Presentation by Dr. Asit Shah on the topic- "All patients 40 days post MI should receive ICD."

1. ALL PATIENTS 40 DAYS
POST MI SHOULD RECEIVE
ICD
DR. AASIT S. SHAH MD, DM
JASLOK HOSPITAL AND RESEARCH CENTRE

2. INTRODUCTION
• Indications for ICD implant have evolved in last few
years
• Not meant only for drug refractory ventricular
arrhythmias
• Focus has changed from identifying patient who
needs ICD to identifying patients who can avoid
ICD.

3. ICD TRIALS
• Multiple RCT’s have shown that ICD is better than
antiarrhythmic drugs
• Applicable to patients for secondary prevention and
for primary prevention

4. ICD TRIALS- SECONDARY PREVENTION
• AVID
• CASH
• CIDS
• 73-83% PTS. HAD CAD
• EF 32-45%

5. Secondary Prevention Trials:
Reduction in Mortality with ICD Therapy
Overall Death
Arrhythmic Death
•Non-significant results.
1 The AVID Investigators. N Engl J Med. 1997;337:1576-1583.
2 Kuck Kh, et al. Circulation. 2000;102:748-754.
3 Connolly SJ, et al. Circulation. 2000;101:1297-1302.
80
60
40
20
0
AVID CASH CIDS
1 2 3
31%
56%
23%*
58%
20%*
33%
% Mortality Reduction w/ ICD Rx

6. ICD TRIALS- PRIMARY PREVENTION
• MADIT
• MUSTT
• MADIT 2
• SCD-HeFT
• Two recent meta-analyses have shown 20-30% net
risk reduction for total mortality

7. Overall Death
Arrhythmic Death
75%
55%
73%
31%
61%
1 2 3, 4
1 Moss AJ. N Engl J Med. 1996;335:1933-40.
2 Buxton AE. N Engl J Med. 1999;341:1882-90.
3 Moss AF. N Engl J Med. 2002;346:877-83.
4 Moss AJ. Presented before ACC 51st Annual Scientific Sessions, Late Breaking Clinical Trials, March
19, 2002.
80
60
40
20
0
54%
MADIT MUSTT MADIT-II
27 Months 39 Months 20 Months
% Mortality Reduction w/ ICD Rx
PRIMARY PREVENTION

8. PRIMARY VS. SECONDARY PREVENTION
ICD mortality
reductions in
primary
prevention trials
are equal to or
greater
than those in
secondary
prevention trials.
80
60
40
20
0
Overall Death
Arrhythmic Death
MADIT MUSTT MADIT-II
80
60
40
20
0
2 3, 4
Overall Death
Arrhythmic Death
1
AVID CASH CIDS
5 6 7
54%
75%
55%
76%
31%
61%
27 months 39 months 20 months
31%
56%
28%
59%
20%
33%
% Mortality Reduction w/ ICD Rx % Mortality Reduction w/ ICD Rx
3 Years 3 Years 3 Years
1 Moss AJ. N Engl J Med. 1996;335:1933-
40.
2 Buxton AE. N Engl J Med.
1999;341:1882-90.
3 Moss AJ. N Engl J Med. 2002;346:877-83
4 Moss AJ. Presented before ACC 51st
Annual Scientific Sessions, Late Breaking
Clinical Trials, March 19, 2002.
5 The AVID Investigators. N Engl J Med.
1997;337:1576-83.
6 Kuck K. Circ. 2000;102:748-54.
7 Connolly S. Circ. 2000:101:1297-1302.

9. ICD TRIALS
Hence it is clear that ICD therapy for SCD provides
greater reduction in SCD mortality than
antiarrhythmic drug therapy in high risk patients post
MI
The most important risk stratification factor is the
ejection fraction

10. SCD INCIDENCE POST MI
• Incidence of SCD is highest in the early phase post MI- first 30
days.
VALIANT TRIAL
 14703 pts.
 HIGHEST SCD IN 1 MTH POST MI-19%
 83% OF ALL SCD OCCURRED IN 1 MTH
 EF<30% HAD HIGHEST RISK OF SCD-
 Hence it is logical that if we provide antiarrhythmic therapy early to our
post MI high risk patients, incidence of SCD should reduce.

11. VALIANT TRIAL
EF <30%
<31-40%
>40%
Rates of sudden death or cardiac arrest

12. ICD TRIALS EARLY AFTER MI
• DINAMIT
• IRIS
• BEST

13. COMPETING RISK: LESSONS FROM
THE NEGATIVE TRIALS

14. COMPETING RISK

15. ICD TRIALS EARLY POST MI
• These trials did not show improvement in overall
mortality when ICD was implanted 6-40 days post MI.
• There was a reduction in SCd in the ICD group;
however non SCD deaths in ICD group also increased.
• This paradox has not been satisfactorily explained

16. ICD TRIALS EARLY POST MI
• Risk stratification factors
• Deleterious effect of ICD therapy –including
appropriate programming
• Other causes of sudden death
• Role of EP study
JACC 2009; 54(22) 2001-2005

17. ACC 2012 RECOMMANDATION
 CLASS I A : ICD therapy is indicated in patients with LVEF less than or
equal to 35% due to prior MI who are at least 40 days post-MI and
are in NYHA functional Class II or III
 CLASS I A : ICD therapy is indicated in patients with LV dysfunction
due to prior MI who are at least 40 days post-MI, have an LVEF less
than or equal to 30%, and are in NYHA functional Class I
 CLASS I B : ICD therapy is indicated in patients with nonsustained VT
due to prior MI, LVEF less than or equal to 40%, and inducible VF or
sustained VT at electrophysiological study.

18. AUC

20. PRIMARY PREVENTION
ICD Therapy
3 4
11
9
20
26
28
37
50
45
40
35
30
25
20
15
10
5
0
simvastatin
captopril
Metoprolol
succinate
MUSTT MADIT MADIT II AVID SAVE Merit-HF 4S Amiodarone
Meta-analysis
(5 Yr) (2.4 Yr) (3 Yr) (3 Yr) (3.5 Yr) (1 Yr) (6 Yr) (2 Yr)
NNTx years = 100 / (% Mortality in Control Group – % Mortality in Treatment Group)
amiodarone
Drug Therapy
Number Needed to Treat
to Save a Life

21. CONCLUSIONS
• All patients who match current guidelines should be
offered ICD implant
• Better risk stratification criteria and more
appropriate device programming
• Need more trials and data to identify patients at
high risk for SCD early after MI

22. THANK YOU!