Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Who Should Receive a Defibrillator in 2021?Primary and Secondary Prevention of Sudden Cardiac Death,Yong-Mei Cha,MD,Mayo Clinic,Dalian,2021,CP1270808-8,400,000 sudden deaths/year in USA,Other causes,Stroke160,000Lung cancer 90,100Breast cancer 40,200Automobile accident 50,000AIDS 16,000Fires 4,000,Pathophysiology and Epidemiology of Sudden Death from Cardiac Causes,Huikuri et al:NEJM 345(20):1473,2003,Uncommoncause,Cardiomyopathy,Risk factors for cor athero-sclerosis:Older age,malesex,hyperlipidemia,smoking,HTN,diabetes,Primary electrical&geneticion-channelabnormalities,valvular orcongenital heartdisease,other causes,Hypertrophiccardiomyopathy,Dilatedcardiomyopathy,Chronicmyocardialscar causedby infarction,Acute plaquedestabilization:Rupture,fissure,hemorrhagethrombosis,Triggers of cardiac arrest:Transient ischemia,hemodynamic fluctuations,neurocardiovascular influences,environmental factors,Sinus rhythm,VT,V Fib,Asystole,Coronaryatherosclerosis,80%,10-15%,5%,Sudden death,Genetic factors,hypertension,Genetic factors,infections,others,Secondary prevention trials,all patients had aborted cardiac arrest or syncope,ICDControl,Trial(no.)(no.)RR(95%CI),-,AVID1997 80/507 122/5090.66(0.51-0.85),CASH200036/99 84/1890.82(0.60-1.11),CIDS 2000 83/328 98/3310.85(0.67-1.10),Subtotal199/934 304/1,0290.76(0.65-0.89),AVID,A,ntiarrhythmics,V,ersus,I,mplantable,D,efibrillators,secondary sudden death prevention trial,Entry Criterion:,VFVT with syncopeVT with EF,40%,CHF,or near syncope,N:,1,016,Therapy:,ICD versus amiodarone or sotalol,Endpoint:,Total mortality,Findings:,ICD reduced overall mortality by 34%,Antiarrhythmic-drug group,Defibrillator group,AVID:NEJM,1997,P1 month,EF,30%,NYHA I-III,Exclusion:,MI within 1 month of enrollment CABG/PCI within 3 months,N,:,1,232,Therapy:,ICD versus optimal medical therapy,Endpoint:,Total mortality,MADIT II:Survival with ICD vs Conventional Therapy,Probabilityofsurvival,Follow-up(mo),ICD742503 274 110 9,Conventional490329 170 65 3,ICD,Conventional,P=0.007,30%reduction in mortality,14.2%,19.8%,Inclusion:,recent MI(6-40 days),LVEF,35%,depressed HRV(SDNN 70 msec or 24 h mean RR 750 msec),Exclusion:,CABG/PCI expected within 4 weeks after randomization,N:,674,Therapy:,Conventional vs.ICD,Primary outcome:,mortality from all causes,DINAMIT,Prophylactic Use of an ICD after Acute MI,CP1242180-13,DINAMIT:N Engl J Med 351:2481,2004,Cumulative risk ofdeath from any cause,Months after randomization,No.at risk,ICD3152992582111721238225,Control3183052722171721247931,ICD group,Control group,P=0.66,DINAMIT,death from any cause,SCD-HeFT,Amiodarone or an ICD for Congestive Heart Failure,CP1145214-12,DCM or ICM,EF,35%,NYHA class II or III,Placebo,Amiodarone,ICD,R,Bardy et al:ACC,2004,N=2,521,No.at risk,Placebo847797724505304 89,Amiodarone845772715484280 97,ICD therapy829778733501304103,Mortalityrate,Kaplan-Meier Estimates of Death from Any Cause,CP1186510-8,SCD-HeFT,Bardy GH:NEJM,2005,Follow-up(mo),Hazard ratio(97.5%CI)P,Amiodarone 1.06(0.86-1.30)0.53vs placebo,ICD therapy 0.77(0.62-0.96)0.007vs placebo,5-yr eventrateDeaths,Placebo0.361244,Amiodarone0.340240,ICD therapy0.289182,Kaplan-Meier Estimates of Death from Any Cause,SCD-HeFT,Bardy GH:NEJM,2005,CP1186510-9,Mortality rate,Follow-up(mo),No.at risk,Placebo45341537024415248,Amiodarone42638434622713046,ICD therapy43139536524414448,39438235426115241,41938836925715051,39838336825716055,Hazard ratio(97.5%CI)P,Amiodarone 1.05(0.81-1.36)0.66vs placebo,ICD therapy0.79(0.60-1.04)0.05vs placebo,Ischemic CHF,0.5,0.4,0.3,0.2,0.1,0,Follow-up(mo),Hazard ratio(97.5%CI)P,Amiodarone 1.07(0.76-1.51)0.65vs placebo,ICD therapy0.73(0.50-1.07)0.06vs placebo,Nonischemic CHF,5-yr eventrate,Placebo0.432,Amiodarone0.417,ICD therapy0.359,5-yr event rate,Placebo0.279,Amiodarone0.258,ICD therapy0.214,10 ICD Primary Prevention Randomized Trials,Trialyearcause of CMPN RR,-,MADIT 1996 ischemic 1960.41,CABG-Patch 1997 ischemic9001.08,MUSTT 1999ischemic6590.46,MADIT II 2002 ischemic12320.71,CAT 2002 non-ischemic1040.83,AMIOVIRT 2003non-ischemic1030.87,DEFINITE 2004non-ischemic4580.70,DINAMIT 2004ischemic6741.10,COMPANION 2004both15200.83,SCD-HeFT 2005both25210.76,-,Total,0.75,total nmortality,-,Non-ICD therapy3,72326.4%,ICD therapy3,53018.5%,Absolute mortality reduction 8%,Relative mortality reduction 25%,10 ICD Primary Prevention,Randomized Trials,ICD efficacy in risk subgroups,Widened QRS duration provide no significant benefit with ICD therapy,ICD therapy is associated with an equivalent reduction of mortality in elderly,75(MADIT II),ICD efficacy is similar in both gender,Renal dysfunction is associated with higher mortality(non-arrhythmic death),and less ICD benefit.,An inverse relationship between BP and risk of SD.ICD benefits more in patients with low BP.(MADIT II),In ICD primary prevention of sudden death trials,patients with NYHA class IV were excluded.,Reprinted