Key result
Implantable defibrillators significantly reduced the risk of death in patients with remote myocardial infarction (≥18 months) compared to conventional care (HR 0.55; 95% CI 0.39-0.78; P=0.001).
Why the study?
Does an implantable defibrillator (ICD) reduce mortality in post-MI patients with ejection fractions <=30% depending on the elapsed time from MI?
RCT (n=1,159)
3:2 ratio
Yes
Does an implantable defibrillator (ICD) reduce mortality in post-MI patients with ejection fractions <=30% depending on the elapsed time from MI?
The survival benefit of prophylactic ICDs in post-MI patients with LVEF <=30% is significantly greater for remote MI (>=18 months) compared to recent MI (<18 months).
Supports ICD use in remote MI with LVEF ≤30%; extends MADIT II evidence to time-dependent mortality benefit.
BACKGROUND: Prophylactic implantable defibrillators (ICDs) improve survival in patients with impaired ventricular function after myocardial infarction (MI), but it is uncertain whether mortality risk and survival benefit depend on the elapsed time from MI. METHODS AND RESULTS: The Multicenter Automatic Defibrillator Implantation Trial II examined the impact of ICDs on survival in post-MI patients with ejection fractions < or =30%. In 1159 patients, mean time from most recent MI to enrollment was 81+/-78 months. Patients were randomized to an ICD (n=699) or conventional care (n=460) in a 3:2 ratio. Mortality rates (deaths per 100 person-years of follow-up) in both treatment groups were analyzed by time from MI divided into quartiles (<18, 18 to 59, 60 to 119, and > or =120 months). In conventional care patients, these rates increased as time from MI increased (7.8%, 8.4%, 11.6%, 14.0%; P=0.03). Mortality rates in ICD patients were consistently lower in each quartile and showed minimal increase over time (7.2%, 4.9%, 8.2%, 9.0%; P=0.19). Covariate-adjusted hazard ratios for risk of death associated with ICD therapy were 0.97 (95% CI, 0.51 to 1.81; P=0.92) for recent MI (<18 months) and 0.55 (95% CI, 0.39 to 0.78; P=0.001) for remote MI (> or =18 months). CONCLUSIONS: Mortality risk in patients with ejection fractions < or =30% increases as a function of time from MI. The survival benefit associated with ICDs appears to be greater for remote MI and remains substantial for up to > or =15 years after MI.
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Wilber et al. (2004) conducted an RCT in Myocardial Infarction with impaired ventricular function (n=1,159). Implantable defibrillator (ICD) vs. Conventional care was evaluated on Risk of death (remote MI ≥18 months subgroup) (HR 0.55, 95% CI 0.39-0.78, p=0.001). Implantable defibrillators significantly reduced the risk of death in patients with remote myocardial infarction (≥18 months) compared to conventional care (HR 0.55; 95% CI 0.39-0.78; P=0.001).
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