ICD Therapy in Patients With Prior Coronary Revascularization in SCD-HeFT
Introduction: We conducted this study to examine the effect of the ICD on the outcomes of patients with prior coronary revascularization enrolled in the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) and to assess the association of time from coronary revascularization to enrollment with death and sudden cardiac death (SCD).
Methods and Results: We included in this analysis patients with ischemic heart disease not randomized to the amiodarone arm. Cox proportional hazards models were used to examine the association of prior CABG and of prior PCI with each outcome. Interactions between randomized treatment and each revascularization type and time were tested in each model. Of the 882 patients who met these inclusion criteria, 255 (29%) had no prior revascularization, 178 (20%) had prior PCI only, 284 (32%) had prior CABG only, and 165 (19%) had prior PCI and CABG. There was no significant difference in ICD benefit across the revascularization subgroups (all P > 0.1). There was a trend toward improved survival with an ICD in patients who had their CABG > 2 years before randomization (HR [CI]= 0.71 [0.49, 1.04]) that was not observed in patients who had their CABG ≤ 2 years before randomization (HR [CI]= 1.40 [0.61, 3.24]).
Conclusion: In SCD-HeFT, there was no significant difference in ICD benefit across the revascularization subgroups. Patients who had their CABG > 2 years before randomization showed a trend toward improved survival with an ICD that was not observed in patients who had their CABG ≤ 2 years before randomization.
Several randomized clinical trials have demonstrated the efficacy of implantable cardioverter defibrillator (ICD) therapy at reducing mortality in patients with significant left ventricular dysfunction due to ischemic or nonischemic heart disease. Whether the ICD offers incremental survival benefit beyond revascularization in patients with ischemic heart disease is uncertain. Indeed, primary prevention clinical trials of ICD therapy did not enroll patients who were within 1 to 3 months after revascularization. However, the coronary artery bypass graft (CABG)-PATCH trial showed no improvement in survival with an ICD implanted at the time of CABG. Although this trial may not have enrolled a very high-risk population and implantation of an epicardial ICD may have a different risk profile than a transvenous system, the absence of ICD benefit may have resulted from the lack of incremental survival benefit beyond concomitant revascularization.
Whether ICD therapy is beneficial in patients with chronic heart failure and prior coronary revascularization is uncertain. Because the sudden cardiac death in heart failure trial (SCD-HeFT) enrolled patients with chronic heart failure, and patients with ischemic heart disease were enrolled in the trial ≥ 1 month from coronary revascularization, this trial provides an opportunity for us to address this question. We conducted this study to examine the effect of ICD therapy on death and sudden cardiac death (SCD) in patients with prior coronary revascularization enrolled in SCD-HeFT and to assess the association of time from revascularization to randomization with ICD benefit and the risk of death and SCD.
Abstract and Introduction
Abstract
Introduction: We conducted this study to examine the effect of the ICD on the outcomes of patients with prior coronary revascularization enrolled in the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) and to assess the association of time from coronary revascularization to enrollment with death and sudden cardiac death (SCD).
Methods and Results: We included in this analysis patients with ischemic heart disease not randomized to the amiodarone arm. Cox proportional hazards models were used to examine the association of prior CABG and of prior PCI with each outcome. Interactions between randomized treatment and each revascularization type and time were tested in each model. Of the 882 patients who met these inclusion criteria, 255 (29%) had no prior revascularization, 178 (20%) had prior PCI only, 284 (32%) had prior CABG only, and 165 (19%) had prior PCI and CABG. There was no significant difference in ICD benefit across the revascularization subgroups (all P > 0.1). There was a trend toward improved survival with an ICD in patients who had their CABG > 2 years before randomization (HR [CI]= 0.71 [0.49, 1.04]) that was not observed in patients who had their CABG ≤ 2 years before randomization (HR [CI]= 1.40 [0.61, 3.24]).
Conclusion: In SCD-HeFT, there was no significant difference in ICD benefit across the revascularization subgroups. Patients who had their CABG > 2 years before randomization showed a trend toward improved survival with an ICD that was not observed in patients who had their CABG ≤ 2 years before randomization.
Introduction
Several randomized clinical trials have demonstrated the efficacy of implantable cardioverter defibrillator (ICD) therapy at reducing mortality in patients with significant left ventricular dysfunction due to ischemic or nonischemic heart disease. Whether the ICD offers incremental survival benefit beyond revascularization in patients with ischemic heart disease is uncertain. Indeed, primary prevention clinical trials of ICD therapy did not enroll patients who were within 1 to 3 months after revascularization. However, the coronary artery bypass graft (CABG)-PATCH trial showed no improvement in survival with an ICD implanted at the time of CABG. Although this trial may not have enrolled a very high-risk population and implantation of an epicardial ICD may have a different risk profile than a transvenous system, the absence of ICD benefit may have resulted from the lack of incremental survival benefit beyond concomitant revascularization.
Whether ICD therapy is beneficial in patients with chronic heart failure and prior coronary revascularization is uncertain. Because the sudden cardiac death in heart failure trial (SCD-HeFT) enrolled patients with chronic heart failure, and patients with ischemic heart disease were enrolled in the trial ≥ 1 month from coronary revascularization, this trial provides an opportunity for us to address this question. We conducted this study to examine the effect of ICD therapy on death and sudden cardiac death (SCD) in patients with prior coronary revascularization enrolled in SCD-HeFT and to assess the association of time from revascularization to randomization with ICD benefit and the risk of death and SCD.
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