Death during acute myocardial infarction: Dodging the first bullet

Abstract

a o t t o t u Survivors of acute myocardial infarction (AMI) are an increased risk for death, particularly in the early post-AMI period when the cause of death is overwhelmingly cardiovascular in origin. Large studies have actually documented a significant clustering of deaths in the early post-AMI period, with declining levels over time reaching a steady state beyond 2 years of the index event. In the Valsartan in Acute Myocardial Infarction Trial (VALIANT), the rate of ll-cause mortality in the immediate post-AMI phase was .4% per month, compared to 0.14% per month between ears 2 and 3 after AMI. Depressed left ventricular function anifested by a low left ventricular ejection fraction (EF) as a major predictor of death in this population. Implantable cardioverter-defibrillators (ICDs) prolong ife in patients with severe ischemic cardiomyopathy, primarily by reducing sudden cardiac death events related to malignant ventricular arrhythmias. In the Multicenter Automatic Defibrillator Implantation Trial (MADIT) II, which andomized survivors of myocardial infarction who had a everely depressed EF to ICD versus medical therapy, the ean time from the index myocardial infarction to randomzation was greater than 6 years. Given the increased risk of ardiac mortality after AMI, it was anticipated that early ntervention with the ICD would be even more protective as ore patients could be saved. Paradoxically, when randomzed clinical trials of ICD implantation in the early (within 0 days or 31 days of the index event) post-AMI period ere conducted, they failed to demonstrate a survival benfit with the ICD despite a significant reduction in the rate f sudden arrhythmic death. Accordingly, the current Amercan Heart Association/American College of Cardiology/ eart Rhythm Society published guidelines recommend voiding ICD implantations in the early post-AMI phase. imilarly, the Center for Medicare and Medicaid Services eimbursement guidelines mandate that ICDs not be imlanted in the first 40 days post-AMI in patients who oth-