CLINICAL STUDY: ELECTROPHYSIOLOGY
Patients at lower risk of arrhythmia recurrence: a subgroup in whom implantable defibrillators may not offer benefit
Alfred P. Hallstrom, PhD*,
John H. McAnulty, MD, FACC ,
Bruce L. Wilkoff, MD, FACC ,
Dean Follmann, PhD#,
Merritt H. Raitt, MD, FACC,
Mark D. Carlson, MD, FACC ,
Anne M. Gillis, MD¶,
Hue-Teh Shih, MD, FACC||,
Judy L. Powell, RN*,
Hank Duff, MD¶,
Blair D. Halperin, MD, FACC the Antiarrhythmics Versus Implantable Defibrillator (AVID) Trial Investigators
* University of Washington, Seattle, Washington, USA
Oregon Health Sciences University/Collaborating Medical Centers, Portland, Oregon, USA
University Hospitals of Cleveland, Cleveland, Ohio, USA
Cleveland Clinic Foundation, Cleveland, Ohio, USA
|| University of Texas Medical School, Houston, Texas, USA
¶ University of Calgary/Calgary Regional Health Authority Hospitals, Calgary, Alberta, Canada
# National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
Manuscript received March 13, 2000;
revised manuscript received November 3, 2000,
accepted December 6, 2000.
Reprint requests and correspondence: Dr. Alfred P. Hallstrom, University of Washington, 1107 Northeast 45th, Suite 505, Seattle, Washington 98105
avidctc{at}u.washington.edu
OBJECTIVES
The goal of this study was to identify subgroups of arrhythmia patients who do not benefit from use of the implantable cardiac defibrillator (ICD).
BACKGROUND
Treatment of serious ventricular arrhythmias has evolved toward more common use of the ICD. Since estimates of the cost per year of life saved by ICD therapy vary from $25,000 to perhaps $125,000, it is important to identify patient subgroups that do not benefit from the ICD.
METHODS
Data for 491 ICD patients enrolled in the Antiarrhythmics Versus Implantable Defibrillators Study were used to create a hazards model relating baseline factors to time to first recurrent arrhythmia. The model was used to predict the hazard for recurrent arrhythmia among all trial patients. A priori cut points provided lower and higher recurrent arrhythmia risk strata. For each stratum the incremental years of life due to ICD versus antiarrhythmic drug therapy were calculated.
RESULTS
Factors that predicted recurrent arrhythmia were: ventricular tachycardia as the index arrhythmia, history of cerebrovascular disease, lower left ventricular ejection fraction, a history of any tachyarrhythmia before the index event and the absence of revascularization after the index event. Survival times (over a follow-up of three years) were identical in each arm of the lowest risk sextile (survival advantage 0.03 ± 0.12 [se] years), while the survival advantage for patients above the first sextile was 0.27 ± 0.07 (se) years (two-sided p = 0.05).
CONCLUSIONS
Patients presenting with an isolated episode of ventricular fibrillation in the absence of cerebrovascular disease or history of prior arrhythmia who have undergone revascularization or who have moderately preserved left ventricular function (left ventricular ejection fraction > 0.27) are not likely to benefit from ICD therapy compared with amiodarone therapy.
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Abbreviations and Acronyms
| | AAD | = antiarrhythmic drug | | ATP | = antitachycardia pacing | | AVID | = Antiarrhythmics Versus Implantable Defibrillators study | | EF | = ejection fraction | | ICD | = implantable cardioverter defibrillator | | LVEF | = left ventricular ejection fraction | | rh | = relative hazards | | VF | = ventricular fibrillation | | VT | = ventricular tachycardia |
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