CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Ilan Goldenberg, MD* and
Arthur J. Moss, MD
* Heart Research Follow-up Program, Box 653, University of Rochester Medical Center, Rochester, New York 14642 (Email: Ilan.Goldenberg{at}heart.rochester.edu).
We agree with the suggestion of Drs. Pascale and Fromer that a coronary evaluation should be carried out in MADIT (Multicenter Automatic Defibrillator Implantation Trial)-II–type patients with a history of remote myocardial infarction (MI) and depressed left ventricular dysfunction. This is also in agreement with current guidelines for the management of patients with heart failure, in which coronary angiography is recommended in patients who present with angina or significant ischemia (Class I) and to eligible asymptomatic heart failure patients with suspected coronary disease (Class IIa) (1). Our data, published in JACC, demonstrate that coronary revascularization (CR) by either coronary artery bypass graft surgery (CABG) or coronary angioplasty confers a significant reduction in the risk of sudden cardiac death (SCD) in this population (2). Furthermore, in the CABG-Patch trial (3) and in the current MADIT-II subgroup analysis (2), no implantable cardioverter-defibrillator (ICD) benefit was observed when the device was implanted at the time of elective CABG or in the immediate post-CR period.
Nevertheless, further studies are required to determine to what extent complete CR provides a long-term protective effect against SCD. In our analysis, the benefit conferred by CR was shown to be time-dependent, and was no longer evident six months after the revascularization procedure. Therefore, we continue to recommend primary ICD therapy in MADIT-II type patients because it is associated with a significant survival benefit in post-MI patients with left ventricular dysfunction (4). Coronary evaluation should be performed in eligible patients, and may be followed by complete or partial revascularization. However, our data suggest that defibrillator implantation may be deferred for only a limited time-period after CR in this high-risk population. In addition, Drs. Pascale’s and Fromer’s suggestion, namely that benefit of the ICD is limited in patients without an ischemic substrate, is not supported by findings from recent primary intervention trials (5,6).
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1. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult J Am Coll Cardiol 2005;46:1116-1143.[Free Full Text]2. Goldenberg I, Moss AJ, McNitt S, et al. MADIT-II Investigators Time dependence of defibrillator benefit after coronary revascularization in the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II J Am Coll Cardiol 2006;47:1811-1817.[Abstract/Free Full Text] 3. Bigger JT, Coronary Artery Bypass Graft (CABG) Patch Trial Investigators Prophylactic use of implantable cardiac defibrillators in patients at high risk for ventricular arrhythmias after coronary-artery bypass graft surgery N Engl J Med 1997;337:1569-1575.[CrossRef][Web of Science][Medline] 4. Moss AJ, Zareba W, Hall WJ, et al. Multicenter Automatic Defibrillation Implantation Trial Investigators Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction N Engl J Med 2002;346:877-883.[CrossRef][Web of Science][Medline] 5. Kadish A, Dyer A, Daubert JP, et al. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy N Engl J Med 2004;350:2151-2158.[CrossRef][Web of Science][Medline] 6. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure N Engl J Med 2005;352:225-237.[CrossRef][Web of Science][Medline]
Related Article
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Time Dependence of Defibrillator Benefit Postcoronary Revascularization
- Patrizio Pascale and Martin Fromer
J. Am. Coll. Cardiol. 2007 49: 124-125.
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