Prophylactic Implantation of a Defibrillator in Patients with Myocardial Infarction and Reduced Ejection Fraction

doi:10.1056/NEJMoa013474

Published at www.nejm.org March 19, 2002 (10.1056/NEJMoa013474)

Prophylactic Implantation of a Defibrillator in Patients with Myocardial Infarction and Reduced Ejection Fraction

Arthur J. Moss, M.D., Wojciech Zareba, M.D., Ph.D., W. Jackson Hall, Ph.D., Helmut Klein, M.D., David J. Wilber, M.D., David S. Cannom, M.D., James P. Daubert, M.D., Steven L. Higgins, M.D., Mary W. Brown, M.S., Mark L. Andrews, B.B.S., for the Multicenter Automatic Defibrillator Implantation Trial II Investigators

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ABSTRACT

Background Patients with reduced left ventricular function after myocardial infarction are at risk for life-threatening ventricular arrhythmias. This randomized trial was designed to evaluate the effect of an implantable defibrillator on survival in such patients.

Methods Over the course of four years, we enrolled 1232 patients with a prior myocardial infarction and a left ventricular ejection fraction of 0.30 or less. Patients were randomly assigned in a 3:2 ratio to receive an implantable defibrillator (742 patients) or conventional medical therapy (490 patients). Invasive electrophysiological testing for risk stratification was not required. Death from any cause was the end point.

Results The clinical characteristics at base line and the prevalence of medication use at the time of the last follow-up visit were similar in the two treatment groups. During an average follow-up of 20 months, the mortality rates were 19.8 percent in the conventional-therapy group and 14.2 percent in the defibrillator group. The hazard ratio for the risk of death from any cause in the defibrillator group as compared with the conventional-therapy group was 0.69 (95 percent confidence interval, 0.51 to 0.93; P=0.016). The effect of defibrillator therapy on survival was similar in subgroup analyses stratified according to age, sex, ejection fraction, New York Heart Association class, and the QRS interval.

Conclusions In patients with a prior myocardial infarction and advanced left ventricular dysfunction, prophylactic implantation of a defibrillator improves survival and should be considered as a recommended therapy. (N Engl J Med 2002;346:877-83.)

Notice: This article is being published early (on March 19, 2002) to correspond with the authors' presentation at the American College of Cardiology in Atlanta. This article will appear in the March 21 issue of the Journal.

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