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Non-ischaemic cardiomyopathy, sudden death and implantable defibrillators: a review and meta-analysis
Simon A S Beggs1, Pardeep S Jhund1, Colette E Jackson2
1British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
Insights
Implantable cardioverter defibrillators (ICDs) may reduce mortality in non-ischaemic cardiomyopathy (NICM) patients, but the benefit is less clear when including recent large trials. Individual patient factors are crucial for deciding on ICD therapy.
Area of Science:
- Cardiology
- Electrophysiology
- Heart Failure Management
Background:
- Non-ischaemic cardiomyopathy (NICM) is a significant cause of heart failure.
- Sudden cardiac death is a major concern in NICM patients.
- Implantable cardioverter defibrillators (ICDs) are used for primary and secondary prevention of sudden cardiac death.
Purpose of the Study:
- To perform an updated meta-analysis on the impact of ICD therapy on overall mortality in NICM patients.
- To reconcile conflicting findings between previous studies and the recent DANISH trial.
Main Methods:
- Systematic literature search for randomized controlled trials comparing ICDs versus no ICD in NICM.
- Meta-analysis of overall mortality as the primary endpoint.
- Inclusion of both primary and secondary prevention trials.
Main Results:
- Analysis of primary prevention trials showed a reduction in overall mortality with ICD therapy (RR 0.76, 95% CI 0.65 to 0.91).
- The inclusion of the large DANISH trial weakened the overall pooled benefit.
- The benefit observed may be influenced by older trials with potentially sub-optimal contemporary patient management.
Conclusions:
- ICD therapy demonstrates a potential survival benefit in NICM, though this is tempered by recent trial data.
- The DANISH trial suggests a personalized approach to ICD implantation in NICM is necessary.
- Clinicians should carefully consider patient age and comorbidities when deciding on primary prevention ICDs for NICM.
Objective:
The recent Danish Study to Assess the Efficacy of ICDs in Patients with Non-ischemic Systolic Heart Failure on Mortality (DANISH) trial suggested that implantable cardioverter defibrillators (ICDs) do not reduce overall mortality in patients with non-ischaemic cardiomyopathy (NICM), despite reducing sudden cardiac death. We performed an updated meta-analysis to examine the impact of ICD therapy on mortality in NICM patients.
Methods:
A systematic search for studies that examined the effect of ICDs on outcomes in NICM was performed. Our analysis compared patients randomised to an ICD with those randomised to no ICD, and examined the endpoint of overall mortality.
Results:
Six primary prevention trials and two secondary prevention trials were identified that met the pre-specified search criteria. Using a fixed-effects model, analysis of primary prevention trials revealed a reduction in overall mortality with ICD therapy (RR 0.76, 95% CI 0.65 to 0.91).
Conclusions:
Although our updated meta-analysis demonstrates a survival benefit of ICD therapy, the effect is substantively weakened by the inclusion of the DANISH trial-which is both the largest and most recent of the analysed trials-indicating that the residual pooled benefit of ICDs may reflect the risk of sudden death in older trials which included patients treated sub-optimally by contemporary standards. As such, these data must be interpreted cautiously. The results of the DANISH trial emphasise that there is no 'one size fits all' indication for primary prevention ICDs in NICM patients, and clinicians must consider age and comorbidity on an individual basis when determining whether a defibrillator is appropriate.
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