http://www.theheart.org/web_slides/1242347.do A trial on ALTITUDE to evaluate mortality after device implantation or after shock therapy in large numbers of patients with implanted devices

1. ALTITUDE: Results (general)

2. ALTITUDE
B Powell (Mayo Clinic, Rochester, MN)
Heart Rhythm Society 2011 Scientific Sessions
• A trial to evaluate mortality after device implantation or after shock therapy in
large numbers of patients with implanted devices
• Outcomes:
One- and five-year survival rates in patients implanted with ICD and CRT
devices
Outcomes were compared between patients followed in device clinic settings
and those who regularly transmit remote data collected from the device an
average of four times monthly
• Follow-up analysis:
Patients receiving shocks were compared with patients who never received a
shock, who were propensity-matched on the basis of age, sex, whether their
device provided cardiac resynchronization, and implantation year

3. ALTITUDE: Results (general)
• Compared with mortality after a first shock for AF/atrial flutter, mortality after a
first shock for sinus tachycardia or supraventricular tachycardia (SVT) was
significantly reduced
HR (95% CI) for mortality, by rhythm at the time of shock, compared
with mortality after shock for AF/atrial flutter
Rhythm at shock HR (95% CI)
Sustained monomorphic VT 1.19 (0.97–1.46)
Polymorphic VT 1.34 (1.06–1.69)
Sustained monomorphic VT and polymorphic VT 1.55 (1.16–2.06)
Nonsustained VT 1.80 (1.06–3.07)
Sinus tachycardia/SVT 0.71 (0.54–0.94)
Noise/artifact/oversensing 0.58 (0.39–0.88)

4. ALTITUDE: Results (follow-up analysis)
• In the follow-up analysis the mortality increase associated with inappropriate
shocks was concentrated in the AF/atrial-flutter group
HR (95% CI) for mortality for 3630 patients receiving shocks vs 3630 not
receiving shocks, by rhythm at time of shock
Rhythm at shock HR (95% CI)
Sustained monomorphic VT 1.65 (1.36–2.01)
Polymorphic VT 2.10 (1.54–2.86)
Sustained monomorphic VT and polymorphic VT 2.77 (1.70–4.51)
Nonsustained VT 2.17 (0.82–5.70)
Sinus tachycardia/SVT 0.97 (0.68–1.37)
Noise/artifact/oversensing 0.91 (0.50–1.67)
AF/atrial flutter 1.61 (1.17–2.21)

5. ALTITUDE: Commentary*
"It appears that the adverse prognosis following an ICD shock may be related to the
underlying arrhythmia as opposed to an adverse effect from the shock itself."
- Dr Brian Powell
"[ALTITUDE] shows further evidence that it's likely the substrate or arrhythmias, and
not the shocks themselves, that are killing people."
- Dr Michael Gold
*All comments from ALTITUDE: "Inappropriate" ICD shocks off the hook for mortality increase
(http://www.theheart.org/article/1221745.do)

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