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ELECTROPHYSIOLOGY AND HEART FAILURE: VIEWPOINT

Prophylactic implantable cardioverter-defibrillator therapy in patients with left ventricular systolic dysfunction

A pooled analysis of 10 primary prevention trials

Kumaraswamy Nanthakumar, MD^*,*, Andrew E. Epstein, MD, G. Neal Kay, MD, Vance J. Plumb, MD and Douglas S. Lee, MD

^* Division of Cardiology, University Health Network
Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
University of Alabama at Birmingham, Birmingham, Alabama

Manuscript received April 29, 2004; revised manuscript received August 9, 2004, accepted August 16, 2004.

^* Reprint requests and correspondence: Dr. Kumaraswamy Nanthakumar, Division of Cardiology, University Health Network, Toronto General Hospital, 150 Gerrard Street West, PMCC 3-558, Toronto, Ontario, Canada M5G 2C4 (Email: nanthaj{at}yahoo.com).

Strategies to decrease sudden cardiac death in patients with left ventricular systolic dysfunction are evolving. Recent clinical trials have evaluated the role of prophylactic implantable cardioverter-defibrillators (ICDs) in patients with and without additional risk stratifiers. We pooled studies comparing treatment with and without ICDs from published data and presented abstracts, irrespective of QRS duration and etiology of systolic dysfunction. On the basis of the available clinical trials, implantation of an ICD for primary prevention of death provides a 7.9% absolute mortality reduction (p = 0.003) in patients with left ventricular (LV) systolic dysfunction who were receiving optimized medical therapy. This finding was not sensitive to the exclusion of any individual trial. The ICD is an effective primary preventative measure in patients who are at risk for death; however, the application of this therapy needs to be individualized for the patient, similar to drug therapies in LV systolic dysfunction. In health care settings without unlimited resources, optimal use of this therapy will require better risk stratification methods or lowering of the initial device cost.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   AMIOVIRT = Amiodarone Versus Implantable Cardioverter-Defibrillator Randomized Trial   CABG-Patch = Coronary Artery Bypass Graft Patch trial   CAT = Cardiomyopathy Trial   CI = confidence interval   COMPANION = Comparison of Medical Therapy, Pacing, and Defibrillation in Patients With Left Ventricular Systolic Dysfunction trial   CRT = cardiac resynchronization therapy   DEFINITE = Defibrillators In Non-Ischemic Cardiomyopathy Treatment Evaluation trial   DINAMIT = Defibrillator In Acute Myocardial Infarction Trial   EP = electrophysiology   ICD = implantable cardioverter-defibrillator   LV = left ventricular   MADIT = Multicenter Automatic Defibrillator Implantation Trial   MUSTT = Multicenter Unsustained Tachycardia Trial   RR = relative risk   SCD-HeFT = Sudden Cardiac Death in Heart Failure Trial

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