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Survival benefit of primary prevention implantable cardioverter-defibrillator therapy after myocardial infarction: Does time to implant matter? A meta-analysis using patient-level data from 4 clinical trials

Published:February 15, 2013DOI:https://doi.org/10.1016/j.hrthm.2013.02.011

      Background

      Whether there is an optimal time to place an implantable cardioverter-defibrillator (ICD) more than 40 days after myocardial infarction (MI) in guideline-eligible patients is unknown.

      Objective

      To evaluate the effect of time from MI to randomization on mortality, rehospitalizations, and complications.

      Methods

      Individual data on patients enrolled in 9 primary prevention ICD trials were provided. Clinical trials were eligible for the current analysis if they enrolled patients with an MI more than 40 days prior to randomization to primary prevention ICD therapy vs usual care: Multicenter Automatic Defibrillator Implantation Trial I, Multicenter UnSustained Tachyardia Trial, Multicenter Automatic Defibrillator Implantation Trial II, and Sudden Cardiac Death in Heart Failure Trial.

      Results

      ICD recipients died less frequently than nonrecipients at 5 years across all subgroups of time from MI to randomization. In unadjusted Cox proportional hazards regression, a survival benefit was evident in most subgroups. Adjusted Bayesian Weibull survival modeling yielded hazard ratio (HR) 0.50, 95% posterior credible interval (PCI) 0.20–1.25 41–180 days after MI; HR 0.98, 95% PCI 0.37–2.37 181–365 days after MI; HR 0.22, 95% PCI 0.07–0.59>1–2 years after MI; HR 0.42, 95% PCI 0.17–0.90>2–5 years after MI; HR 0.55, 95% PCI 0.25–1.15>5–10 years after MI; and HR 0.48, 95% PCI 0.20–1.02>10 years after MI. There was no evidence of an interaction between time from MI and all-cause mortality, rehospitalizations, or complications.

      Conclusions

      In this meta-analysis, there was scant evidence that the efficacy of primary prevention ICD therapy depends on time to implantation more than 40 days after MI. Similarly, there was no evidence that the risks of rehospitalizations or complications depend on time more than 40 days after MI.

      Abbreviations:

      DINAMIT (Defibrillator in Acute Myocardial Infarction Trial), HR (hazard ratio), ICD (implantable cardioverter-defibrillator), IRIS (Immediate Risk Stratification Improves Survival), LVEF (left ventricular ejection fraction), MADIT-I (Multicenter Automatic Defibrillator Implantation Trial I), MADIT-II (Multicenter Automatic Defibrillator Implantation Trial II), MI (myocardial infarction), MUSTT (Multicenter UnSustained Tachyardia Trial), PCI (posterior credible interval), SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial)

      Keywords

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