-DARE Score is shown in Figure 2C.
10
DOI: 10.1161/CIRCEP.114.001671
Finally, a receiver operating characteristic (ROC) analysis characterized the sensitivity
and specificity of the REPLACE DARE Score in predicting subjects who died (Figure 2D). The
REPLACE DARE Score had a statistically significant predictive area under the curve value (c
statistic = 0.758, p<0.001).
LVEF was available for 56% of subjects, but prior admission for HF in the past 12
months in the REPLACE study was a better predictor of all-cause death than LVEF in cases
where LVEF was available. When Cox regression analysis was limited to cases with
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
LVEF, hazard ratio estimates for the 6 identified predictors were comparable
for
parable to those fo
or th
tthe
entire population, but LVEF was not a significant predictor: Prior admission
dmisssio
i n for
forr HF hazard
fo
hazzar
ha
za
ratio = 2.55,
change
When
5 p= 0.005;
5,
0.005
005
0 ; LVEF
LV
VEF hazard ratio=0.99 forr eevery
very 10% cha
hangge in LVEF, p=0.899. W
adjusted for
variables,
significantly
prediction
or oother
or
ther variabl
les, LV
LVEF
F ddid
id nnot
ot si
ignif
iffican
ntly contribute
co
ont
ntriibuutee to the
th
he pr
predic
ctiion
o ooff aall-cause
lll-cc
death; thus,, LV
LVEF
was
into
mortality
VEF w
as not
nott included
inclludedd in
int
to the
he mo
m
rtal
t lit
ityy score.
scor
ore.
or
Discussion
n
Although mortality rates have been well studied after initial PM or ICD implants, survival
outcomes have not been well defined after device replacement procedures. Prior reported 1-year
all-cause mortality rates after initial ICD implants in randomized clinical trials range from 2.610.7%4-7 and after PM implants 5.4-8.4%.8-10 In the REPLACE Registry, no deaths occurred
during or within 24 hours of the replacement procedure. This sub-study demonstrated that allcause 6-month mortality after CIED replacement was 4%: 3.0% after PM, 4.7% after ICD and
6.2% after CRT device implants. Surprisingly, although major complications occurred in 8.6% of
all patients followed in the REPLACE Registry and were associated with a strong trend toward
higher 6-month mortality in univariate analyses, significant associations of complications with 6month survival were not observed in adjusted analyses. This may reflect the higher disease
11
DOI: 10.1161/CIRCEP.114.001671
burden of patients who experienced complications. Comorbid conditions, such as heart failure,
kidney and cerebrovascular disease, rather than complications, were identified as the most likely
contributors to mortality after CIED replacement procedures.
Our study highlights the impact of heart failure as a significant predictor of 6-month
mortality. Both prior admission for heart failure in the previous 12 months and NYHA functional
class III/IV significantly predicted mortality. Prior heart failure admission significantly predicted
mortality across CRT and upgrade subgroups. Although only 14% of subjects in the REPLACE
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
Registry had been hospitalized for heart failure within the preceding 12
2 months, these ppatients
atie
at
i
ie
accounted for 43% of the observed deaths. Similarly 31% of the patients
nts had
had NYHA
NYHA ffunctional
unnct
cti
cti
class III/IV
heart
failure
deaths.
V he
ear
artt fa
ail
i ur
u e bu
bbutt accounted for 60% of the
the
h observed de
eaths
h . The higher risk
hs
associated with
complication
mortality
witth heart failure
faillure is
is concordant
conncorddan
ant with
with ana
aanalyses
nallysses
sess of acute
acutee ccom
om
mplic
ication
cattion an
aand
dm
mortalit
orrtaalit risk
analyses from
National
Cardiovascular
Registry
o the
om
the Na
N
tionall C
ardi
d ovas
asccular
as
cu Data
Data R
egiisttry of
eg
o ICD
ICD iimplants.
m lants.111 Th
mp
The use off pri
prior
i
heart failure
re admission
ad
dmiissiion rather
raath
her than
tha
h n LVEF
LV
VEF
F in
in the
th
he riskk score mayy prove
proove to
to be
b more clinically
cllin
nic
i al
a ly
y uuseful
and accessible.
study,
only
patients;
ible
ibl
ib
le As
As seen in
in the
the REPLACE
REP
EPLA
LACE
CE st
t d LVEF
LVEF was
as available
a ailable
ilabl
ble for
f onl
nll 56
56%
% off patie
ati
tie
re-assessment of LVEF is often not routinely performed prior to device replacement procedures.
Moreover, LVEF was correlated with other variables, including prior admission for HF, and did
not contribute independent information when the other variables were present in the model.
That higher CKD stage was strongly associated with mortality after device replacement
was not unexpected. Renal disease, and in particular end stage kidney failure requiring dialysis,
has been associated with higher mortality rates and infections in patients with PMs and ICDs.12-14
In fact, the risk of excess mortality becomes evident at even a moderate level of renal
dysfunction (<60 ml/min/1.73 m2).12
In our current prospective study, we found CKD to be a strong risk factor for mortality.
12
DOI: 10.1161/CIRCEP.114.001671
Patients with normal renal function (>90 ml/min/1.73 m2) and those with only mild CKD (60-89
ml/min/1.73 m2) had a 2 and 2.5% 6-month mortality, respectively. In contrast, mortality was 2fold higher with moderate (30-59 ml/min/1.73 m2), 4-fold higher with severe CKD (15-29
ml/min/1.73 m2), and nearly 8-fold higher with end-stage CKD. Remarkably, these differences in
mortality as a function of CKD stage became evident by the first month following the CIED
generator change. Future investigation should be directed towards identification of the
mechanisms of death and reduction of mortality in CIED patients with moderate-end stage CKD.
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
Other significant factors associated with mortality were cerebrovascular
ovascular diseasee aand
n
nd
antiarrhythmic drug use. Present in 16% of the cohort, cerebrovascularr disea
disease
ease
se w
was
as aassociated
s oc
ss
ociia
iat
iat
o the
the deaths
d at
de
a hs
h and
and
n is not an unexpected risk
sk factor for mortality.
mo
ortal
allit
ity. In the National
with 27% of
cular Data Reg
cu
gisstry
y ((NCDR)
NCDR
NC
CD ) ICD
IC
CD Regi
giistry
y, cerebrovascular
ceere
rebr
brrovvasscularr ddisease
isseaase wa
w
gniifii
Cardiovascular
Registry
Registry,
wass a sig
significant
1
adv
dvver
erse
see eve
nts
t or ddeath
eath
h rrelated
elated
el
l d ttoo primary
priimaryy pr
pr
rev
even
nti
tionn IICD
C iimplantation.
CD
mpla
lant
la
ntation.15
nt
predictor off adverse
events
prevention
Antiarrhythmic
h ic ddrug
hmi
rugg usee hhas
as been
been associated
associatted
d wi
with
ith hi
higher
high
gh
her ri
risk
iskk off m
mortality
orta
tali
ta
liity
t in pa
ppatients
tiients
ts w
with
ith
structural hheart
e t di
diseasee16 and
ndd ma
may bbe associated
ciiatted
d with
ithh hi
it
higher
gh
h non
non-cardiovascular
cardio
rdi
dio asc lar
l mortalit
mortality.
tali
litt 17 A
significant proportion of the REPLACE population was burdened with structural heart disease,
including heart failure, which may predispose to proarrhythmia risks. Also, antiarrhythmic drug
use may serve as a marker for higher disease burden, including atrial fibrillation or ICD shocks,
both factors that have been associated with higher risk of mortality.18, 19
In the total cohort older age showed a trend toward higher mortality after CIED
replacement (adjusted p=0.065) with the oldest quartile (•age 80) being at highest risk for 6month mortality. Higher age quartile was a significant predictor of mortality in the implanted
CRT, upgrade to CRT, upgrade to CRT or ICD, and Cohort 2 (planned lead revision or addition)
subgroups, suggesting that older age may be a consideration when contemplating device
13
DOI: 10.1161/CIRCEP.114.001671
upgrades or CRT.
The REPLACE DARE mortality risk prediction score was developed as a tool for risk
stratification in patients undergoing CIED replacement. The 6 variables can be entered into an
on-line calculator application at http://www.replacedare.org/. The score yielded significant
predictive capability to discriminate survivors and non-survivors at 6 months after CIED
replacement. The components of the REPLACE DARE score highlight the potential importance
of considering heart failure status, advanced CKD stage, cerebrovascular disease, advanced age,
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
and use of antiarrhythmic therapy when considering risks for CIED replacements
p acements or upgrades.
pl
upgr
up
grad
gr
a
This risk analysis may also be useful to assess risk in patients contemplating
plating
ngg tthe
he rrisk-benefit
he
iissk-b
-ben
en
nefi
efi
pr
rim
imar
aryy pprevention
reve
veention ICD device replacement,
replaceeme
m nt, but who no llonger
onger meet conventional
conventioo
balance forr prim
primary
for ICD impl
lan
ntattioon.
indicationss for
implantation.
m
mplica
atio
tiions
Clinical implications
d g the
ding
th
he predictors
p ed
pr
dicctors off morbidity
morbbiditty andd mortality
mortalit
li y after
affte
t r generator
g neerato
ge
torr repl
to
placemen
pl
nts hhas
as
Understanding
replacements
ntt interest.
iinterest
ntt
t 20 Th
These iss
issues
is es are particularly
partic
ti llarl
arll relevant
rele
le ant
ntt tto elderly
eld
elderl
lderll patients
ti ts or th
those with
generated recent
significant comorbidities seeking to decide whether the benefits outweigh risks of device
upgrade or replacement. Since REPLACE did not enroll patients who did not undergo CIED
replacement, these analyses cannot fully address these issues. Older age was a significant
predictor of mortality in upgrade and CRT subgroups and was highly correlated with other high
risk factors, such as CKD stage.
The REPLACE DARE mortality risk prediction score stratified mortality risk in the 6
months after CIED replacement, including identifying a small subgroup with >50% mortality at
6 months. Evaluation of appropriateness for a CIED replacement procedure may be particularly
important in these very high risk patients, as device implantation is not recommended for
14
DOI: 10.1161/CIRCEP.114.001671
patients with a life expectancy of less than one year in current device-based therapy guidelines.
Thus, the REPLACE DARE score may serve as a useful tool to identify very high risk patients in
whom reevaluation of antiarrhythmic drugs, optimization of heart failure and renal function,
and/or reassessment of CIED replacement may be appropriate.
Limitations
Although this sub-analysis of the REPLACE registry was retrospective, the REPLACE data,
including mortality, were collected prospectively. The study was also not powered to detect
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
significant differences in short-term mortality in all subgroup analyses.
s. Although
g the REPLACE
REP
EPL
L
DARE Score significantly identified patients with varying risk for mortality,
rtalitty,
y iincluding
nclu
nc
l di
lu
ding
ngg a vvery
e
high risk group,
r up, the
rou
the Score
Score
ree will require external validation
valid
idaation in otherr populations.
id
poppulations. The highestt risk
cohort was aalso
clinical
impact
lso small, and
an
nd thee llargest
arg
gest cl
lin
i iccal imp
mp
pacct is llimited
i itted ttoo thiss high
im
hig
gh riskk cohort.
coh
ohoort.
Conclusions
n
ns
Six-month aall-cause
REPLACE
Registry
Significant
ll-ca
caus
usee mortality
mo
orttallit
i y in
in tthe
h pprospective
he
roosp
spec
pecti
t vee R
ti
EPLA
EP
LACE
LA
CE R
egis
eg
gistr
try
y was
was 4%
4%.. S
ignifica
ig
cantt
comorbidities, including heart failure, kidney, cerebrovascular disease, and aget80 years old,
rather than complications, were identified as the most likely contributors to mortality after CIED
replacement procedures. The REPLACE DARE Score identified subjects at high and low risk for
mortality in the 6 months after CIED replacement. Reevaluation of antiarrhythmic drugs,
optimization of heart failure and renal function, and/or reassessment of CIED replacement would
seem appropriate in patients with very high scores.
Funding Sources: The REPLACE Registry was sponsored by BIOTRONIK
Conflict of Interest Disclosures: M.K. Chung has been an unpaid speaker and participant in
industry-supported research for Medtronic, Boston Scientific Corp., St. Jude Medical, and
15
DOI: 10.1161/CIRCEP.114.001671
Zoll/LifeCor, and is an unpaid REPLACE study steering committee member (Biotronik). R. G.
Holcomb has received support from Biotronik, Medtronic, and Boston Scientific Corp. S. Mittal
is a consultant for Biotronik, Boston Scientific, Medtronic, Tyrx, and St. Jude Medical. J.
Steinberg is a consultant for Medtronic, St. Jude Medical, Cameron Health, Biosense-Webster,
Sanofi-Aventis, Janssen, and Ambucor; he receives research support from Medtronic, BiosenseWebster, Lifewatch, and Glaxo-Smith-Kline. M.J. Gleva has received support from Biotronik
and Medtronic. T. Mela has received speaker honoraria from Medtronic, Boston Scientific,
Biotronik, and St. Jude Medical. D.Z. Uslan has received honoraria from Boston Scientific.
K. Mitchell is an employee of Biotronik. J.E. Poole has received honoraria from Medtronic,
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
Boston Scientific Corp., Biotronik, St. Jude Medical; consultant for Boston Scientific Corp.,
p and
Physio Control.
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n JC,
JC
C, Kristensen
Kris
Kr
isste
tens
nssen L,
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Ande
An
ders
de
rssen H
HR,
R Mortensen
R,
Morteens
nsen
en PT,
PT, Pedersen
Ped
eder
erse
er
senn OL,
se
OL, Pedersen
Pede
Pe
d rs
de
rsen
en A
K A
K.
randomized
d comparison
compa
p riisonn of atrial
atriial and
d ddual-chamber
uall-chhamber ppacing
aciingg in
i 177
7 cconsecutive
77
onse
seecutiive ppatients
ati
tient
ntss w
with
ith sick
sinus syndrome:
Echocardiographic
clinical
Coll
Cardiol.
2003;42:614-623.
r
rome:
Echo
hoocaardio
hoca
rd
dio
iogr
grap
gr
aphi
ap
hicc an
hi
andd cl
clin
inic
in
ical
ic
a ooutcome.
al
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ut
come
m . J Am C
me
oll Ca
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oll
Card
rdio
rd
io
ol. 20
2003
03;42:614
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11. Haines DE, Wang Y, Curtis J. Implantable cardioverter-defibrillator registry risk score
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implantation. Circulation. 2011;123:2069-2076.
12. Korantzopoulos P, Liu T, Li L, Goudevenos JA, Li G. Implantable cardioverter defibrillator
therapy in chronic kidney disease: A meta-analysis. Europace. 2009;11:1469-1475.
13. Sakhuja R, Keebler M, Lai TS, McLaughlin Gavin C, Thakur R, Bhatt DL. Meta-analysis of
mortality in dialysis patients with an implantable cardioverter defibrillator. Am J Cardiol.
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14. Tompkins C, McLean R, Cheng A, Brinker JA, Marine JE, Nazarian S, Spragg DD, Sinha S,
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15. Tsai V, Goldstein MK, Hsia HH, Wang YF, Curtis J, Heidenreich PA, Registr NCDsI.
Influence of age on perioperative complications among patients undergoing implantable
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cardioverter-defibrillators for primary prevention in the united states. Circ-Cardiovasc Qual.
2011;4:549-U111.
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366:2
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18
DOI: 10.1161/CIRCEP.114.001671
Table 1: Baseline Clinical and Device Procedure Characteristics at time of CIED Replacement:
Univariable Associations with Survival Status at 6 Months
Alive
96.0%
(N=1674/1744)
Dead
4.0%
(N=70/1744)
70.0±13.7
95.8%(1133)
96.4%(541)
96.2%(1474)
94.8%(200)
28.3±6.3
94.1%(482)
96.8%(1192)
93.4%(268)
96.5%(1406)
93.1%(255)
996.5%(1419)
96
.5%(1419)
5%(1419)
92.5%(196)
92.5%(1
( 96)
996.5%(1478)
6.5
5%(1
(147
4 8))
47
73.8±12.7
4.2%(50)
3.6%(20)
3.8%(59)
5.2%(11)
27.2±5.8
5.9%(30)
( )
3.2%(40)
3.2%
3.
2%
%(4
( 0)
6.6%(19)
6 6%
6.
6%(1
(19)
(1
9)
3.5%(51)
3.5%
5%(5
5%
(51)
(5
1)
6.9%(19)
6 9%
9%(1
(19)
(1
9)
3.5%(51)
3 5%(51)
7.5%(16)
7.5%(1
( 6)
3.5%(54)
3.5%
3.
5%(5
5%
(54)
(5
4
4)
95.0
0%(
% 574))
95.0%(574)
96.5%(1100)
96
6.5
5%(1
( 10
100
0)
5.0%
5.
0 (30)
0
0)
5.0%(30)
3.5%(40)
3.5%
5%(4
5%
(40)
(4
0
94.7%(604)
94
4.7
7%(
% 60
6 4)
96.7%(1070)
96
.7%
7%(1
(107
070)
0)
97.7%(561)
97.7
97
7%(5
561
61))
98.6%(209)
97.1%(406)
92.6%(478)
83.3%(20)
5.3%(34)
5.
5
3%(3
3%
(34)
(3
4)
33.3%(36)
.3%
3%(3
3%
(36)
6)
2.3%(13)
2.3%
3%(1
( 3)
(1
1.4%(3)
2.9%(12)
7.4%(38)
16.7%(4)
87.9%(218)
97.3%(1456)
36.6±16.4
97.7%(210)
97.6%(652)
94.7%(648)
91.4%(64)
84.0%(21)
12.1%(30)
2.7%(40)
31.8±17.5
2.3%(5)
2.4%(16)
5.3%(36)
8.6%(6)
16.0%(4)
96.8%(30)
96.0%(1644)
86.7%(13)
96.1%(1661)
3.2%(1)
4.0%(69)
13.3%(2)
3.9%(68)
1.000
93.7%(340)
96.6%(1334)
94.6%(211)
96.2%(1463)
95.7%(1191)
6.3%(23)
3.4%(47)
5.4%(12)
3.8%(58)
4.3%(54)
0.016
P value
CLINICAL CHARACTERISTICS
Age, years
Gender
Race
Male
Female
White
Non-White
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
Body mass index
Diabetes mellitus
+
Chronic pulmonary disease +
Cerebrovascular disease
+
Peripheral vascular
a cu
ascu
c la
l r diseas
disease
se +
Remote myocardial
cardial infarctionn >
ca
>4
4 we
w
weeks
eeks
+
Prior Coronary
r art
ry
artery
rtter
e y by
bypass
ypa
pass
ss oorr vvalve
alve
al
ve ssurgery
u ge
ur
gery
ry
(638)
+ (6
(638
38))
38
(1106)
- (1
(110
106)
6)
NYHA Classs (0-II vs. III-IV)
III
I -IV
II
IV
V) 0
I
II
III
IV
Admission for heart failure within past 12 months
+
Left ventricular ejection fraction
Chronic kidney disease stage 1
2
3
4
5
Liver disease
Mild
+
Moderate or severe
+
Medications
Any Class I or III antiarrhythmic drug
+
Amiodarone
+
Beta-adrenergic blocker
+
0.023
0.60
0.35
0.13
0.015
0.020
0..
0.011
0
0.009
0.
0.16
0
0.042
0.
<0.001
<0
0
<0.001
19
0.052
0.001
0.12
0.27
0.35
DOI: 10.1161/CIRCEP.114.001671
+
Digoxin
+
Diuretic
+
Statin
+
Angiotensin converting enzyme inhibitor +
Angiotensin receptor blocker +
Warfarin
+
Aspirin
+
Clopidogrel or ticlopidine
+
Calcium channel blocker
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
96.8%(483)
97.9%(229)
95.7%(1445)
95.7%(487)
96.1%(1187)
94.9%(1015)
97.6%(659)
96.1(958)
95.9%(716)
96.4%(803)
95.6%(871)
95.0%(285)
96.2%(1389)
95.5%(682)
96.3%(992)
95.6%(816)
96.4%(858)
96.9%(222)
95.8%(1452)
3.2%(16)
2.1%(5)
4.3%(65)
4.3%(22)
3.9%(48)
5.1%(54)
2.4%(16)
3.9%(39)
4.1%(31)
3.6%(30)
4.4%(40)
5.0%(15)
3.8%(55)
4.5%(32)
3.7%(38)
4.4%(38)
3.6%(32)
3.1%(7)
3.1%(7
( )
4.2%(63)
4..2%
4
2%(6
(63)
(6
3)
96.4%(488)
9 .4%(488)
96
4%(488)
995.8%(1182)
5.8%(1182)
3.6%(18)
3 6%(18)
4.2%(52)
0.59
0
96.7%(816)
96.7%(
%(8
%(
816)
95.7%(619)
95.7
7%(619)
94.5%(239)
9 .5
94
5%(2
(239
39))
39
3.3%(28)
3.3%(28
8)
4.3%(28)
4.3
3%(288)
5.5%(14)
5.5%
5%(1
5%
( 4)
(1
0.24
0
97.2%(597)
97
7.2
.2%(
% 59
%(
5 7)
97.3%(461)
97
.3%(
3%(46
461
1)
93.8%(604)
93.8
93
8%(6
604
04))
2.8%(17)
2.8
2.
8%(
%(17
17))
17
22.7%(13)
.7
7%(
%(13
13))
66.2%(40)
.2%
2%(4
( 0)
(4
0.003
0.
93.8%(557)
97.1%(1117)
6.2%(37)
2.9%(33)
0.001
96.4%(994)
95.4%(680)
93.4%(368)
96.7%(1306)
93.8%(407)
96.7%(1267)
79.2% (19)
96.2% (1655)
78.3% (18)
96.2% (1656)
3.6%(37)
4.6%(33)
6.6%(26)
3.3%(44)
6.2%(27)
3.3%(43)
20.8% (5)
3.8% (65)
21.7% (5)
3.8% (65)
0.32
100.0%(58)
98.6%(214)
96.4%(829)
95.6%(845)
0%(0)
1.4%(3)
3.6%(31)
4.4%(39)
0.15
0.69
0.006
0.81
0.46
0.33
0.46
0.39
00.59
DEVICE PROCEDURE CHARACTERISTICS
Pacemaker dependent
ependent
epend
nden
den
entt
+
-
Pre-procedure
re device
re
deevice type
Pacemaker
ema
ema
maker
ICD
D
CRT-P,
T CRT-D
T-P,
CRT
RT--D
Device Implanted
a d
anted
Pacemaker
e ke
emake
kerr
ICD
D
CRT-P,
T CRT-D
T-P,
D
Device Implanted
d-C
CRT-D
CRT-D implanted
Non-CRT-D
Cohort
1 (without planned lead revision)
2 (with planned lead revision)
Upgrade to CRT
+
LV/CS lead addition/revision +
Any epicardial lead addition +
LV epicardial lead addition
+
Existing single upgraded to dual chamber device
+
Defibrillation testing done
Not Done
0.005
0.01
0.002
0.002
1.00
0.40
CRT=cardiac resynchronization therapy device; CRT-D=cardiac resynchronization therapy defibrillator; CRTP=cardiac resynchronization therapy pacemaker; ICD=implantable cardioverter-defibrillator; NYHA=New
York Heart Association
20
DOI: 10.1161/CIRCEP.114.001671
Table 2: Cox Proportional Hazards Regression Model
Hazard Ratio
95% Confidence
Interval
P value
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
Prior admission for heart failure (in 12 months)
3.097
1.795-5.344
<0.001
New York Heart Association class III or IV
1.959
1.122-3.418
0.018
Antiarrhythmic drug use
1.901
1.141-3.169
0.014
Chronic Kidney Disease Stage
1.425
1.053-1.930
1.930
0.022
0..0222
Cerebrovascular disease
1.801
1.052-3.084
3.0844
00.032
0.
03
032
Age in Quartiles
r il
rtil
iles
e
es
1.238
1.2338
0.987-1.552
0 987-1.552
0.
0.065
5
21
DOI: 10.1161/CIRCEP.114.001671
Table 3: REPLACE DARE Mortality Risk Score. A. Comparison of mean score values by
survival status. B. Cox regression analysis including the score variable.
A.
REPLACE DARE Score
Survivor
N
1595
Nonsurvivor
67
Mean
Standard
Deviation
Standard error of
mean
1.993
1.359
0.034
3.534
1.758
0.215
2-sided t-test p-value <0.001
Nonparametric Mann-Whitney test p-value <0.001
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
B.
REPLACE
ED
DARE
ARE S
Score
core
co
ree
p value
Hazard
Ha
aza
zard Ratio
995%
95
% Confidence Int
Interval
<0.001
<0
<0.0
0.00011
1.795
1.79
95
11.567-2.057
1.
56756
7--2.
7-2.
2 0557
Variables no
not
n
ot iinn thee equation
equaatiionn after
eq
afterr adjustment
adju
ad
just
ju
sttment
stm
ment
n for
forr REPLACE
REPL
RE
PL
LAC
ACE
E DARE
DARE
R Sc
Score
corre
Score
Scor
Sc
orre
P va
valu
value
luee
lu
Prior admission
s
ssion
for heart
hear
he
hear
artt fa
fail
failure
ilur
il
u e ((in
ur
in 112
2 mo
m
mos)
s)
s)
0.13
0.
0.138
1388
13
00.711
0.
0.71
.71
7111
New York Heart Association class III or IV
0.051
0.822
Antiarrhythmic drug use
0.147
0.702
Chronic Kidney Disease Stage
0.301
0.583
Cerebrovascular disease
0.191
0.662
Age in Quartiles
0.143
0.705
22
DOI: 10.1161/CIRCEP.114.001671
Figure Legends:
Figure 1: Kaplan-Meier survival curves by (A) REPLACE Cohort; Cohort 1=without planned
lead revision, Cohort 2=with planned lead revision. (B) Implanted CIED Type. (C) CRT or ICD
Upgrade. (D) Occurrence of Any (Major or Minor) Complication. (E) Occurrence of Prior Major
Complication.
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
Figure 2: The REPLACE DARE Score. A. Frequency of REPLACE DARE risk scores.
s.. B.
B.
Distribution of all-cause 6-month mortality across REPLACE DARE risk sc
scores.
scor
ores
es. C.
C. Kaplan
Kapl
Ka
plan
pl
a
Meier survival
the
REPLACE
Operating
ival
al bby
y th
he RE
EPLACE DARE Score. D. The
Th Receiver O
peera
r ting Characteristic ((ROC)
curve for the
REPLACE
DARE
Score.
ROC
value
he R
EPLACE D
ARE
RE Sco
core. RO
co
R
C va
alu
ue 00.758,
.7758,
8, p<0.001
p<
<00.001
01
23
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A
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B
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
C
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
D
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A
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B
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
C
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D
REPLACE DARE (Death After Replacement Evaluation) Score: Determinants of All-Cause
Mortality After Implantable Device Replacement Or Upgrade from the REPLACE Registry
Mina K. Chung, Richard G. Holcomb, Suneet Mittal, Jonathan S. Steinberg, Marye J. Gleva,
Theofanie Mela, Daniel Z. Uslan, Kevin Mitchell and Jeanne E. Poole
Downloaded from http://circep.ahajournals.org/ by guest on November 18, 2016
Circ Arrhythm Electrophysiol. published online September 14, 2014;
Circulation: Arrhythmia and Electrophysiology is published by the American Heart Association, 7272 Greenville Avenue,
Dallas, TX 75231
Copyright © 2014 American Heart Association, Inc. All rights reserved.
Print ISSN: 1941-3149. Online ISSN: 1941-3084
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://circep.ahajournals.org/content/early/2014/09/14/CIRCEP.114.001671
Data Supplement (unedited) at:
http://circep.ahajournals.org/content/suppl/2014/09/14/CIRCEP.114.001671.DC1.html
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in
Circulation: Arrhythmia and Electrophysiology can be obtained via RightsLink, a service of the Copyright Clearance
Center, not the Editorial Office. Once the online version of the published article for which permission is being
requested is located, click Request Permissions in the middle column of the Web page under Services. Further
information about this process is available in the Permissions and Rights Question and Answerdocument.
Reprints: Information about reprints can be found online at:
http://www.lww.com/reprints
Subscriptions: Information about subscribing to Circulation: Arrhythmia and Electrophysiology is online at:
http://circep.ahajournals.org//subscriptions/
1
DATA SUPPLEMENT
TABLE I. A. Complications: Univariable Associations with Survival Status at 6 Months.
B. Deaths in Patients with Major Complications after CIED Replacement
A. Complications: Univariable Associations with Survival Status at 6 Months.
Alive
Dead
96.0%
4.0%
(N=1674/1744)
(N=70/1744)
Prior Major complication +
93.2%(136)
6.8%(10)
96.2%(1538)
3.8%(60)
Prior Minor complication +
99.2%(129)
0.8%(1)
95.7%(1545)
4.3%(69)
Any prior complication
+
95.7%(245)
4.3%(11)
96.0%(1429)
4.0%(59)
P value
0.077
0.058
0.733
2
B. Deaths in Patients with Major Complications after CIED Replacement
MAJOR COMPLICATIONS
N (%)
Unplanned lead addition/revision 1/29 (3.4%)
Cardiac perforation
1/5 (20.0%)
Pneumothorax
1/4 (25.0%)
Peri-op cardiac arrest
2/2 (100.0%)
Major hemodynamic instability
0/4 (0%)
Peri-op respiratory failure
0/1 (0%)
Deep venous thrombosis
0/6 (0%)
Pulmonary embolism
0/1 (0%)
Infection
0/14 (0%)
Prolonged hospitalization
5/23 (21.7%)
Malfunction, reopen pocket
2/58 (3.4%)
Pocket revision
Major hematoma
0/7 (0%)
3/21 (14.3%)
Non-healing pocket
0/2 (0%)
Hospital admission
1/16 (6.3%)
Pneumonia, UTI
1/1 (100%)
Drug reaction
0/1 (0%)
Coronary venous dissection
0/1 (0%)
Peripheral embolus
0/1 (0%)
Other
2/9 (22.2%)
3
SUPPLEMENTAL TABLE II. Cox Regression Analyses by Upgrade or CRT Subgroups
Implanted CRT Group (n = 644)
Hazard Ratio 95% Confidence Interval P value
Age (quartiles)
1.664
1.225, 2.261
0.001
Diabetes mellitus
1.967
1.025, 3.778
0.042
Prior admission for HF (in 12 mos)
4.522
2.288, 8.937
<0.001
Antiarrhythmic drug use
2.016
1.039, 3.911
0.038
Upgrade to CRT (n = 394)
Hazard Ratio 95% Confidence Interval P value
Age (quartiles)
1.495
1.022, 2.188
0.038
Prior admission for HF (in 12 mos)
4.395
1.806, 10.694
0.001
Upgrade to ICD (n = 206)
Hazard Ratio 95% Confidence Interval P value
Diabetes mellitus
5.194
1.039, 25.965
0.045
Prior admission for HF (in 12 mos)
7.310
1.462, 36.543
0.015
Upgrade to CRT or ICD (n = 461)
Hazard Ratio 95% Confidence Interval P value
Age (quartiles)
1.470
1.013, 2.134
0.043
NYHA class III/IV
3.328
0.686, 16.150
0.136
Prior admission for HF (in 12 mos)
3.820
1.627, 8.973
0.002
Upgrade to CRT
0.073
0.008, 0.621
0.017
LV lead attempt
0.031
1.317, 377.376
0.031
Cohort 2 (n = 713)
Hazard Ratio 95% Confidence Interval P value
Age (quartiles)
1.497
1.074, 2.089
0.017
NYHA class III/IV
3.175
1.068, 9.440
0.038
Prior admission for HF (in 12 mos)
4.034
1.847, 8.810
<0.001
Moderate or severe liver disease
7.922
1.049, 59.841
0.045
4
SUPPLEMENTAL TABLE III. Bootstrapping Predictors of Mortality. A. Cox Model
Coefficients. Results demonstrate that there was low estimated bias associated with the original
estimates of model coefficients (-1.9% to 3.3%), and that the significant levels associated with
the bootstrap estimates were nearly identical to the original. All identified variables would have
been retained in the original model, where the criterion for retention was a p-value of 0.10 or
less. B. Estimated Hazard Ratios. The 95% confidence intervals for the bootstrap estimates of
hazard ratios [Exp(B)] were consistent (that is, had similar coverage) to the original estimates.
A. Cox Model Coefficients
Coefficient
Variable
Standard Error (SE)
P-value
B
Bias (%)
Original
Bootstrap
Original
Bootstrap
Prior Admit HF
1.130
.004 (0.4%)
.278
.273
<0..001
<0.001
NYHA Class
.672
.009 (1.3%)
.284
.285
.018
.018
CKD Stage
.354
-.004 (-1.1%)
.155
.177
.022
.042
Antiarrhythmic Rx
.643
-.007 (-1.1%)
.261
.270
.014
.012
Cerebrovasc Dis
.589
-.011 (-1.9%)
.274
.291
.032
.033
Age in Quartiles
.213
.007 (3.3%)
.115
.121
.065
.069
B. Estimated Hazard Ratios
Hazard
Variable
95% Lower Bound
95% Upper Bound
Ratio
Exp(B)
Original
Bootstrap*
Original
Bootstrap*
Prior Admit HF
3.097
1.795
1.831
5.344
5.307
NYHA Class
1.959
1.122
1.130
3.418
3.501
CKD Stage
1.425
1.053
.989
1.930
1.982
Antiarrhythmic Rx
1.901
1.141
1.096
3.169
3.149
Cerebrovasc Dis
1.801
1.052
.986
3.084
3.056
Age in Quartiles
* Percentile method
1.238
.987
.988
1.552
1.586
5
FIGURE I. Kaplan-Meier survival curves by occurrence of (A) Prior Heart Failure
Hospitalization in the prior 12 months; (B) New York Heart Association Functional Class;
(C) Antiarrhythmic Drug Use; and (D) Cerebrovascular Disease.
(A)
6
(B)
7
(C)
8
(D)
9
FIGURE II. Chronic kidney disease and survival after CIED replacement. A. All-Cause 6month mortality (%) by chronic kidney disease stage (GFR, mL/min/1.73 m2). B. Kaplan-Meier
survival analyses by chronic kidney disease.
A. All-Cause 6-month mortality (%) by chronic kidney disease stage (GFR, mL/min/1.73
m2).
10
B. Kaplan-Meier survival analyses by chronic kidney disease.
11
FIGURE III. Kaplan-Meier Survival Analysis by Occurrence of Any (Major or Minor) Prior
Complication
12
FIGURE IV. Quartile of Age and Survival After CIED Replacement. A. Distribution of age
by REPLACE Cohort. Kaplan-Meier Survival by Age in: B. All Subjects. C. By REPLACE
Cohort 1. D. REPLACE Cohort 2. E. Patients with Implanted Pacemakers. F. Patients with
implanted ICDs, not including CRT-D ICDs. G. Patients with Implanted CRT devices (CRT-P
and CRT-D). H. Patients Upgraded to a CRT CIED. and J. Patients Upgraded to an ICD.
A. Distribution of age by quartile and REPLACE Cohort.
13
B. Kaplan-Meier Survival by Age Quartile in All Subjects
14
C. Kaplan-Meier Survival by Age Quartile in REPLACE Cohort 1.
15
D. Kaplan-Meier Survival by Age Quartile in Cohort 2.
16
E. Kaplan-Meier Survival by Age in Patients with Implanted Pacemakers.
17
F. Kaplan-Meier Survival by Age in Patients with Implanted ICDs, excluding CRT-Ds.
18
G. Kaplan-Meier Survival by Age in Patients with Implanted CRT devices (CRT-P and
CRT-D).
19
H. Kaplan-Meier Survival by Age in Patients Upgraded to a CRT device.