September 6, 2022Open Access

Implantable defibrillator therapy and mortality in patients with non-ischaemic dilated cardiomyopathy

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Non-ischaemic dilated cardiomyopathy (n=3547). Intervention: Implantable cardioverter-defibrillator (ICD) vs. Medical therapy (MT). Primary outcome: All-cause mortality (HR 0.76, 95% CI 0.62-0.93, p=0.008).

Key Result

Implantable cardioverter-defibrillators reduced all-cause mortality by 24% (HR 0.76) compared to medical therapy in patients with non-ischaemic cardiomyopathy not eligible for CRT.

Study Design

Type

Meta-Analysis (n=3,547)

Structured PICO

Does implantable cardioverter-defibrillator therapy reduce mortality in patients with non-ischaemic cardiomyopathy?

Population

Patients with non-ischaemic cardiomyopathy (NICMP) from 6 RCTs

Intervention

Implantable cardioverter-defibrillator (ICD) therapy

Comparator

No ICD therapy (or CRT pacemaker for those receiving CRT)

Outcome

Mortalityhard clinical

ICD therapy significantly improves survival among patients with non-ischaemic cardiomyopathy who are not eligible for CRT, but does not significantly reduce mortality when added to CRT.

Main Result

Effect estimate: HR 0.76 (95% CI 0.62-0.93)

p-value: p=0.008

Limitations

Absence of patient-level data, which limited the ability to assess ICD benefit in subgroups
Absence of patient-level data prevented the exploration of the impact of baseline mortality risk on ICD benefit
Studies reporting outcomes on CRT-P versus CRT-D were limited in number and sample size

Abstract

BACKGROUND: Primary prophylactic implantable cardioverter-defibrillators (ICDs) in patients with non-ischaemic cardiomyopathy (NICMP) remains controversial. This study sought to assess the benefit of ICD therapy with or without cardiac resynchronisation therapy (CRT) in patients with NICMP. In addition, data were compared with real-world clinical data to perform a risk/benefit analysis. METHODS: Relevant randomised clinical trials (RCTs) published in meta-analyses since DANISH, and in PubMed, EMBASE and Cochrane databases from 2016 to 2020 were identified. The benefit of ICD therapy stratified by CRT use was assessed using random effects meta-analysis techniques. RESULTS: Six RCTs were included in the meta-analysis. Among patients without CRT, ICD use was associated with a 24% reduction in mortality (hazard ratio HR: 0.76; 95% confidence interval CI: 0.62-0.93; P = 0.008). In contrast, among patients with CRT, a CRT-defibrillator was not associated with reduced mortality (HR: 0.74, 95% CI 0.47-1.16; P = 0.19). For ICD therapy without CRT, absolute risk reduction at 3‑years follow-up was 3.7% yielding a number needed to treat of 27. CONCLUSION: ICD use significantly improved survival among patients with NICMP who are not eligible for CRT. Considering CRT, the addition of defibrillator therapy was not significantly associated with mortality benefit compared with CRT pacemaker.

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