Prophylactic Use of an Implantable CardioverterDefibrillator after Acute Myocardial Infarction
Stefan H. Hohnloser, M.D., Karl Heinz Kuck, M.D., Paul Dorian, M.D., Robin S. Roberts, M.Tech., John R. Hampton, M.D., Robert Hatala, M.D., Eric Fain, M.D., Michael Gent, D.Sc., Stuart J. Connolly, M.D., for the DINAMIT Investigators
Background Implantable cardioverterdefibrillator (ICD)therapy has been shown to improve survival in patients withvarious heart conditions who are at high risk for ventriculararrhythmias. Whether benefit occurs in patients early aftermyocardial infarction is unknown.
Methods We conducted the Defibrillator in Acute Myocardial InfarctionTrial, a randomized, open-label comparison of ICD therapy (in332 patients) and no ICD therapy (in 342 patients) 6 to 40 daysafter a myocardial infarction. We enrolled patients who hadreduced left ventricular function (left ventricular ejectionfraction, 0.35 or less) and impaired cardiac autonomic function(manifested as depressed heart-rate variability or an elevatedaverage 24-hour heart rate on Holter monitoring). The primaryoutcome was mortality from any cause. Death from arrhythmiawas a predefined secondary outcome.
Results During a mean (±SD) follow-up period of 30±13months, there was no difference in overall mortality betweenthe two treatment groups: of the 120 patients who died, 62 werein the ICD group and 58 in the control group (hazard ratio fordeath in the ICD group, 1.08; 95 percent confidence interval,0.76 to 1.55; P=0.66). There were 12 deaths due to arrhythmiain the ICD group, as compared with 29 in the control group (hazardratio in the ICD group, 0.42; 95 percent confidence interval,0.22 to 0.83; P=0.009). In contrast, there were 50 deaths fromnonarrhythmic causes in the ICD group and 29 in the controlgroup (hazard ratio in the ICD group, 1.75; 95 percent confidenceinterval, 1.11 to 2.76; P=0.02).
Conclusions Prophylactic ICD therapy does not reduce overallmortality in high-risk patients who have recently had a myocardialinfarction. Although ICD therapy was associated with a reductionin the rate of death due to arrhythmia, that was offset by anincrease in the rate of death from nonarrhythmic causes.
Source Information
From J.W. Goethe University, Frankfurt (S.H.H.), and St. Georg's Hospital, Hamburg (K.H.K.) both in Germany; St. Michel's Hospital, Toronto (P.D.), and Hamilton Civic Hospitals Research Center (R.S.R., M.G.) and McMaster University (S.J.C.), Hamilton, Ont. all in Canada; University Hospital, Nottingham, United Kingdom (J.R.H.); Slovak Cardiovascular Institute, Bratislava, Slovak Republic (R.H.); and St. Jude Medical, Sunnyvale, Calif. (E.F.).
Address reprint requests to Dr. Hohnloser at the Department of Medicine, Division of Cardiology, J.W. Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany, or at hohnloser{at}em.uni-frankfurt.de.
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