Evaluation of MADIT-II Risk Stratification Score Among Nationwide Registry of Heart Failure Patients With Primary
Moshe Rav-Acha1, Orli Wube2, Oholi Tovia Brodie3
1Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University, Jerusalem, Israel.
Insights
The MADIT-II-based Risk Stratification Score (MRSS) helps identify heart failure patients who benefit most from prophylactic implantable cardioverter-defibrillators (ICDs). This score refines risk assessment for optimal ICD implantation in heart failure patients.
Area of Science:
- Cardiology
- Medical Devices
- Public Health
Background:
- Current guidelines recommend prophylactic implantable cardioverter-defibrillators (ICDs) for symptomatic heart failure (HF) patients with low ejection fraction.
- A significant number of patients receive ICDs without experiencing device utilization, highlighting the need for improved risk stratification.
- Identifying subgroups with differential ICD benefit is crucial for optimizing prophylactic device implantation.
Purpose of the Study:
- To evaluate the feasibility of the MADIT-II-based Risk Stratification Score (MRSS) in delineating ICD survival benefit.
- To assess the MRSS's ability to stratify risk in a nationwide registry of HF patients receiving prophylactic ICDs.
- To analyze the competing risks of ventricular arrhythmia (VA) versus nonarrhythmic death in relation to MRSS subgroups.
Main Methods:
- Utilized a nationwide registry of Israeli patients with HF who received prophylactic ICDs or cardiac resynchronization therapy defibrillators.
- Categorized patients into MRSS-based risk subgroups.
- Analyzed endpoints including overall mortality, sustained VA, and competing risks of VA versus nonarrhythmic death.
- Estimated potential ICD survival benefit using the area between cumulative incidence curves.
Main Results:
- The MRSS risk subgroups were significantly associated with overall mortality (p < 0.001) but weakly with VA (p = 0.3).
- Competing risk analysis revealed diminishing ICD survival benefit with increasing MRSS risk.
- Estimated 5-year survival benefits were 76, 60, 38, and 0 life days gained for low, intermediate, high, and very high MRSS risk subgroups, respectively (p for trend < 0.05).
Conclusions:
- The MRSS effectively delineates subgroups with varying prophylactic ICD survival benefits in a nationwide HF patient registry.
- MRSS application can aid in evaluating the survival benefit of prophylactic ICD implantation in patients with ischemic and nonischemic cardiomyopathy.
- This score may help personalize prophylactic ICD therapy decisions, avoiding unnecessary implantation in low-benefit groups.
Abstract:
The current guidelines advocate prophylactic implantable cardioverter-defibrillator (ICD) for all patients with symptomatic heart failure (HF) with low left ventricular ejection fraction. Because many patients will never use their device, a score delineating subgroups with differential ICD benefit is crucial. We aimed to evaluate the MADIT-II-based Risk Stratification Score (MRSS) feasibility to delineate the ICD survival benefit in a nationwide registry of patients with HF with prophylactic ICDs. Accordingly, all Israeli patients with HF with prophylactic ICD/cardiac resynchronization therapy defibrillators were categorized into MRSS-based risk subgroups. The study end points included overall mortality, sustained ventricular arrhythmia (VA), and a competing risk of VA (potential preventable arrhythmic death, where ICD could benefit survival) versus nonarrhythmic death. Potential ICD survival benefit was estimated by the area between these cumulative incidence curves. In 2,177 patients with HF implanted prophylactic device, 189 patients (8.7%) had VA and 316 (14.5%) died during a median follow-up of 2.9 years. The MRSS risk subgroups were significantly associated with overall mortality (p <0.001) and weakly with VA (p = 0.3). The competing risk analysis of VA versus nonarrhythmic death revealed a significantly shorter duration (p <0.001) and smaller magnitude of ICD survival benefit with increased risk subgroups, yielding an estimated 76, 60, 38, and 0 life days gained from prophylactic ICD implant during a 5-year follow-up for the MRSS low-, intermediate-, high-, and very high-risk subgroups, respectively (p for trend <0.05). In conclusion, MRSS use in a nationwide registry of patients with ischemic and nonischemic cardiomyopathy, revealed subgroups with differing ICD survival benefit, suggesting it could help evaluate prophylactic ICD survival benefit.
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