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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
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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