Current guidelines are continuing to extend the range of patients who may benefit from device therapy. However more and more of these patients are quite elderly which raises concerns about overselling the benefits of technology that takes years to reveal their true value. Consider the case of a 93 year old woman with an EF of 25-30% and LBBB on the 12-lead ECG. She is on as much guideline directed therapy as she can tolerate and is eligible for an ICD or CRT-D. What kind of discussions concerning implantation of an ICD or CRT device should the provider be having with her and her family?
Should the conversation be all about the clinical evidence data or should some consideration be given to a more individualized approach that honestly discusses the true benefit as it applies the particular patient. Arguably the true benefit of an ICD or CRT for a 93 year old is not at all clearly known. A more patient-centered approach, as recently advocated by the AHA/HFSA skilled nursing facility guidelines, which focuses on shared decision-making that includes consideration of co-morbidities and overall goals of care is quite reasonable.