ALL PATIENTS 40 DAYS POST MI SHOULD RECEIVE

ICD

DR. AASIT S. SHAH MD, DMJASLOK HOSPITAL AND RESEARCH CENTRE

INTRODUCTION

• Indications for ICD implant have evolved in last few years

• Not meant only for drug refractory ventricular arrhythmias

• Focus has changed from identifying patient who needs ICD to identifying patients who can avoid ICD.

ICD TRIALS

• Multiple RCT’s have shown that ICD is better than antiarrhythmic drugs

• Applicable to patients for secondary prevention and for primary prevention

ICD TRIALS- SECONDARY PREVENTION

• AVID• CASH• CIDS

• 73-83% PTS. HAD CAD• EF 32-45%

•Non-significant results.1 The AVID Investigators. N Engl J Med. 1997;337:1576-1583.2 Kuck Kh, et al. Circulation. 2000;102:748-754.3 Connolly SJ, et al. Circulation. 2000;101:1297-1302.

Secondary Prevention Trials: Reduction in Mortality with ICD Therapy

AVID CASH CIDS0

20

40

60

80Overall Death

Arrhythmic Death

1 2 3

31%

56%

23%*

58%

20%*

33%

% M

orta

lity

Redu

ction

w/

ICD

Rx

ICD TRIALS- PRIMARY PREVENTION

• MADIT• MUSTT• MADIT 2• SCD-HeFT

• Two recent meta-analyses have shown 20-30% net risk reduction for total mortality

1 Moss AJ. N Engl J Med. 1996;335:1933-40.2 Buxton AE. N Engl J Med. 1999;341:1882-90.3 Moss AF. N Engl J Med. 2002;346:877-83.4 Moss AJ. Presented before ACC 51st Annual Scientific Sessions, Late Breaking Clinical Trials, March 19, 2002.

MADIT MUSTT MADIT-II0

20

40

60

80 Overall Death

Arrhythmic Death

1 2 3, 4

54%

75%

55%

73%

31%

61%

27 Months 39 Months 20 Months

% M

orta

lity

Redu

ction

w/

ICD

Rx

PRIMARY PREVENTION

ICD mortality reductions in

primary prevention trialsare equal to or

greaterthan those in

secondaryprevention trials.

MADIT MUSTT MADIT-II0

20

40

60

80Overall Death

Arrhythmic Death

AVID CASH CIDS0

20

40

60

80Overall DeathArrhythmic Death

13, 42

5 76

54%

75%

55%

76%

31%

61%

27 months 39 months 20 months

31%

56%

28%

59%

20%

33%

% M

orta

lity

Redu

ction

w/

ICD

Rx

% M

orta

lity

Redu

ction

w/

ICD

Rx

3 Years 3 Years 3 Years

PRIMARY VS. SECONDARY PREVENTION

1 Moss AJ. N Engl J Med. 1996;335:1933-40.2 Buxton AE. N Engl J Med. 1999;341:1882-90.3 Moss AJ. N Engl J Med. 2002;346:877-834 Moss AJ. Presented before ACC 51st Annual Scientific Sessions, Late Breaking Clinical Trials, March 19, 2002.5 The AVID Investigators. N Engl J Med. 1997;337:1576-83.6 Kuck K. Circ. 2000;102:748-54.7 Connolly S. Circ. 2000:101:1297-1302.

ICD TRIALS

Hence it is clear that ICD therapy for SCD provides greater reduction in SCD mortality than antiarrhythmic drug therapy in high risk patients post MI

The most important risk stratification factor is the ejection fraction

SCD INCIDENCE POST MI

• Incidence of SCD is highest in the early phase post MI- first 30 days.

14703 pts.

HIGHEST SCD IN 1 MTH POST MI-19%

83% OF ALL SCD OCCURRED IN 1 MTH

EF<30% HAD HIGHEST RISK OF SCD-

Hence it is logical that if we provide antiarrhythmic therapy early to our post MI high risk patients, incidence of SCD should reduce.

VALIANT TRIAL

VALIANT TRIAL

EF <30%

<31-40%

>40%

Rates of sudden death or cardiac arrest

ICD TRIALS EARLY AFTER MI

• DINAMIT

• IRIS

• BEST

COMPETING RISK: LESSONS FROM THE NEGATIVE TRIALS

COMPETING RISK

ICD TRIALS EARLY POST MI

• These trials did not show improvement in overall mortality when ICD was implanted 6-40 days post MI.

• There was a reduction in SCd in the ICD group; however non SCD deaths in ICD group also increased.

• This paradox has not been satisfactorily explained

ICD TRIALS EARLY POST MI

• Risk stratification factors

• Deleterious effect of ICD therapy –including appropriate programming

• Other causes of sudden death

• Role of EP study

JACC 2009; 54(22) 2001-2005

ACC 2012 RECOMMANDATION CLASS I A : ICD therapy is indicated in patients with LVEF less than or

equal to 35% due to prior MI who are at least 40 days post-MI and are in NYHA functional Class II or III

CLASS I A : ICD therapy is indicated in patients with LV dysfunction due to prior MI who are at least 40 days post-MI, have an LVEF less than or equal to 30%, and are in NYHA functional Class I

CLASS I B : ICD therapy is indicated in patients with nonsustained VT due to prior MI, LVEF less than or equal to 40%, and inducible VF or sustained VT at electrophysiological study.

AUC

3 4

119

20

2628

37

0

5

10

15

20

25

30

35

40

45

50

MUSTT MADIT MADIT II AVID SAVE Merit-HF 4S AmiodaroneMeta-

analysis (5 Yr) (2.4 Yr) (3 Yr) (3 Yr) (3.5 Yr) (1 Yr) (6 Yr) (2 Yr)

NNTx years = 100 / (% Mortality in Control Group – % Mortality in Treatment Group)

ICD Therapysimvastatin

captopril

Metoprololsuccinate

amiodarone

Drug Therapy

PRIMARY PREVENTION

Number Needed to Treatto Save a Life

CONCLUSIONS

• All patients who match current guidelines should be

offered ICD implant

• Better risk stratification criteria and more

appropriate device programming

• Need more trials and data to identify patients at

high risk for SCD early after MI

THANK YOU!