Use of implantable cardiac devices in Europe doubles, but uptake
9 December 2009
The use of implantable devices for the treatment of heart
failure increased "enormously" in Europe between the years 2004 and
2008, but there still remain large differences between countries,
according to a study reported in the European Journal of Heart Failure
The findings suggest that there is an underuse of devices in many of the
15 countries surveyed (2), most notably, the UK, Spain and Portugal.
The investigators note that the prognosis of heart failure — by far
the single biggest reason for acute hospital admission — has not been
improved by the introduction of new medical treatments in recent years,
with continuing high rates of mortality and morbidity. Thus, while drug
therapy is still the mainstay of treatment, "relatively few new
approaches have proven beneficial," they write.
However, the use of device therapy, in particular the implantable
cardioverter defibrillator (ICD) and an advanced pacemaker more usually
referred to as cardiac resynchronisation therapy (CRT), has gained
increasing acceptance and is now being used on a large scale as an
adjunct to traditional drug treatment(3).
Indeed, some reports have described these two devices as a revolution
in heart failure. One important study cited in the most recent
guidelines on heart failure suggested that implantation of an ICD was
associated with a 23% reduction in all-cause mortality(4).
The present analysis found that throughout the 15 European countries
the number of ICD implantations increased substantially, from 80/million
population in 2004 to 140/million in 2008. The highest rate of ICD
implants was in Germany (264/million in 2008), followed by Denmark and
the Netherlands. The lowest number of implants was observed in Spain
(63/million), Portugal (68/million) and the UK (74/million).
The use of CRT implants also rose substantially, from 46/million in
2004 to 99/million in 2008, an increase of 115%. This increase was
mainly explained by more use of devices which combine heart failure CRT
and ICD therapies (CRT-D).
A study reported at this year's ESC Congress in Barcelona (MADIT-CRT)
found that CRT combined with ICD decreased the risk of heart failure
events even in relatively asymptomatic patients (with a 34% reduction in
the risk of all-cause mortality or heart failure)(5).
The use of ICD (either alone or as part of a CRT-D device) has now
become standard therapy for many patients with symptomatic heart
failure, and is a Class I recommendation in the 2008 ESC Guidelines. The
investigators thus note its relatively low use in some countries such as
Spain or the UK. They cite one study suggesting "a big gap between the
number of patients who fit the criteria for ICD implantation ... and the
number who actually get such a device".
Based on their calculation on a heart failure prevalence rate of 2-3%
in the general population, the investigators estimate that around half
of them would potentially have an indication for an ICD — or 10,000 per
million population. However, the present data suggest that only around
250 per million population are actually receiving an ICD today - just
2.5% of those thought eligible.
Noting that cost and different healthcare systems may explain some of
the discrepancies in usage, the study's first author, Professor Dirk van
Veldhuisen from the University of Groningen, the Netherlands, says: "It
is difficult to speculate why we see such a low rate of use in countries
like Spain or UK. However, while some studies have found an added
benefit from device therapy in heart failure, others have not — and we
still have no clear cost-benefit analysis of their more widespread use.
Certainly, implantable devices are expensive, and, if we follow the
guidelines, the cost implications will be substantial."
1. Van Veldhuisen DJ, Maass AH, Priori SG, et al. Implementation of
device therapy (cardiac resynchronization therapy and implantable
cardioverter defibrillator) for patients with heart failure in Europe:
changes from 2004 to 2008. Eur J Heart Fail 2009;
2. Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Italy,
The Netherlands, Norway, Portugal, Spain, Sweden, Switzerland, and the
UK. Data is provided from each of these countries.
3. Cardiac resynchronisation pacemakers and defibrillators for treating
heart failure, which have evolved from conventional pacemakers, aim to
correct abnormal contractions of the heart's ventricles. More than half
of the mortality associated with heart failure is because of sudden
cardiac death — and the most important predictor of SCD is left
ventricular dysfunction, the underlying cause of heart failure. The use
of device therapy (either ICD or CRT in combination with an ICD) aims to
correct dyssynchrony and prevent sudden cardiac death.
4. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or implantable
cardioverter-deﬁrbrillator for congestive heart failure. N Engl J
Med 2005; 352: 225–237.
5. Moss AJ, Hall WJ, Cannom DS, et al. Cardiac-resynchronization therapy
for the prevention of heart-failure events. N Engl J Med 2009;