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Arrhythmic and Mortality Outcomes Among Ischemic Versus Nonischemic Cardiomyopathy Patients Receiving Primary ICD
Craig R Narins1, Mehmet K Aktas1, Anita Y Chen2
1Division of Cardiology, University of Rochester Medical Center, Rochester, New York, USA.
Insights
Patients with ischemic cardiomyopathy have a similar risk of ventricular arrhythmias as those with nonischemic cardiomyopathy. However, ischemic cardiomyopathy patients face a higher risk of all-cause mortality, primarily from non-sudden cardiac causes.
Area of Science:
- Cardiology
- Electrophysiology
- Heart Failure Management
Background:
- Conflicting data exist regarding the efficacy of primary prevention implantable cardioverter-defibrillator (ICD) therapy in patients with ischemic versus nonischemic cardiomyopathy.
- Understanding these differences is crucial for optimizing patient selection and treatment strategies.
Purpose of the Study:
- To investigate the association between cardiomyopathy etiology (ischemic vs. nonischemic) and the risk of ventricular arrhythmias, appropriate ICD therapy, and mortality.
- To compare outcomes in patients with ischemic cardiomyopathy (ICM) versus nonischemic cardiomyopathy (NICM) receiving primary prevention ICDs.
Main Methods:
- Analysis of data from 4803 patients (3106 ICM, 1697 NICM) enrolled in 5 randomized primary prevention ICD trials (1997-2017).
- Primary endpoint: sustained ventricular tachycardia (VT) ≥200 beats/min or ventricular fibrillation (VF).
- Secondary endpoints: appropriate ICD therapy, all-cause mortality, and cause-specific mortality (noncardiac, sudden cardiac, non-sudden cardiac).
Main Results:
- ICM patients were older with more comorbidities; NICM patients had more advanced heart failure and received more cardiac resynchronization therapy.
- Multivariate analysis revealed similar risks for VT/VF events (HR: 0.98) and appropriate ICD therapy (HR: 1.03) between ICM and NICM.
- All-cause mortality risk was 1.8-fold higher in ICM patients (HR: 1.84), driven by non-sudden cardiac death.
Conclusions:
- In primary prevention ICD patients, ischemic cardiomyopathy is associated with a similar risk of life-threatening ventricular arrhythmias compared to nonischemic cardiomyopathy.
- Ischemic cardiomyopathy patients exhibit a significantly increased risk of all-cause mortality, predominantly due to non-sudden cardiac causes.
- These findings highlight the importance of considering non-arrhythmic mortality risks in ICM patients with ICDs.
Objectives:
This study sought to determine the association of cardiomyopathy etiology with the likelihood of ventricular arrhythmias, appropriate implantable cardioverter-defibrillator (ICD) therapy, and mortality.
Background:
There are conflicting data on the benefit of primary prevention ICD therapy in patients with ischemic versus nonischemic cardiomyopathy (ICM/NICM).
Methods:
The study population comprised 4803 patients with ICM (n = 3,106) or NICM (n = 1,697) with a primary prevention ICD enrolled in 5 randomized trials conducted between 1997 and 2017. The primary end point was sustained ventricular tachycardia (VT) ≥200 beats/min or ventricular fibrillation (VF). Secondary end points included appropriate ICD therapy and all-cause mortality. Differences in cause-specific mortality, including noncardiac, sudden cardiac, and non-sudden cardiac death, were also examined.
Results:
Patients with ICM were significantly older and had more comorbid conditions, whereas those with NICM had a more advanced heart failure class at enrollment and were more often prescribed medical or cardiac resynchronization therapy for heart failure. Multivariate analysis showed that ICM versus NICM had a similar risk of VT/VF events (HR: 0.98 [95% CI: 0.79-1.20]) and appropriate ICD therapy (HR: 1.03 [95% CI: 0.87-1.22]), whereas the risk of all-cause mortality was 1.8-fold higher among ICM versus NICM patients (HR: 1.84 [95% CI: 1.42-2.38]), dominated by non-sudden cardiac mortality.
Conclusions:
Combined data from 5 landmark ICD clinical trials show that ICM patients experience a similar risk of life-threatening ventricular arrhythmic events but have an increased risk of all-cause mortality, dominated by non-sudden cardiac death, compared with NICM patients.
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