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Primary Prevention Implantable Cardioverter Defibrillators in Patients With Nonischemic Cardiomyopathy: A
Sana M Al-Khatib1, Gregg C Fonarow2, Jose A Joglar3
1Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
Insights
Implantable cardioverter defibrillators (ICDs) effectively reduce all-cause mortality in patients with nonischemic cardiomyopathy. This meta-analysis supports ICD use for primary prevention in this population.
Area of Science:
- Cardiology
- Electrophysiology
- Preventive Medicine
Background:
- Conflicting data exist regarding the efficacy of implantable cardioverter defibrillators (ICDs) for primary prevention of sudden cardiac death in nonischemic cardiomyopathy.
- Nonischemic cardiomyopathy is a significant cause of heart failure and sudden cardiac death.
Purpose of the Study:
- To investigate the association between primary prevention ICDs and all-cause mortality in patients with nonischemic cardiomyopathy.
- To synthesize evidence from randomized clinical trials on ICD efficacy in this patient group.
Main Methods:
- A systematic literature search of PubMed was conducted from 2000 to 2016.
- Inclusion criteria specified randomized clinical trials with at least 100 patients, comparing ICDs with medical therapy, and reporting all-cause mortality over a minimum 12-month follow-up.
- Data from four eligible trials involving 1874 patients were pooled using fixed- and random-effects models.
Main Results:
- The meta-analysis included four randomized clinical trials with 1874 participants (937 ICD, 937 control).
- Primary prevention ICDs demonstrated a significant reduction in all-cause mortality (hazard ratio, 0.75; 95% CI, 0.61-0.93; P=.008).
- No significant heterogeneity was observed between the studies (P=.87).
Conclusions:
- Primary prevention ICDs are efficacious in reducing all-cause mortality for patients with nonischemic cardiomyopathy.
- These findings provide strong support for current professional guidelines recommending ICD implantation in this patient population.
- ICDs represent a crucial intervention for improving survival in nonischemic cardiomyopathy.
Importance:
Conflicting data have emerged on the efficacy of implantable cardioverter defibrillators (ICDs) for primary prevention of sudden cardiac death (primary prevention ICDs) in patients with nonischemic cardiomyopathy.
Objective:
To investigate the association of primary prevention ICDs with all-cause mortality in patients with nonischemic cardiomyopathy.
Data Sources:
PubMed was searched from January 1, 2000, through October 31, 2016, for the terms implantable defibrillator OR implantable cardioverter defibrillator AND non-ischemic cardiomyopathy. Additional references were identified from bibliographies of pertinent articles and queries to experts in this field.
Study Selection:
Inclusion criteria consisted of a randomized clinical trial design and comparison of the ICD with medical therapy (control) in at least 100 patients with nonischemic cardiomyopathy. In addition, studies had to report on all-cause mortality during a follow-up period of at least 12 months and be published in English. The search yielded 10 studies, of which only 1 met the inclusion criteria. A search of bibliographies of pertinent articles and queries of experts in this field led to 3 additional studies.
Data Extraction And Synthesis:
The PRISMA guidelines were used to abstract data and assess data quality and validity. Data were pooled using fixed- and random-effects models.
Main Outcomes And Measures:
The primary end point was all-cause mortality. Before data collection started, primary prevention ICDs were hypothesized to reduce all-cause mortality among patients with nonischemic cardiomyopathy.
Results:
Four randomized clinical trials met the selection criteria and included 1874 unique patients; 937 were in the ICD group and 937 in the control group. Pooling data from these trials showed a significant reduction in all-cause mortality with an ICD (hazard ratio, 0.75; 95% CI, 0.61-0.93; P = .008; P = .87 for heterogeneity).
Conclusions And Relevance:
Primary prevention ICDs are efficacious at reducing all-cause mortality among patients with nonischemic cardiomyopathy. These findings support professional guidelines that recommend the use of ICDs in such patients.