Primary prevention of sudden cardiac death after acute myocardial infarction: lessons from Leiden

Abstract

Several important conclusions can be drawn from the interesting observations made in this issue by the Leiden group in relation to patients with acute myocardial infarction (AMI) treated using a guideline-based protocol.1 First, left ventricular function can be preserved using an evidence-based protocol to manage AMI; second, with preservation of left ventricular function, the proportion of post-MI patients fulfilling criteria for implantable cardioverter defibrillator (ICD) implantation is small; and third, that relatively few of those patients who received ICDs receive appropriate ICD therapy delivery during follow-up. This last observation brings into question the current guidelines for the selection of patients for ICD implantation as primary prophylaxis against sudden cardiac death and should prompt a review of the evidence on which these guidelines are based. The MISSION! protocol for the management of AMI combines a strategy for early percutaneous coronary intervention with rigorous attention to prescription of appropriate drug therapy and modification of risk factors, with rehabilitation, and out patient follow-up.2 Performance indicators related to each of these have been described throughout. Significant improvement in several of these indicators has been achieved in comparison with a historical cohort, with a significant reduction in length of hospital stay.2 Atary et al .1 describe the outcome in 799 patients treated according to this protocol. Of these, 6% died within 3 months of the index event, mostly of progressive heart failure. The … *Corresponding author. Tel: +44 191 2137543; fax: +44 191 223 1400, Email: janet.mccomb{at}nuth.nhs.uk