Clinical practice of defibrillator implantation after myocardial infarction: impact of implant time: results from the PreSCD II Registry

Abstract

AimsCurrent guidelines recommend implantable cardioverter-defibrillator (ICD) therapy for primary prevention of sudden cardiac death in patients with the reduced left ventricular function (LVEF ≤30%) not earlier than 40 days after myocardial infarction (MI). The aim of the prospective Prevention of Sudden Cardiac Death II (PreSCD II) registry was to investigate the clinical practice of ICD therapy in post-MI patients and to assess the impact on survival.Methods and results10 612 consecutive patients (61 ± 12 years, 76% male) were enrolled 4 weeks or later after MI in 19 cardiac rehabilitation centres in Germany from December 2002 to May 2005. All patients with left ventricular ejection fraction (LVEF) ≤40% (n = 952) together with a randomly selected group of patients with preserved left ventricular function (n = 1106) were followed for 36 months. Cox proportional hazard models were used to correlate ICD implantation and survival with baseline characteristics. Of all patients studied, 75.9% were enrolled within 4–8 weeks, 10.7% more than 1 year after MI. Pre-specified Group 1 with an LVEF ≤30% consisted of 269 patients (2.5%), Group 2 with LVEF 31–40% of 727 patients (6.9%), and Group 3 with LVEF >40% of 1148 randomly selected patients from the cohort of 9616 patients with preserved LV function. After 36 months, only 142 patients (6.9%) had received an ICD; 82 (31.7%) of Group 1, 49 (7%) of Group 2, and 11 (1%) in Group 3. The ICD was implanted in 47% of all patients within 1 year after their index MI. Implantable cardioverter-defibrillator patients were predominantly characterized by low ejection fraction, but also by several other independent risk factors. Patients who received an ICD had an adjusted 44% lower mortality (hazard ratio 0.56, 95% confidence intervals 0.32–1.01; P = 0.053) than comparable patients without ICD therapy. All cause mortality of ICD recipients was significantly lower if the ICD was implanted later than 11 months after acute MI (P < 0.001).ConclusionsThe PreSCD II registry demonstrated that the number of patients who develop a low LVEF (≤30%) after acute MI is small. However, only few patients with guideline-based ICD indication received ICD therapy. All cause mortality was significantly reduced only if the ICD was implanted late (>11 months) after MI.

Failure to reassess ejection fraction after acute myocardial infarction in potential implantable cardioverter/defibrillator candidates: Insights from the Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health Status (TRIUMPH) registry

“…Although the rate of LVEF reassessment in this study is consistent with rates of primary prevention ICD placement post-AMI in previous studies, 8 our findings should ideally be validated across a wider scope of institutions and practices. The reliance on patient self-report of LVEF reassessment is a second point of concern given the potential for omissions or inaccurate reporting.…”

“…25 In the PreSCD II Registry, only 14% of post-MI patients with LVEF≤40% received ICD therapy after 36 months of follow-up, with an average interval from AMI until implantation of 307 days. 8 Our findings highlight a critical gap in LVEF reassessment that may explain the low rate of primary prevention ICD implantation after AMI.…”

“…8 As such, AMI patients with a low LVEF during the index hospitalization need interval reassessment of LVEF post-discharge in order to be considered for primary prevention ICD. This process requires care coordination between inpatient and outpatient care teams and engenders multiple points of vulnerability in the transition of care process that risk failure to reassess LVEF, and by extension, missed opportunities to offer patients a primary prevention ICD.…”

Non-Compaction-Kardiomyopathie

“…Wurde dieser Wert kurz nach Implantation des ICD-CRT-Systems erhoben? [5,7,9], der kongenitalen Muskeldystrophie Fukuyama, die mit einer Hörstörung einhergehen kann [10], der kongenitalen myotubulären Myopathie [3,8], oder der Arthrogryposis multiplex congenita [6] Die Leistungsminderung des Patienten war überwiegend durch die Herzinsuffizienz-Symptomatik bei eingeschränkter systolischer linksventrikulärer Funktion erklärt, wenn auch eine bedeutsame Erhöhung der natriuretischen Peptide zu diesem Zeitpunkt nicht vorhanden waren. Nach Therapie der Herzinsuffizienz (medikamentös und durch Resynchronisationstherapie) war die Leistungsminderung deutlich gebessert und über Jahre stabil im Stadium NYHA II einzuordnen wie in der Kasuistik ausgeführt, so dass eine myopathische Genese der Leistungsminderung zumindest nicht im Vordergrund stand.…”

“…Es muss betont werden, dass bei dem Patienten im Verlauf anhaltende ventrikuläre Tachykardien durch das Device erfolgreich therapiert wurden und somit ein potenzieller plötzlicher Herztod verhindert wurde. Desweiteren dokumentiert die Versorgungsrealität auch in europäischen Ländern eine beträchtliche Unterversorgung potenzieller Kandidaten mit implantierbaren Defibrillatoren in Relation zu etablierten und durch Leitlinien gesicherten Indikationen [1,2,6]. Insofern muss die Aussage zur Versorgung der LVHT-Patienten mit ICD-Systemen relativiert werden, und die Leser vielmehr aufgefordert werden, proaktiv die Indikation bei jedem Patienten mit LVHT und Herzinsuffizienz oder Risikofaktoren individuell anhand der publizierten Leitlinien sorgfältig zu prüfen [4,5,7].…”