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Nevzorov R, Goldenberg I, Konstantino Y, Golovchiner G, Strasberg B, Souleiman M, Khalameizer V, Ben-Zvi S, Sela R, Rosenheck S, Freedberg NA, Geist M, Cohen ME, Cohen T, Shlomo N, Gabrielov-Yusim N, Geva D, Glikson M, Haim M. Developing a risk score to predict mortality in the first year after implantable cardioverter defibrillator implantation: Data from the Israeli ICD Registry. J Cardiovasc Electrophysiol 2018; 29:1540-1547. [PMID: 30168227 DOI: 10.1111/jce.13725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/17/2018] [Accepted: 07/30/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Life expectancy of less than 1 year is usually a contraindication for implantable cardioverter defibrillator (ICD) implantation. The aim was to identify patients at risk of death during the first year after implantation. METHODS AND RESULTS Data were derived from a prospective Israeli ICD Registry. Two groups of patients were compared, those who died and those who were alive 1 year after ICD implantation. Factors associated with 1-year mortality were identified on a derivation cohort. A risk score was established and validated. A total of 2617 patients have completed 1 year of follow-up after ICD or cardiac resynchronization therapy defibrillator (CRT-D) implantation. Age greater than 75 years (hazard ratio [HR], 2.7; 95% confidence interval [95% CI], 1.6 to 4.4), atrial fibrillation (AF; HR, 1.9; 95% CI, 1.12 to 3.17), chronic lung disease (HR, 2.0; 95% CI, 1.1 to 3.76), anemia (HR, 2.3; 95% CI, 1.3 to 3.93) and chronic renal failure (CRF; HR, 3.4; 95% CI, 1.74 to 6.6) were independent risk factors for 1-year mortality. We propose a simple AAACC ("triple A double C") score for prediction of 1-year mortality after ICD implantation: Age greater than 75 years (3 points(pts)), anemia (2 pts), AF (1 pt), CRF (3 pts) and chronic lung disease (1 pt). Mortality risk increased with rising number of points (from 1% with 0 pts to 12.5% with >4 pts). The risk score was evaluated with receiver operating characteristic curve and the area under the curve of the validation curve is 0.71 (95% CI, 0.66 to 0.76). CONCLUSIONS Age greater than 75, AF, chronic lung disease, anemia, and CRF were independent risk factors for 1-year mortality. AAACC risk score identifies patients at high risk of death during 1 year after ICD implantation.
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Affiliation(s)
- Roman Nevzorov
- Electrophysiology and Pacing Unit and ICCU, Barzilai University Medical Center, Ashkelon, Affiliated with Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Ilan Goldenberg
- Leviev Heart Center, Chaim Sheba Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yuval Konstantino
- Electrophysiology and Pacing Unit, Soroka University Medical Center, Beer Sheva, Affiliated with Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Gregory Golovchiner
- Electrophysiology and Pacing Unit, Rabin Medical Center, Petah Tikva, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boris Strasberg
- Electrophysiology and Pacing Unit, Rabin Medical Center, Petah Tikva, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mahmoud Souleiman
- Electrophysiology and Pacing Unit, Rambam Health Care Campus, Affiliated with the Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Vladimir Khalameizer
- Electrophysiology and Pacing Unit and ICCU, Barzilai University Medical Center, Ashkelon, Affiliated with Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Shlomit Ben-Zvi
- Electrophysiology and Pacing Unit, Chaim Sheba Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Sela
- Electrophysiology and Pacing Unit, Galilee Medical Center, Affiliated with the Bar Ilan University Faculty of Medicine, Tel Aviv, Israel
| | - Shimon Rosenheck
- Electrophysiology and Pacing Unit, Meir Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nahum A Freedberg
- Electrophysiology and Pacing Unit, HaEmek Medical Center, Afula, Affiliated with the Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Michael Geist
- Electrophysiology and Pacing Unit, Edith Wolfson Hospital, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Einhorn Cohen
- Leviev Heart Center, Chaim Sheba Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Cohen
- Leviev Heart Center, Chaim Sheba Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nir Shlomo
- Leviev Heart Center, Chaim Sheba Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Natalie Gabrielov-Yusim
- Leviev Heart Center, Chaim Sheba Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Diklah Geva
- Leviev Heart Center, Chaim Sheba Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Glikson
- Electrophysiology and Pacing Unit, Shaare Zedek Medical Center, Affiliated with Hebrow University of Jerusalem, Tel Aviv, Israel
| | - Moti Haim
- Electrophysiology and Pacing Unit, Soroka University Medical Center, Beer Sheva, Affiliated with Ben-Gurion University of the Negev, Beer Sheva, Israel
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Bailey JJ, Hodges M, Church TR. Decision to Implant a Cardioverter Defibrillator after Myocardial Infarction: The Role of Ejection Fraction v. Other Risk Factor Markers. Med Decis Making 2016; 27:151-60. [PMID: 17409365 DOI: 10.1177/0272989x06297392] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background . The Multicenter Automatic Defibrillator Implantation Trial showed that in post—myocardial infarction patients with a left ventricular ejection fraction (EF) ≤ 0.30, an implantable cardioverter defibrillator (ICD) resulted in a 31% relative reduction in the risk of death when compared with a conventional therapy group. Whether further refinement in risk estimation could be achieved with additional clinical testing to qualify patients for primary prevention with ICDs remains problematic. Methods . The authors analyzed Cardiac Arrhythmia Suppression Trial registry data to estimate sensitivity and specificity of EF, ventricular premature frequency, and nonsustained ventricular tachycardia for predicting death. They combined the results with similar data from the literature and used summarizing receiver operating characteristic (meta-ROC) curves to estimate overall operational values for sensitivity and specificity for each clinical test. They estimated aggregate values for prior probability to project risks when tests were used singly and in combination. Results . The authors used arrhythmia markers and heart rate variability to further stratify low-EF patients (prior risk = 20.3%); proportionately, 20.4% were predicted at high risk (> 30%) and 40.5% at low risk (< 10%). When heart rate variability is normal, those at high risk reduced proportionately to 9.2%, and those at low risk increased to 51.6%. Conclusions . The combined use of noninvasive markers for arrhythmia substrate and altered autonomic tone can improve risk stratification in low EF without optimal beta-block therapy, whereas for those with optimal beta-block therapy, markers for arrhythmia substrate alone work. Ancillary use of electrophysiologic stimulation can improve results.
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Affiliation(s)
- James J Bailey
- Center for Information Technology, National Institutes of Health, Bethesda, Maryland 20892-5620, USA.
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Parkash R, Sapp JL, Basta M, Doucette S, Thompson K, Gardner M, Gray C, Brownell B, Kidwai H, Cox J. Use of Primary Prevention Implantable Cardioverter-Defibrillators in a Population-Based Cohort Is Associated With a Significant Survival Benefit. Circ Arrhythm Electrophysiol 2012; 5:706-13. [DOI: 10.1161/circep.112.970798] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ratika Parkash
- From the Department of Medicine, Queen Elizabeth II Health Sciences Center (R.P., J.L.S., M.B., K.T., M.G., C.G., B.B., H.K., J.C.) and the Department of Community Health and Epidemiology (S.D.), Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John L. Sapp
- From the Department of Medicine, Queen Elizabeth II Health Sciences Center (R.P., J.L.S., M.B., K.T., M.G., C.G., B.B., H.K., J.C.) and the Department of Community Health and Epidemiology (S.D.), Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Magdy Basta
- From the Department of Medicine, Queen Elizabeth II Health Sciences Center (R.P., J.L.S., M.B., K.T., M.G., C.G., B.B., H.K., J.C.) and the Department of Community Health and Epidemiology (S.D.), Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Steve Doucette
- From the Department of Medicine, Queen Elizabeth II Health Sciences Center (R.P., J.L.S., M.B., K.T., M.G., C.G., B.B., H.K., J.C.) and the Department of Community Health and Epidemiology (S.D.), Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kara Thompson
- From the Department of Medicine, Queen Elizabeth II Health Sciences Center (R.P., J.L.S., M.B., K.T., M.G., C.G., B.B., H.K., J.C.) and the Department of Community Health and Epidemiology (S.D.), Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Martin Gardner
- From the Department of Medicine, Queen Elizabeth II Health Sciences Center (R.P., J.L.S., M.B., K.T., M.G., C.G., B.B., H.K., J.C.) and the Department of Community Health and Epidemiology (S.D.), Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Chris Gray
- From the Department of Medicine, Queen Elizabeth II Health Sciences Center (R.P., J.L.S., M.B., K.T., M.G., C.G., B.B., H.K., J.C.) and the Department of Community Health and Epidemiology (S.D.), Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Brenda Brownell
- From the Department of Medicine, Queen Elizabeth II Health Sciences Center (R.P., J.L.S., M.B., K.T., M.G., C.G., B.B., H.K., J.C.) and the Department of Community Health and Epidemiology (S.D.), Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Hena Kidwai
- From the Department of Medicine, Queen Elizabeth II Health Sciences Center (R.P., J.L.S., M.B., K.T., M.G., C.G., B.B., H.K., J.C.) and the Department of Community Health and Epidemiology (S.D.), Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jafna Cox
- From the Department of Medicine, Queen Elizabeth II Health Sciences Center (R.P., J.L.S., M.B., K.T., M.G., C.G., B.B., H.K., J.C.) and the Department of Community Health and Epidemiology (S.D.), Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada
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Bunch TJ, White RD, Gersh BJ, Shen WK, Hammill SC, Packer DL. Outcomes and in-hospital treatment of out-of-hospital cardiac arrest patients resuscitated from ventricular fibrillation by early defibrillation. Mayo Clin Proc 2004; 79:613-9. [PMID: 15132402 DOI: 10.4065/79.5.613] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe and evaluate the in-hospital treatment of ventricular arrhythmias and underlying structural heart disease in patients who survive ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA) in a region with a high survival rate after hospital discharge. PATIENTS AND METHODS The study included all patients presenting in Olmsted County, Minnesota, who had experienced OHCA between November 1990 and December 2000 and who underwent defibrillation of VF by an emergency medical service system. RESULTS Of 200 patients who experienced VF arrest, 138 (69%) survived to hospital admission (7 died in the emergency department before admission), and 79 (40%) were discharged. Of patients who were discharged, 37 (47%) had a reversible cause of the arrest (perimyocardial infarction) and received treatment of the primary process. The other 42 patients who were discharged had ischemic coronary heart disease (CHD) (n=25), nonischemic CHD (n=10), or idiopathic VF (n=7). Four of the patients with CHD but no left ventricular dysfunction were treated with coronary artery bypass grafting or percutaneous coronary intervention alone. A total of 52 patients (66%) were candidates for electrophysiologic testing. Of these patients, 48 (92%) underwent electrophysiologic testing; of these patients, 10 received amiodarone alone, and 35 received an implantable cardioverter-defibrillator (ICD) (of whom 3 also received amiodarone). Patients who did not receive ICD therapy typically presented before 1998 with CHD and underwent coronary artery bypass grafting or percutaneous coronary intervention only. Of 79 patients who were discharged, 14 (18%) with an ICD have received subsequent shocks. Nineteen (24%) of 79 patients have died, 5 of a primary cardiac etiology (including 2 with repeated OHCA). CONCLUSIONS The VF OHCA survival rate is high in the setting of rapid defibrillation, with 40% of patients being discharged from the hospital. By the end of the 10-year study, more patients were receiving antiarrhythmic therapy, in particular ICD implantation, after hospital admission. Overall, the long-term survival in patients with VF OHCA is favorable.
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Affiliation(s)
- T Jared Bunch
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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Bailey JJ, Hodges M, Church TR. Risk stratification in diabetic patients with a previous myocardial infarction. J Electrocardiol 2003; 36 Suppl:121-5. [PMID: 14716612 DOI: 10.1016/j.jelectrocard.2003.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We used Kaplan-Meier 2-year survival analysis on CAST registry patients to estimate prognostic power of VPC frequency (> or =10/hr), presence of nonsustained ventricular tachycardia (NSVT), left ventricular ejection fraction, and presence of diabetes. We also used meta-analysis of reports in the literature to estimate prognostic power of signal-averaged electrocardiogram (SAECG) and electrophysiological tests (EPS) as well as VPCs, NSVT, and LVEF. Combined results from CAST analysis and literature meta-analysis yielded sensitivity and specificity for VPCs, NSVT, SAECG, LVEF, Diabetes, and EPS. The overall 2 year event rate for life-threatening arrhythmias or death was 7.88% for 51,144 cases in the combined CAST and literature data. After segmenting the population 21.3% were diabetic with a predicted 2 yr event rate of 13.5% and 78.7% were nondiabetic event rate of 6.4%. We defined low risk as <10% and high risk as > or =30%. Otherwise predicted event rate was classified as "unstratified." When all possible combination of noninvasive tests were applied, a prominent difference in the proportions of cases at risk between the diabetics and nondiabetics was revealed. When the unstratified cases were subsequently tested with EPS, the difference between the two groups was even more marked.
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Affiliation(s)
- James J Bailey
- Center for Information Technology, National Institutes of Health, Bethesda, MD, USA.
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8
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MADIT II, the Multi-center Autonomic Defibrillator Implantation Trial II stopped early for mortality reduction, has ICD therapy earned its evidence-based credentials? Int J Cardiol 2002. [DOI: 10.1016/s0167-5273(01)00629-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bailey JJ, Berson AS, Handelsman H, Hodges M. Utility of current risk stratification tests for predicting major arrhythmic events after myocardial infarction. J Am Coll Cardiol 2001; 38:1902-11. [PMID: 11738292 DOI: 10.1016/s0735-1097(01)01667-9] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES We surveyed the literature to estimate prediction values for five common tests for risk of major arrhythmic events (MAEs) after myocardial infarction. We then determined feasibility of a staged risk stratification using combinations of noninvasive tests, reserving an electrophysiologic study (EPS) as the final test. BACKGROUND Improved approaches are needed for identifying those patients at highest risk for subsequent MAE and candidates for implantable cardioverter-defibrillators. METHODS We located 44 reports for which values of MAE incidence and predictive accuracy could be inferred: signal-averaged electrocardiography; heart rate variability; severe ventricular arrhythmia on ambulatory electrocardiography; left ventricular ejection fraction; and EPS. A meta-analysis of reports used receiver-operating characteristic curves to estimate mean values for sensitivity and specificity for each test and 95% confidence limits. We then simulated a clinical situation in which risk was estimated by combining tests in three stages. RESULTS Test sensitivities ranged from 42.8% to 62.4%; specificities from 77.4% to 85.8%. A three-stage stratification yielded a low-risk group (80.0% with a two-year MAE risk of 2.9%), a high-risk group (11.8% with a 41.4% risk) and an unstratified group (8.2% with an 8.9% risk equivalent to a two-year incidence of 7.9%). CONCLUSIONS Sensitivities and specificities for the five tests were relatively similar. No one test was satisfactory alone for predicting risk. Combinations of tests in stages allowed us to stratify 91.8% of patients as either high-risk or low-risk. These data suggest that a large prospective study to develop a robust prediction model is feasible and desirable.
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MESH Headings
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Electrocardiography, Ambulatory
- Humans
- Myocardial Infarction/complications
- Myocardial Infarction/physiopathology
- Myocardial Infarction/therapy
- Predictive Value of Tests
- ROC Curve
- Risk Assessment
- Signal Processing, Computer-Assisted
- Stroke Volume
- Tachycardia, Ventricular/etiology
- Tachycardia, Ventricular/physiopathology
- Tachycardia, Ventricular/therapy
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Function, Left/physiology
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Affiliation(s)
- J J Bailey
- Center for Information Technology, National Institutes of Health, Bethesda, Maryland 20892-5620, USA.
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Delacretaz E, Schlaepfer J, Metzger J, Fromer M, Kappenberger L. Evidence rather than costs must guide use of the implantable cardioverter defibrillator. Am J Cardiol 2000; 86:52K-57K. [PMID: 11084101 DOI: 10.1016/s0002-9149(00)01292-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Randomized controlled trials have shown superior survival rates with implantable cardioverter defibrillators (ICDs) compared with antiarrhythmic drugs in survivors of cardiac arrest and life-threatening ventricular tachyarrhythmias, as well as in high-risk patients with ischemic heart disease and inducible ventricular tachycardia (VT). Current defibrillators are small and implanted with techniques similar to standard pacemakers. They provide high-energy shocks for ventricular fibrillation (VF) and rapid VT, antitachycardia pacing for monomorphic VT, and antibradycardia pacing. Limited evidence suggests that ICD therapy is cost-effective when compared with other widely accepted treatments. The use of ICDs is likely to continue to expand in the future. Ongoing clinical trials will define further prophylactic indications of the ICD and clarify its cost-effectiveness ratio in different clinical settings.
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Affiliation(s)
- E Delacretaz
- Division of Cardiology, University Hospital, Lausanne, Switzerland
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12
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Cannom DS. Matching cardiac rhythm management technology to patient needs: pacing/ablation/implantable cardioverter defibrillators. Am J Cardiol 2000; 86:58K-70K. [PMID: 11084102 DOI: 10.1016/s0002-9149(00)01293-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Data from 2 decades of clinical electrophysiologic studies have allowed great progress in the evaluation and treatment of patients with sustained ventricular arrhythmias and the appropriate identification of those patients at high risk for subsequent sudden death. The goals of treatment of the patient with ventricular arrhythmias are to suppress symptoms and prevent a fatal event. The steps in providing such therapy include (1) defining the cardiac anatomy; (2) assessing arrhythmia risk through noninvasive or invasive testing; and (3) prescribing treatment based on these results. Patients may be separated into high- and low-risk groups to help identify appropriate treatment. Although low-risk groups may benefit from reassurance or medications such as beta-blockers or verapamil, high-risk groups have been more difficult to treat. Recent randomized trials of implantable cardioverter defibrillators (ICDs) for ventricular arrhythmias suggest that they may provide better protection for high-risk patients than do antiarrhythmic medications.
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MESH Headings
- Anti-Arrhythmia Agents/therapeutic use
- Cardiac Pacing, Artificial/methods
- Cardiopulmonary Resuscitation
- Catheter Ablation/methods
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Electric Countershock/instrumentation
- Humans
- Risk
- Tachycardia, Ventricular/complications
- Tachycardia, Ventricular/mortality
- Tachycardia, Ventricular/therapy
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/mortality
- Ventricular Fibrillation/complications
- Ventricular Fibrillation/mortality
- Ventricular Fibrillation/therapy
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Affiliation(s)
- D S Cannom
- University of California-Los Angeles School of Medicine, Division of Cardiology, Good Samaritan Hospital, Los Angeles, California, USA
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Affiliation(s)
- G S Reeder
- Mayo Medical School, Rochester, Minn., USA
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Hallstrom AP, Anderson JL, Cobb LA, Friedman PL, Herre JM, Klein RC, McAnulty J, Steinberg JS. Advantages and disadvantages of trial designs: a review of analysis methods for ICD studies. AVID Investigators. Pacing Clin Electrophysiol 2000; 23:1029-38. [PMID: 10879390 DOI: 10.1111/j.1540-8159.2000.tb00892.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
General modalities of analyses that have been used for ICD studies are reviewed. Published "typical" examples are briefly described. The historical cohort method is exemplified with previously unpublished data from the Seattle Cardiac Arrest Survivor database. The AVID Study database is used to compare the results obtained from nonrandomized methodologies with randomized methodologies. Particular issues related to the use of the ICD for example, mode of death, inability to blind, selection practice, and treatment decision times make this a natural pedagogic platform.
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Affiliation(s)
- A P Hallstrom
- Department of Biostatistics, University of Washington, Seattle 98105, USA.
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Strobel JS, Epstein AE. Large clinical trials in the management of ventricular arrhythmias. Applying group results to individual cases. Cardiol Clin 2000; 18:337-56, viii. [PMID: 10849877 DOI: 10.1016/s0733-8651(05)70145-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Applying the results of clinical trials to everyday practice in an appropriate manner can be difficult. Earlier clinical trials focused on the secondary prevention of ventricular arrhythmias. Studying patients at high risk of recurrent ventricular arrhythmias is important, but the overall impact on arrhythmic death is low. Recent arrhythmia trials have studied specific patient populations for the primary prevention of ventricular arrhythmias. New trials will expand the investigation to other populations. This article summarizes the results of large clinical trials in the management of ventricular arrhythmias and attempts to provide guidelines for applying their results to everyday clinical practice.
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Affiliation(s)
- J S Strobel
- Department of Medicine, University of Alabama at Birmingham, USA
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16
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García García J, Serrano Sánchez JA, del Castillo Arrojo S, Cantalapiedra Alsedo JL, Villacastín J, Almendral J, Arenal A, González S, Delcán Domínguez JL. [Predictors of sudden death in coronary artery disease]. Rev Esp Cardiol 2000; 53:440-62. [PMID: 10712973 DOI: 10.1016/s0300-8932(00)75108-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Although advances in the management of acute myocardial infarction have resulted in a decline in long-term risk of sudden death, it continues to be high in certain subsets of patients. Thus, it is important to identify and treat these patients. Left ventricular ejection fraction less than 0.40, frequent premature ventricular ectopy on Holter monitoring, late potentials on signal-averaged electrocardiogram, impaired heart rate variability, abnormal baroreflex sensitivity and inducible sustained monomorphic ventricular tachycardia during electrophysiological study are predictors of sudden death and arrhythmic events. Although the negative predictive value of each factor is high, the positive predictive accuracy is low. Several tests can be combined to obtain higher positive predictive values. In fact, in some studies combined noninvasive tests have been used to select patients for ventricular stimulation study. Some preventive treatment can be applied in these patients. Available data do not justify prophylactic therapy with amiodarone in high-risk survivors of acute myocardial infarction. Sudden death and total mortality have been significantly reduced in postinfarction patients by long-term beta blockade. Hence, beta blockers should be given to all patients with acute myocardial infarction who do not have contraindications to their use. The MADIT study has shown the beneficial effect of implantable cardioverter defibrillator in reducing mortality in patients with prior myocardial infarction, an ejection fraction less than 0.36, asymptomatic nonsustained ventricular tachycardia, and inducible sustained ventricular tachycardia, unsuppressable by procainamide. Besides, several studies are under way to evaluate the prophylactic use of implantable defibrillator for improving survival in high-risk patients.
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Affiliation(s)
- J García García
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid
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Block M, Breithardt G. The implantable cardioverter defibrillator and primary prevention of sudden death: the Multicenter Automatic Defibrillator Implantation Trial and the Coronary Artery Bypass Graft (CABG)-Patch Trial. Am J Cardiol 1999; 83:74D-78D. [PMID: 10089844 DOI: 10.1016/s0002-9149(98)01028-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Multicenter Automatic Defibrillator Implantation Trial (MADIT) and the Coronary Artery Bypass Graft (CABG)-Patch study were the first 2 randomized trials investigating the usefulness of the implanted cardioverter defibrillator (ICD) for primary prevention of sudden death. Patients enrolled in MADIT and CABG-Patch had never experienced a sustained ventricular tachycardia (VT) but were thought to be at high risk of sudden death. All patients had coronary artery disease and severely suppressed left ventricular ejection fraction. CABG-Patch patients received their ICD during CABG surgery. Most MADIT patients already had received CABG or percutaneous transluminal coronary angiography and had no indication for revascularization procedures at study entry. MADIT patients had nonsustained spontaneous VT and inducible, nonsuppressible VT; CABG-Patch patients had only an abnormal signal-averaged electrocardiogram as an indicator of their arrhythmic risk. CABG-Patch patients did not benefit from ICD implantation, presumably due to the influence of revascularization on ischemia and left ventricular function. In contrast, MADIT patients showed an improved survival by the ICD. MADIT patients had no need for revascularization and, presumably, their risk indicator for arrhythmic events was stronger than the one used in CABG-Patch. MADIT criteria have become a class I indication for ICD implantation and, in the absence of testing for suppressibility of induced VTs, a class IIb criterion for ICD implantation. Screening for MADIT patients is expensive, as only relatively few patients after myocardial infarction fulfill the criteria. Nevertheless, in comparison with amiodarone, treatment of MADIT patients with ICDs seems to be cost-effective, especially if ICDs are implanted transvenously and have the improved battery longevity of the current devices.
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MESH Headings
- Aged
- Cardiac Output, Low/complications
- Cardiac Output, Low/mortality
- Cardiac Output, Low/therapy
- Combined Modality Therapy
- Coronary Artery Bypass
- Coronary Disease/complications
- Coronary Disease/mortality
- Coronary Disease/therapy
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Female
- Humans
- Male
- Middle Aged
- Multicenter Studies as Topic
- Randomized Controlled Trials as Topic
- Survival Rate
- Tachycardia, Ventricular/etiology
- Tachycardia, Ventricular/mortality
- Tachycardia, Ventricular/therapy
- Treatment Outcome
- Ventricular Fibrillation/etiology
- Ventricular Fibrillation/mortality
- Ventricular Fibrillation/therapy
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Affiliation(s)
- M Block
- Stiftsklinik Augustinum München
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