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Zhao S, Ching CK, Huang D, Liu YB, Rodriguez-Guerrero DA, Hussin A, Kim YH, Van Dorn B, Zhou X, Singh B, Zhang S. Regional disparities and risk factors of mortality among patients at high risk of sudden cardiac death in emerging countries: a nonrandomized controlled trial. BMC Med 2024; 22:130. [PMID: 38519982 PMCID: PMC10960430 DOI: 10.1186/s12916-024-03310-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 02/20/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Comprehensive data on patients at high risk of sudden cardiac death (SCD) in emerging countries are lacking. The aim was to deepen our understanding of the SCD phenotype and identify risk factors for death among patients at high risk of SCD in emerging countries. METHODS Patients who met the class I indication for implantable cardioverter-defibrillator (ICD) implantation according to guideline recommendations in 17 countries and regions underrepresented in previous trials were enrolled. Countries were stratified by the WHO regional classification. Patients were or were not implanted with an ICD at their discretion. The outcomes were all-cause mortality and SCD. RESULTS We enrolled 4222 patients, and 3889 patients were included in the analysis. The mean follow-up period was 21.6 ± 10.2 months. There were 433 (11.1%) instances of all-cause mortality and 117 (3.0%) cases of SCD. All-cause mortality was highest in primary prevention (PP) patients from Southeast Asia and secondary prevention (SP) patients from the Middle East and Africa. The SCD rates among PP and SP patients were both highest in South Asia. Multivariate Cox regression modelling demonstrated that in addition to the independent predictors identified in previous studies, both geographic region and ICD use were associated with all-cause mortality in patients with high SCD risk. Primary prophylactic ICD implantation was associated with a 36% (HR = 0.64, 95% CI 0.531-0.802, p < 0.0001) lower all-cause mortality risk and an 80% (HR = 0.20, 95% CI = 0.116-0.343, p < 0.0001) lower SCD risk. CONCLUSIONS There was significant heterogeneity among patients with high SCD risk in emerging countries. The influences of geographic regions on patient characteristics and outcomes were significant. Improvement in increasing ICD utilization and uptake of guideline-directed medical therapy in emerging countries is urgent. TRIAL REGISTRATION ClinicalTrials.gov, NCT02099721.
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Affiliation(s)
- Shuang Zhao
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Chi-Keong Ching
- National Heart Centre Singapore, Outram District, Singapore, Singapore
| | | | - Yen-Bin Liu
- National Taiwan University Hospital, Taipei City, Taiwan, China
| | - Diego A Rodriguez-Guerrero
- Instituto de Cardiología Fundación Cardioinfantil, Centro Internacional de Arritmias, Bogotá, Colombia
- Universidad de La Sabana, Bogota, Colombia
| | | | - Young-Hoon Kim
- Korea University Medical Center, Seoul, Republic of Korea
| | | | | | - Balbir Singh
- Pan Max Hospital, Delhi, India
- Max Super Speciality Hospital, Delhi, India
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 Beilishi Rd, Xicheng District, Beijing, 100037, China.
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Singh B, Hsieh YC, Liu YB, Lin KH, Joung B, Rodriguez DA, Chasnoits AR, Huang D, Zhang S, O'Brien JE, Lexcen DR, Cerkvenik J, Van Dorn B, Ching CK. Cardioverter-defibrillator reduces mortality risk in eligible ischemic and non-ischemic cardiomyopathy patients: Sub-analysis of the multi-center Improve SCA study. Indian Heart J 2023; 75:115-121. [PMID: 36736459 PMCID: PMC10123448 DOI: 10.1016/j.ihj.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 01/09/2023] [Accepted: 01/29/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND & OBJECTIVE Despite the burden of sudden cardiac arrest (SCA) worldwide, implantable cardioverter-defibrillators (ICDs) are underutilized, particularly in Asia, Latin America, Eastern Europe, the Middle East, and Africa. The Improve SCA trial demonstrated that primary prevention (PP) patients in these regions benefit from an ICD or a cardiac resynchronization therapy defibrillator (CRT-D). We aimed to compare the rate of device therapy and mortality among ischemic and non-ischemic cardiomyopathy (ICM and NICM) PP patients who met guideline indications for ICD therapy and had an ICD/CRT-D implanted. METHODS Improve SCA was a prospective, non-randomized, non-blinded multicenter trial that enrolled patients from the above-mentioned regions. All-cause mortality and device therapy were examined by cardiomyopathy (ICM vs NICM) and implantation status. Cox proportional hazards methods were used, adjusting for factors affecting mortality risk. RESULTS Of 1848 PP NICM patients, 1007 (54.5%) received ICD/CRT-D, while 303 of 581 (52.1%) PP ICM patients received an ICD/CRT-D. The all-cause mortality rate at 3 years for NICM patients with and without an ICD/CRT-D was 13.1% and 18.3%, respectively (HR 0.51, 95% CI 0.38-0.68, p < 0.001). Similarly, all-cause mortality at 3 years in ICM patients was 13.8% in those with a device and 19.9% in those without an ICD/CRT-D (HR 0.54, 95% CI 0.33-.0.88, p = 0.011). The time to first device therapy, time to first shock, and time to first antitachycardia pacing (ATP) therapy were not significantly different between groups (p ≥ 0.263). CONCLUSIONS In this large data set of patients with a guideline-based PP ICD indication, defibrillator device implantation conferred a significant mortality benefit in both NICM and ICM patients. The rate of appropriate device therapy was also similar in both groups. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov ID: NCT02099721.
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Affiliation(s)
- Balbir Singh
- Department of Cardiology, Pan Max Hospital, New Delhi, India.
| | - Yu-Cheng Hsieh
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan; National Chung Hsing University School of Medicine, Taichung, Taiwan
| | - Yen-Bin Liu
- Division of Cardiology, Internal Medicine Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuo-Hung Lin
- Department of Cardiology, China Medical Center University Hospital, Taichung, Taiwan
| | - Boyoung Joung
- Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Diego A Rodriguez
- Instituto de Cardiología, Fundación Cardio Infantil, Centro Internacional de Arritmias, Bogotá, Colombia; Universidad de la Sabana, Chía, Columbia
| | - Alexandr R Chasnoits
- Department of Roentgen-Endovascular Surgery, Republican Scientific and Practical Centre Cardiology, Minsk, Belarus
| | - Dejia Huang
- Department of Cardiovascular Medicine, West China Hospital, Cardiology, Chengdu, China
| | - Shu Zhang
- The Cardiac Arrhythmia Center, Fuwai Cardiovascular Hospital, Beijing, China
| | - Janet E O'Brien
- Cardiac Rhythm Management, Medtronic Inc., Mounds View, Minnesota, USA
| | - Daniel R Lexcen
- Cardiac Rhythm Management, Medtronic Inc., Mounds View, Minnesota, USA
| | - Jeffrey Cerkvenik
- Cardiac Rhythm Management, Medtronic Inc., Mounds View, Minnesota, USA
| | - Brian Van Dorn
- Cardiac Rhythm Management, Medtronic Inc., Mounds View, Minnesota, USA
| | - Chi-Keong Ching
- Department of Cardiology, National Heart Centre of Singapore, Outram District, Singapore
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Zhang S, Chen WJ, Sankardas MA, Ahmed WH, Liew HB, Gwon HC, Nesa Malik FT, Tang B, Haggui A, Oh IY, Ong TK, Cheng CI, Liu X, Seth A, Choi YJ, Qamar N, Rungpradubvong V, Wang CC, Jeon J, Wong G, Lemme F, Van Dorn B, Lexcen D, Huang D. Improve the Prevention of Sudden Cardiac Arrest in Patients With Post-Acute Myocardial Infarction. JACC Asia 2022; 2:559-571. [PMID: 36518723 PMCID: PMC9743445 DOI: 10.1016/j.jacasi.2022.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/24/2022] [Accepted: 06/03/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Implantable cardioverter-defibrillator (ICD) implantation to prevent sudden cardiac death (SCD) in post-myocardial infarction (MI) patients varies by geography but remains low in many regions despite guideline recommendations. OBJECTIVES This study aimed to characterize the care pathway of post-MI patients and understand barriers to referral for further SCD risk stratification and management in patients meeting referral criteria. METHODS This prospective, nonrandomized, multi-nation study included patients ≥18 years of age, with an acute MI ≤30 days and left ventricular ejection fraction <50% ≤14 days post-MI. The primary endpoint was defined as the physician's decision to refer a patient for SCD stratification and management. RESULTS In total, 1,491 post-MI patients were enrolled (60.2 ± 12.0 years of age, 82.4% male). During the study, 26.7% (n = 398) of patients met criteria for further SCD risk stratification; however, only 59.3% of those meeting criteria (n = 236; 95% CI: 54.4%-64.0%) were referred for a visit. Of patients referred for SCD risk stratification and management, 94.9% (n = 224) attended the visit of which 56.7% (n =127; 95% CI: 50.1%-63.0%) met ICD indication criteria. Of patients who met ICD indication criteria, 14.2% (n = 18) were implanted. CONCLUSIONS We found that ∼40% of patients meeting criteria were not referred for further SCD risk stratification and management and ∼85% of patients who met ICD indications did not receive a guideline-directed ICD. Physician and patient reasons for refusing referral to SCD risk stratification and management or ICD implant varied by geography suggesting that improvement will require both physician- and patient-focused approaches. (Improve Sudden Cardiac Arrest [SCA] Bridge Study; NCT03715790).
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Key Words
- CRT-D, cardiac resynchronization therapy-defibrillator
- ICD, implantable cardioverter-defibrillator
- ISC, India subcontinent
- LVEF, left ventricular ejection fraction
- MEACAT, Middle East, Africa, Central Asia, and Turkey
- MI, myocardial infarction
- OR, odds ratio
- SCD, sudden cardiac death
- SEA, South East Asia
- cardiac resynchronization therapy–defibrillator
- delivery of health care
- implantable cardioverter-defibrillator
- myocardial infarction
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Affiliation(s)
- Shu Zhang
- Fu Wai Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | | | | | - Houng-Bang Liew
- Clinical Research Centre, Queen Elizabeth Hospital II, Sabah, Malaysia
| | - Hyeon-Cheol Gwon
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | - Baopeng Tang
- Fu Wai Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | | | - Il-Young Oh
- National Taiwan University Hospital, Taipei, Taiwan
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | | | - Cheng-I Cheng
- Kaohsiung Chang Gung Memorial Hospital of CGMF, Kaohsiung, Taiwan
| | - Xingbin Liu
- West China Hospital, Sichuan University, Chengdu, China
| | - Ashok Seth
- Fortis Escorts Heart Institute, New Delhi, India
| | | | - Nadeem Qamar
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Voravut Rungpradubvong
- Fortis Escorts Heart Institute, New Delhi, India
- King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chun-Chieh Wang
- Chang Gung Memorial Hospital Linkou and Chang Gung University, Taoyuan City, Taiwan
| | | | - Grace Wong
- Medtronic Australasia, Sydney, Australia
| | - Francesca Lemme
- National Taiwan University Hospital, Taipei, Taiwan
- Medtronic Bakken Research Center, Maastricht, the Netherlands
| | | | - Dan Lexcen
- National Taiwan University Hospital, Taipei, Taiwan
| | - Dejia Huang
- National Taiwan University Hospital, Taipei, Taiwan
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Ching CK, Hsieh YC, Liu YB, Rodriguez DA, Kim YH, Joung B, Singh B, Huang D, Hussin A, Chasnoits AR, O'Brien JE, Cerkvenik J, Lexcen D, Van Dorn B, Zhang S. The mortality analysis of primary prevention patients receiving a cardiac resynchronization defibrillator (CRT-D) or implantable cardioverter-defibrillator (ICD) according to guideline indications in the improve SCA study. J Cardiovasc Electrophysiol 2021; 32:2285-2294. [PMID: 34216069 DOI: 10.1111/jce.15149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/10/2021] [Accepted: 06/27/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND In primary prevention (PP) patients the utilization of implantable cardioverter-defibrillators (ICD) and cardiac resynchronization therapy-defibrillators (CRT-D) remains low in many geographies, despite the proven mortality benefit. PURPOSE The objective of this analysis was to examine the mortality benefit in PP patients by guideline-indicated device type: ICD and CRT-D. METHODS Improve sudden cardiac arrest was a prospective, nonrandomized, nonblinded multicenter trial that enrolled patients from regions where ICD utilization is low. PP patient's CRT-D or ICD eligibility was based upon the 2008 ACC/AHA/HRS and 2006 ESC guidelines. Mortality was assessed according to guideline-indicated device type comparing implanted and nonimplanted patients. Cox proportional hazards methods were used, adjusting for known factors affecting mortality risk. RESULTS Among 2618 PP patients followed for a mean of 20.8 ± 10.8 months, 1073 were indicated for a CRT-D, and 1545 were indicated for an ICD. PP CRT-D-indicated patients who received CRT-D therapy had a 58% risk reduction in mortality compared with those without implant (adjusted hazard ratio [HR]: 0.42, 95% confidence interval [CI]: 0.28-0.61, p < .0001). PP patients with an ICD indication had a 43% risk reduction in mortality with an ICD implant compared with no implant (adjusted HR: 0.57, 95% CI: 0.41-0.81, p = .002). CONCLUSIONS This analysis confirms the mortality benefit of adherence to guideline-indicated implantable defibrillation therapy for PP patients in geographies where ICD therapy was underutilized. These results affirm that medical practice should follow clinical guidelines when choosing therapy for PP patients who meet the respective defibrillator device implant indication.
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Affiliation(s)
- Chi Keong Ching
- Department of Cardiology, National Heart Centre of Singapore, Outram, Singapore
| | - Yu-Cheng Hsieh
- Division of Cardiology, Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Internal Medicine, Faculty of Medicine, Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yen-Bing Liu
- Division of Cardiology, Internal Medicine Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Diego A Rodriguez
- Fundación Cardioinfantil, Instituto de Cardiología Fundación Cardio infantil, Centro Internacional de Arritmias, Bogotá, Colombia
| | - Young-Hoon Kim
- Department of Cardiology, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Boyoung Joung
- Department of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Balbir Singh
- Department of Cardiology, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Dejia Huang
- Department of Cardiovascular Medicine, West China Hospital, Chengdu, China
| | - Azlan Hussin
- Department of Cardiology, Institut Jantung Negara, Kuala Lumpur, Malaysia
| | | | - Janet E O'Brien
- Cardiac Rhythm Management, Medtronic plc, Mounds View, Minnesota, USA
| | - Jeffrey Cerkvenik
- Cardiac Rhythm Management, Medtronic plc, Mounds View, Minnesota, USA
| | - Daniel Lexcen
- Cardiac Rhythm Management, Medtronic plc, Mounds View, Minnesota, USA
| | - Brian Van Dorn
- Cardiac Rhythm Management, Medtronic plc, Mounds View, Minnesota, USA
| | - Shu Zhang
- Fu Wai Hospital Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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