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Previous Volume 341:1882-1890 December 16, 1999 Number 25 Next

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ABSTRACT

Background Empirical antiarrhythmic therapy has not reduced mortality among patients with coronary artery disease and asymptomatic ventricular arrhythmias. Previous studies have suggested that antiarrhythmic therapy guided by electrophysiologic testing might reduce the risk of sudden death.

Methods We conducted a randomized, controlled trial to test the hypothesis that electrophysiologically guided antiarrhythmic therapy would reduce the risk of sudden death among patients with coronary artery disease, a left ventricular ejection fraction of 40 percent or less, and asymptomatic, unsustained ventricular tachycardia. Patients in whom sustained ventricular tachyarrhythmias were induced by programmed stimulation were randomly assigned to receive either antiarrhythmic therapy, including drugs and implantable defibrillators, as indicated by the results of electrophysiologic testing, or no antiarrhythmic therapy. Angiotensin-converting–enzyme inhibitors and beta-adrenergic–blocking agents were administered if the patients could tolerate them.

Results A total of 704 patients with inducible, sustained ventricular tachyarrhythmias were randomly assigned to treatment groups. Five-year Kaplan–Meier estimates of the incidence of the primary end point of cardiac arrest or death from arrhythmia were 25 percent among those receiving electrophysiologically guided therapy and 32 percent among the patients assigned to no antiarrhythmic therapy (relative risk, 0.73; 95 percent confidence interval, 0.53 to 0.99), representing a reduction in risk of 27 percent. The five-year estimates of overall mortality were 42 percent and 48 percent, respectively (relative risk, 0.80; 95 percent confidence interval, 0.64 to 1.01). The risk of cardiac arrest or death from arrhythmia among the patients who received treatment with defibrillators was significantly lower than that among the patients discharged without receiving defibrillator treatment (relative risk, 0.24; 95 percent confidence interval, 0.13 to 0.45; P<0.001). Neither the rate of cardiac arrest or death from arrhythmia nor the overall mortality rate was lower among the patients assigned to electrophysiologically guided therapy and treated with antiarrhythmic drugs than among the patients assigned to no antiarrhythmic therapy.

Conclusions Electrophysiologically guided antiarrhythmic therapy with implantable defibrillators, but not with antiarrhythmic drugs, reduces the risk of sudden death in high-risk patients with coronary disease.

Source Information

From the Department of Medicine, Brown University School of Medicine and Rhode Island Hospital, Providence (A.E.B.); Duke University Clinical Research Institute, Durham, N.C. (K.L.L., G.H.); the Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, N.Y. (J.D.F.); the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.E.J.); and Care Group, Indianapolis (E.N.P.).

Address reprint requests to Dr. Buxton at the Division of Cardiology, Rhode Island Hospital, 2 Dudley St., Suite 360, Providence, RI 02905.

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Prevention of Sudden Death in Patients with Coronary Artery Disease
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N Engl J Med 2000; 342:1291-1292, Apr 27, 2000. Correspondence

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• Writing Committee Members, , Epstein, A. E., DiMarco, J. P., Ellenbogen, K. A., Estes, N.A. M. III, Freedman, R. A., Gettes, L. S., Gillinov, A. M., Gregoratos, G., Hammill, S. C., Hayes, D. L., Hlatky, M. A., Newby, L. K., Page, R. L., Schoenfeld, M. H., Silka, M. J., Stevenson, L. W., Sweeney, M. O. (2008). ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 117: e350-e408 [Full Text]  
• Almendral, J., Arribas, F., Wolpert, C., Ricci, R., Adragao, P., Cobo, E., Navarro, X., Quesada, A., the DATAS Steering Committee and Writing Committee, (2008). Dual-chamber defibrillators reduce clinically significant adverse events compared with single-chamber devices: results from the DATAS (Dual chamber and Atrial Tachyarrhythmias Adverse events Study) trial. Europace 10: 528-535 [Abstract] [Full Text]  
• Gibson, D. P., Kuntz, K. K., Levenson, J. L., Ellenbogen, K. A. (2008). Decision-making, emotional distress, and quality of life in patients affected by the recall of their implantable cardioverter defibrillator. Europace 10: 540-544 [Abstract] [Full Text]  
• Berul, C. I., Van Hare, G. F., Kertesz, N. J., Dubin, A. M., Cecchin, F., Collins, K. K., Cannon, B. C., Alexander, M. E., Triedman, J. K., Walsh, E. P., Friedman, R. A. (2008). Results of a Multicenter Retrospective Implantable Cardioverter-Defibrillator Registry of Pediatric and Congenital Heart Disease Patients. J Am Coll Cardiol 51: 1685-1691 [Abstract] [Full Text]  
• Koller, M. T., Schaer, B., Wolbers, M., Sticherling, C., Bucher, H. C., Osswald, S. (2008). Death Without Prior Appropriate Implantable Cardioverter-Defibrillator Therapy: A Competing Risk Study. Circulation 117: 1918-1926 [Abstract] [Full Text]  
• Daubert, J. P., Zareba, W., Cannom, D. S., McNitt, S., Rosero, S. Z., Wang, P., Schuger, C., Steinberg, J. S., Higgins, S. L., Wilber, D. J., Klein, H., Andrews, M. L., Hall, W. J., Moss, A. J., for the MADIT II Investigators, (2008). Inappropriate Implantable Cardioverter-Defibrillator Shocks in MADIT II: Frequency, Mechanisms, Predictors, and Survival Impact. J Am Coll Cardiol 51: 1357-1365 [Abstract] [Full Text]  
• Albert, N. M., Lewis, C. (2008). Recognizing and Managing Asymptomatic Left Ventricular Dysfunction: After Myocardial Infarction. Crit Care Nurse 28: 20-37 [Full Text]  
• Wellens, H. J. (2008). Forty Years of Invasive Clinical Electrophysiology: 1967-2007. Circ Arrhythm Electrophysiol 1: 49-53 [Full Text]  
• Elgarhi, N, Kreuz, J, Balta, O, Nickenig, G, Hoium, H, Lewalter, T, Schwab, J O. (2008). Significance of Wedensky Modulation testing in the evaluation of non-invasive risk stratification for ventricular tachyarrhythmia in patients with coronary artery disease and implantable cardioverter-defibrillator. Heart 94: e16-e16 [Abstract] [Full Text]  
• Scott, P.A., Gorman, S., Andrews, N.P., Roberts, P.R., Kalra, P.R. (2008). Estimation of the requirement for implantable cardioverter defibrillators for the primary prevention of sudden cardiac death post-myocardial infarction based on UK national guidelines (2006). Europace 10: 453-457 [Abstract] [Full Text]  
• Gardiwal, A., Yu, H., Oswald, H., Luesebrink, U., Ludwig, A., Pichlmaier, A. M., Drexler, H., Klein, G. (2008). Right ventricular pacing is an independent predictor for ventricular tachycardia/ventricular fibrillation occurrence and heart failure events in patients with an implantable cardioverter-defibrillator. Europace 10: 358-363 [Abstract] [Full Text]  
• Travin, M. I. (2008). A Potential Key Role for Radionuclide Imaging in the Prediction and Prevention of Sudden Arrhythmic Cardiac Death. JNM 49: 173-175 [Full Text]  
• DeMaria, A. N., Bax, J. J., Ben-Yehuda, O., Clopton, P., Feld, G. K., Ginsburg, G. S., Greenberg, B. H., Knoke, J. D., Lew, W. Y.W., Lima, J. A.C., Maisel, A. S., Narayan, S. M., Narula, J., Sahn, D. J., Tsimikas, S. (2008). Highlights of the year in JACC 2007.. J Am Coll Cardiol 51: 490-512 [Full Text]