Improved Survival with an Implanted Defibrillator in Patients with Coronary Disease at High Risk for Ventricular Arrhythmia
Arthur J. Moss, M.D., W. Jackson Hall, Ph.D., David S. Cannom, M.D., James P. Daubert, M.D., Steven L. Higgins, M.D., Helmut Klein, M.D., Joseph H. Levine, M.D., Sanjeev Saksena, M.D., Albert L. Waldo, M.D., David Wilber, M.D., Mary W. Brown, M.S., Moonseong Heo, Ph.D., for The Multicenter Automatic Defibrillator Implantation Trial Investigators
Background Unsustained ventricular tachycardia in patients withprevious myocardial infarction and left ventricular dysfunctionis associated with a two-year mortality rate of about 30 percent.We studied whether prophylactic therapy with an implanted cardioverterdefibrillator,as compared with conventional medical therapy, would improvesurvival in this high-risk group of patients.
Methods Over the course of five years, 196 patients in New YorkHeart Association functional class I, II, or III with priormyocardial infarction; a left ventricular ejection fraction<0.35; a documented episode of asymptomatic unsustained ventriculartachycardia; and inducible, nonsuppressible ventricular tachyarrhythmiaon electrophysiologic study were randomly assigned to receivean implanted defibrillator (n = 95) or conventional medicaltherapy (n = 101). We used a two-sided sequential design withdeath from any cause as the end point.
Results The base-line characteristics of the two treatment groupswere similar. During an average follow-up of 27 months, therewere 15 deaths in the defibrillator group (11 from cardiac causes)and 39 deaths in the conventional-therapy group (27 from cardiaccauses) (hazard ratio for overall mortality, 0.46; 95 percentconfidence interval, 0.26 to 0.82; P = 0.009). There was noevidence that amiodarone, beta-blockers, or any other antiarrhythmictherapy had a significant influence on the observed hazard ratio.
Conclusions In patients with a prior myocardial infarction whoare at high risk for ventricular tachyarrhythmia, prophylactictherapy with an implanted defibrillator leads to improved survivalas compared with conventional medical therapy.
Source Information
From the Cardiology Unit, Department of Medicine (A.J.M., J.P.D.), the Department of Biostatistics (W.J.H., M.H.), and the Department of Community and Preventive Medicine (M.W.B.), University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; Good Samaritan Hospital, Los Angeles (D.S.C.); Scripps Memorial Hospital, La Jolla, Calif. (S.L.H.); University Hospital, Magdeburg, Germany (H.K.); St. Francis HospitalHeart Center, Roslyn, N.Y. (J.H.L.); Eastern Heart Institute, Passaic, N.J. (S.S.); the Department of Medicine, Case Western Reserve University, and University Hospitals of Cleveland, Cleveland (A.L.W.); and the Cardiology Unit, University of Chicago, Chicago (D.W.).
Address reprint requests to Dr. Moss at the Heart Research Follow-up Program, Box 653, University of Rochester Medical Center, Rochester, NY 14642.
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