European Heart Journal Advance Access originally published online on July 26, 2007
European Heart Journal 2007 28(19):2416; doi:10.1093/eurheartj/ehm313
Implantation of cardioverter defibrillator in post-myocardial infarction patients: when and how?
First Department of Cardiology
AHEPA Hospital
Stilp. Kiriakidi 1
Thessaloniki 54637
Greece
Saint Lukes Hospital
Panorama, 55236
Thessaloniki
Greece
First Department of Cardiology
AHEPA Hospital
Stilp. Kiriakidi 1
Thessaloniki 54637
Greece
Tel: +30 2310994830 Fax: +30 2310994673 E-mail address: efthymos{at}med.auth.gr
We read with great interest the recently published guidelines in the European Heart Journal ‘for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death’.1 In chapter XIV, page 2115, it is recommended (class I) that an implantable cardioverter defibrillator (ICD) should be implanted at least 40 days post myocardial infarction (MI) in patients with left ventricular dysfunction with an ejection fraction (EF) of 30–40% and NYHA functional class II or III. We presume that this recommendation is based on the results of MADIT II trial.2
MADIT II trial clearly demonstrated that the Kaplan–Meier estimates of survival in the two groups began to diverge at approximately 9 months and continued their separate paths thereafter favouring the group who received an ICD. In our opinion, there is no obvious or reasonable explanation for this delay. If we wanted to follow strictly the outcome of MADIT II, we would recommend an ICD implantation not earlier than 9 months post MI. There is strong evidence to support this hypothesis although its mechanism is not entirely clear. Furthermore, according to the results of MADIT I trial,3 clear benefit from ICD implantation was documented in post MI patients with NYHA functional class I, II, or III, a left ventricular EF < 0.35, documented episodes of asymptomatic non-sustained ventricular tachycardia (VT) and inducible non-suppressible VT on electrophysiologic study. Therefore, based on the results of these two large-scale trials, it seems reasonable to treat post MI patients according to MADIT I data during the first 9 months, and according to MADIT II data thereafter. This strategy may reduce the number of unnecessary ICD implantations.
In view of the recent developments in the treatment of acute MI, it is more than evident that ischaemic cardiomyopathy is an evolving area. Does this mean that new studies are required to resolve this issue?
References
- Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Blanc JJ, Budaj A, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL, Smith SC Jr, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B. American College of Cardiology/American Heart Association Task Force; European Society of Cardiology Committee for Practice Guidelines; European Heart Rhythm Association and the Heart Rhythm Society. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death—executive summary: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Eur Heart J (2006) 27:2099–2140.
[Free Full Text] - Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, Daubert JP, Higgins SL, Brown MW, Andrews ML. Multicenter Automatic Defibrillator Implantation Trial II Investigators. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med (2002) 346:877–883.
[Abstract/Free Full Text] - Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med (1996) 335:1933–1940.
[Abstract/Free Full Text]
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