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J Am Coll Cardiol, 2007; 49:1427-1433, doi:10.1016/j.jacc.2006.11.042 (Published online 20 March 2007). © 2007 by the American College of Cardiology Foundation

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CLINICAL RESEARCH: CORONARY ARTERY DISEASE

Inverse Relationship of Blood Pressure Levels to Sudden Cardiac Mortality and Benefit of the Implantable Cardioverter-Defibrillator in Patients With Ischemic Left Ventricular Dysfunction

Ilan Goldenberg, MD^_*,_*, Arthur J. Moss, MD^_*, Scott McNitt, MS^_*, Wojciech Zareba, MD, PhD^_*, W. Jackson Hall, PhD, Mark L. Andrews, BBS^_* for the MADIT-II Investigators

^_* Cardiology Unit of the Department of Medicine, University of Rochester Medical Center, Rochester, New York
Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York.

Manuscript received September 21, 2006; revised manuscript received October 20, 2006, accepted November 1, 2006.

^_* Reprint requests and correspondence: Dr. Ilan Goldenberg, Heart Research Follow-Up Program, Box 653, University of Rochester Medical Center, Rochester, New York 14642. (Email: Ilan.Goldenberg{at}heart.rochester.edu).

Objectives: This study was designed to evaluate the relationship among blood pressure (BP) levels, risk of sudden cardiac death (SCD), and benefit of the implantable cardioverter-defibrillator (ICD) in patients with ischemic left ventricular (LV) dysfunction.

Background: Low BP has been shown to be associated with increased mortality in patients with LV dysfunction and heart failure. We hypothesized that increasing BP levels are associated with a reduction in the risk of SCD in this population, thereby limiting ICD efficacy in a lower-risk subset.

Methods: The independent contribution of systolic blood pressure (SBP) and diastolic blood pressure (DBP) to outcome was analyzed in 1,231 patients enrolled in the prospective MADIT-II (Multicenter Automatic Defibrillator Implantation Trial II).

Results: Multivariate analysis showed that in the conventional therapy arm of the trial, 10-mm Hg increments in systolic BP were independently associated with a respective 14% (p = 0.01) and 16% (p = 0.04) reduction in the risk of cardiac mortality and SCD; similar trends were shown for DBP. Defibrillator therapy provided the least survival benefit to patients in the lower-risk, upper SBP (>130 mm Hg) and DBP (80 mm Hg) quartiles (hazard ratio 1.04 [p = 0.89] and 1.05 [p = 0.88], respectively), whereas a respective 39% and 38% (p = 0.002) reduction in the risk of death with ICD therapy was observed among patients with lower BP values.

Conclusions: In patients with ischemic LV dysfunction, SBP and DBP levels show an inverse correlation with sudden cardiac mortality. These noninvasive hemodynamic parameters may be useful for identifying lower-risk patients, in whom the benefit of primary defibrillator implantation is more limited.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   DBP = diastolic blood pressure   EF = ejection fraction   ICD = implantable cardioverter-defibrillator   LV = left ventricular   MADIT-II = Multicenter Automatic Defibrillator Implantation Trial II   MI = myocardial infarction   NYHA = New York Heart Association   SBP = systolic blood pressure   SCD = sudden cardiac death

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