THE VANISH STUDY IN CONTEXT - A NETWORK META-ANALYSIS OF TREATMENTS TO PREVENT VENTRICULAR TACHYCARDIA IN PATIENTS WITH ISCHEMIC CARDIOMYOPATHY

Abstract

Recurrent ventricular tachycardia (VT) is associated with high morbidity in patients with ischemic heart disease. Treatment strategies include antiarrhythmic drugs (AADs) and catheter ablation (CA). A 2016 meta-analysis found significant reduction in the risk of VT with CA, but direct comparisons of AADs to CA were not available. To assess the comparative effectiveness of CA, non-amiodarone AADs, amiodarone, and standard medical care in patients with ischemic cardiomyopathy and ICDs. A recent, high-quality systematic review was updated with a systematic review of MEDLINE, Embase, Cochrane CENTRAL, the Cochrane Library and PubMed to include randomized controlled trials (RCTs) published since the date of the prior review (Oct 2015) and Sept 1, 2016. A study level network meta-analysis (NMA) was performed by using a Bayesian evidence network. Treatments were pooled into 4 treatment nodes: 1) standard medical care, 2) non-amiodarone AADs, 3) amiodarone, and 4) CA. Fourteen RCTs from the prior review (Santangeli) met inclusion criteria. The search update identified 105 further titles/abstracts of which one RCT (Sapp et al. VANISH 2016) met inclusion criteria. Treatment networks and risk ratio estimates for appropriate shocks are reported in Figure 1. Comparison of CA to non-amiodarone AADs became statistically significant with the addition of the VANISH study to the NMA. With the addition of the VANISH study and using Bayesian NMA, amiodarone was found to be superior to control for reduction of appropriate ICD shocks and CA was superior to non-amiodarone AADs, a comparison that has not been directly studied in a RCT.