Key result
ICD implantation at 60 days post-MI yielded a 10-year survival of 42.4%, compared to 42.3% at 6 months and 42.0% at 1 year (P=0.0028), providing modest incremental survival benefits.
Why the study?
Does the timing of ICD implantation (60 days vs 6 months vs 1 year) improve survival in patients after myocardial infarction?
Does the timing of ICD implantation (60 days vs 6 months vs 1 year) improve survival in patients after myocardial infarction?
Absolute Event Rate: 42.4% vs 42%
p-value: p=0.0028
Early ICD implantation at 60 days post-MI provides only modest survival benefits compared to delayed implantation at 6 months or 1 year, suggesting that ensuring appropriate patients receive an ICD is more important than the exact timing.
Small modeled survival gains with earlier ICD timing warrant no practice change; leaves open need for RCTs to confirm differences.
BACKGROUND: The optimal timing of implantable cardioverter defibrillator (ICD) placement for the primary prevention of sudden cardiac death after myocardial infarction (MI) remains unknown. METHODS AND RESULTS: We developed a Markov model to investigate the optimal timing of ICD implantation after MI (no ICD, ICD at 60 days, 6 months, and 1 year) in patients who meet current guidelines. Estimates of arrhythmic death (baseline risk 6%, range 1-20% per year), nonarrhythmic death, and ICD efficacy were based upon MADIT-II and other contemporary post-MI clinical trials. We used both deterministic and stochastic modeling processes in our analysis. After 10 years follow-up, the baseline probability of survival was higher in those treated with ICD implantation versus not (42% vs 30%, P < 0.001). Survival was highest with ICD implantation at 60 days versus 6 months versus 1 year: 42.4%, 42.3%, and 42.0% (P = 0.0028). ICD implantation at 60 days provided a mean incremental survival of 0.28 months and 0.84 months per patient (compared with implantation at 6 months and 1 year). In sensitivity analyses, patients' competing risk for nonarrhythmic death was the primary determinant of benefit from ICD implantation. Overall, ICD implantation at 60 days resulted in the greatest life expectancy over a wide range of plausible nonarrhythmic and arrhythmic death rates. CONCLUSIONS: The benefits of early ICD implantation are modest when compared with delayed implantation at 6 months/1 year. Our results suggest that making sure a patient receives an ICD, when appropriate, may be more important than the timing of the implantation procedure.
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Piccini et al. (2010) studied Myocardial infarction. ICD implantation at 60 days vs. ICD implantation at 6 months or 1 year, or no ICD was evaluated on 10-year survival probability (p=0.0028). ICD implantation at 60 days post-MI yielded a 10-year survival of 42.4%, compared to 42.3% at 6 months and 42.0% at 1 year (P=0.0028), providing modest incremental survival benefits.
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