Risk stratification after myocardial infarction: it is time for intervention

Abstract

This editorial refers to ‘Non-invasive risk stratification for sudden cardiac death by heart rate turbulence and microvolt T-wave alternans in patients after myocardial infarction’ by V. Sulimov et al ., on page 1786 Despite significant advances in interventional and pharmacological therapies, late mortality after acute myocardial infarction (MI) is still high. Approximately 50% of cardiovascular deaths after MI occur suddenly and are potentially preventable by prophylactic implantation of a cardioverter-defibrillator (ICD). In recent decades, substantial efforts have been made to identify high-risk patients who may benefit from prophylactic therapy. While initial risk stratification strategies guiding ICD therapy were based on the comprehensive electrophysiological testing in highly selected subgroups of patients, a revolutionary concept was proposed in 2002, when Moss et al. 1 presented the results of MADIT-2 (Multicentre Automatic Defibrillator Implantation Trial). In contrast with all previous attempts, MADIT-2 used the finding of a reduced left ventricular ejection fraction (LVEF) as the single selection criterion for prophylactic ICD-implantation. In terms of efficacy and effectiveness, the MADIT-2 criterion was a great success. Subsequent trials confirmed the concept of prophylactic ICD-implantation in patients with impaired LVEF, and later economic analyses verified the cost-effectiveness of this approach. However, when looking from an epidemiological point of view at the global impact of ICD …