Abstract
BackgroundThere is clear evidence that patients with prior myocardial infarction and a reduced ejection fraction benefit from implantation of a cardioverter-defibrillator (ICD). It is unclear whether this benefit is altered by whether or not revascularization is performed prior to ICD implantation.MethodsThis was a retrospective cohort study following patients who underwent ICD implantation from 2002 to 2014. Patients with ischemic cardiomyopathy and either primary or secondary prevention ICDs were selected for inclusion. Using the electronic medical record, cardiac catheterization data, revascularization status (percutaneous coronary intervention or coronary bypass surgery) were recorded. The outcomes were mortality and ventricular arrhythmia.ResultsThere were 606 patients included in the analysis. The mean age was 66.3 ± 10.1 years, 11.9% were women, and the mean LVEF was 30.5 ± 12.0, 58.9% had a primary indication for ICD, 82.0% of the cohort had undergone coronary catheterization prior to ICD implantation. In the overall cohort, there were fewer mortality and ventricular arrhythmia events in patients who had undergone prior revascularization. In patients who had an ICD for secondary prevention, revascularization was associated with a decrease in mortality (HR 0.46, 95% CI (0.24, 0.85) p = 0.015), and a trend towards fewer ventricular arrhythmia (HR 0.62, 95% CI (0.38, 1.00) p = 0.051). There was no association between death or ventricular arrhythmia with revascularization in patients with primary prevention ICDs.ConclusionRevascularization may be beneficial in preventing recurrent ventricular arrhythmia, and should be considered as adjunctive therapy to ICD implantation to improve cardiovascular outcomes.
Highlights
Sudden cardiac death accounts for at least 300,000 deaths each year in the United States alone [1] with at least 80% occurring in the setting of coronary artery disease [2]
The basic programming principles in primary prevention patients were as follows: Ventricular tachycardia (VT) zone range 176–188 bpm, three bursts of Anti-tachycardia pacing (ATP) followed by the maximum number of shocks, detection intervals varied by device manufacturer but were based on programming in the RAFT study [14]
Revascularization was performed in one patient (14.3%) with PMVT/Ventricular fibrillation (VF) storm and one patient (4.3%) with MMVT storm. In this large cohort study, we found that a history of revascularization was associated with fewer deaths or recurrent ventricular arrhythmia events in patients with a secondary, but not with a primary prevention indication for implantation of a cardioverter-defibrillator (ICD)
Summary
Sudden cardiac death accounts for at least 300,000 deaths each year in the United States alone [1] with at least 80% occurring in the setting of coronary artery disease [2]. In patients with ischemic cardiomyopathy (ICM), the effect of revascularization on mortality has largely been driven from surgical trials assessing the benefit of coronary artery bypass surgery (CABG) with limited evidence for the mortality benefit of percutaneous coronary intervention in this patient population [6]. The overall survival association between coronary revascularization and mortality in this patient population is clear. In this study we assessed the association between revascularization and the clinical outcomes of mortality and recurrent ventricular arrhythmia in patients with ICM and implantable cardiac defibrillator (ICD) utilizing data from a large provincial ICD registry in real world setting. There is clear evidence that patients with prior myocardial infarction and a reduced ejection fraction benefit from implantation of a cardioverter-defibrillator (ICD) It is unclear whether this benefit is altered by whether or not revascularization is performed prior to ICD implantation
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